introduction: use of smart phone, which has become an integral activity of daily life now, has begun to show subtle untoward effects on health. various health related problems associated with electronic devices, especially smart phones, use are being studied. phantom ringing & vibration syndrome is one such adverse effect, which is an auditory hallucination seen in mobile phone users when they feel that their phone is ringing when it is actually not. to the best of our knowledge and literature search, we could not nd any indian study on phantom ringing & vibration syndrome in rst year mbbs students. this study was conducted to determine the prevalence of phantom ringing & vibration syndrome and to nd the factors associated with it. methods: this was a prospective, cross-sectional questionnaire based study, conducted in rst year a 7-item validated questionnaire was administered to 100 participants & were analyzed results: out of 100 respondents, 95 per cent of them say that they've experienced these phantom vibrations.83 per cent of them say they've experienced this phantom ringing.both the syndrome occurs more in students who kept their cell phone in shirt or paint pocket than to who kept mobile in handbag.85% of students felt vibration or ringing even when the phone is switched off discussion: phantom ringing syndrome is the belief that your phone is ringing when it actually isn't, and repeatedly checking. it is also called ringxiety, a term coined by psychologist david laramie, and linked to phantom vibration syndrome – the mistaken sensation that your phone is vibrating when in your pocket, is caused by 'learned bodily habits.' 'through bodily habit, your phone actually becomes a part of you, and you become trained to perceive the phone's vibrations as an incoming call or text,' so, due to these kinds of habits, it becomes really easy to misperceive other similar sensations. it may be considered as normal brain mechanism (1) phantom vibration syndrome is a sensory hallucination. phantom vibration syndrome were common in medical staffs who used electronic devices (2) neurodevelopment changes associated with the hypoth alamic-pituitary-adrenal (hpa) axis have been investigated as mechanisms of auditory hallucination. phantom vibration was more prevalent than phantom ringing syndrome.stress in medical studies is reason for this syndrome. there may be a relation between this syndrome and emotional symptoms with burnout syndrome. mohammadbeigi [ ] reported a higher female prevalence for 3 vibration and male prevalence for ringing; other studies did not nd differences across genders (taking vibration and ringing together the cause of phantom vibrations is not known. ... it has been suggested that, when anticipating a phone call, the cerebral cortex may misinterpret other sensory input (such as muscle contractions, pressure from clothing, or music) as a phone vibration or ring tone. medical students are “just so anxious these days, because of all of our different technologies”, which include emails and text messages, “keep them on edge.” & inclined to be jumpy and feel something in our pocket as a phantom vibration," conclusions: the prevalence rate of phantom vibration in our study was 95% & phantom ringing was 85%, which occurs irrespective of gender, age, profession, and physical location, duration and mode of phone use. it would be interesting to nd exact site of involvement, in auditory circuit; by bera studies. phantom ringing syndrome is common among medical students who use mobile phones references: 1. goyal ak. studies on phantom vibration and ringing syndrome among postgraduate students. indian j comm health. 2015; 27, 1: 35-40. 2. m b rothberg, phantom vibration syndrome among medical staff: a cross sectional survey; bmj 2010;341:c6914 3. mohammadbeigi a, mohammadsalehi n, moshiri e, anbari z, ahmadi a, ansari h. the prevalence of phantom vibration/ringing syndromes and their related factors in iranian' students of medical sciences. asian j psychiatr. 2017;27:76–80. pmid:28558902 study of phantom ringing & vibration syndrome in first year indian medical graduate students original research paper naik anshuman associate professor, department of physiology hi-tech medical college, rourkela, odisha x 15gjra global journal for research analysis physiology introduction: this study was conducted to determine the prevalence of phantom ringing & vibration syndrome and to nd the factors associated with it. . methods: validated questionnaire was administered to 100 participants & were analysed. results: 95 per cent of them say that they've experienced these phantom vibrations. 83 per cent of them say they've experienced this phantom ringing. conclusion:it would be interesting to nd exact site of involvement, in auditory circuit abstract keywords : indian medical graduate, mbbs, first year, phantom ringing, phantom vibration, smart phone patel shashikala* associate professor, department of anatomy hi-tech medical college, rourkela, odisha *corresponding author volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: latin name: abarus precatorious. family fabaceae seeds weigh 105 mg, measure (8 x 6 m) seeds are bright red with a black spot on one end other verities are pale and brown while and black yellow or blue seeds are often used as beads in rosaries (for playing) it is anti inammatory, analgesic it has kusthaghna, krumighna, vedana stapana, balya, vrushya, mutral, jwaragnha properties. aim to study ayurvedic respect of gunja. objective ÿ to collect the literature review of abrus precatorius. ÿ to study systemic effect of abrus precatorius. ÿ to study toxicity of abrus precatorius. synonyms sanskrit name raktika, kakananti marathi gunja hindi rattis english rosary pea, lucky bean ratty, qunchi, indian liquorices' crabl's eye, love bean botanical name abrus precatorius kul shimbhi kul bengali kunch gujarathi chanothi varjikaran sthavar visha vanspatij visha modern – irritant organic, vegetable poison patra 20-40 number 3-7 inch length, (imali) pushpa 1-3 inch length pink, blue in colour pala (fruit red, blue, white colour utpatti sthan all over india rasayanik sanghatan – abrin, glycyrrhizin and n-methyl tryptophan ayurvedic properties guna laghu, tikshna, ruksha rasa tikta, kashay vipak katu virya ushna doshkarma kaphavatshamak seeds patra vatapitta shamak local action vranaropan, vedanasthapan system karma 1) pachan sansthan snehan, dipan(digestive) 2) swasan sansthan snehan, kaphanisarak 3) mutravah sansthan use in mutrakruchrra, mutral 4) prajanan sansthan uterian excitment, vajikaran, reproductive 5) tapakram (fever) jwaraghna 6) twaka kushtaghna 7) nadisansthan balya, therpeutic use in samhita: 1) mukhoshoshahar, vatapitta shamak, shwasa, trushna madha vinashan shothahar 2) graha visha, kandu, kusthna, krumi nashan aushadhi matra – beeja chruna 60 180 mg, mula and patra churna 1-3g vishakta lakshana: permatitis, tash, redness vishakta chikitsa: tandulja swaras + sharkara cow milk + sharkara post mortem appearance 1) fragments of sui in wound 2) oedema at the site of injection 3) patches of ecchymosis under the skin, pleura, peri cardium and peritonium hemorrhagic patches on external and internal surface of body. mediclegal aspect: 1) sui poisoning seeds are powdered mixed with dhatura, opium and made into paste with spirit and water and applied into needles. 2) sui poisoning is a cattle poisoning. 3) accidental poisoning is seen into children because of its attractive colour. 4) used as arrow poison. 5) it also used for homicide. pharmological activity: 1. neuromuscular effects: some neuromuscular effects of the crude extracts of the leaves of abrus precatorius were investigated using isolated toad rectus abdominals and rat phrenic nerve-diaphragm muscle preparations as well as young chicks. 2. dalton's lymphoma: it has been reported that abrus abrin, isolated from the seeds ayurvedic aspects of (gunja) abrus precatorius w. s. t. agadtantra original research paper dr. vipul tanaji gurav m.d. agadtantra reader agadtantra, rural ayurved institute and research centre, mayni. x 151gjra global journal for research analysis ayurveda abrus precatorius also known as lucky bean, crab's eye, buddhist rosary bead family belong to fabaceae. in ayurveda it is described as vanaspaty visha as in modem science it is irritant organic vegetable poison. all parts are poisonous mostly seeds, root and leaves are hazardous to human. its medicinal kalpa are prepared it contain abrin, abric acid, glycyrrhizin. it also used as non-medico purpose as seeds used in necklaces rosary beads, jewellary qunja detoxied in milk cow's. while qunja used as medicinal purpose used as a weighing measures for gold or precious stones. this article suggests the ayurvedic reviews of abrus precatorius w.s.r. to agadtantra. abstract keywords : gunja, agadtantra dr. anuja vasant nagrare* md. agadtantra -assisstant prof. – jupitar ayurved college, nagpur. *corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 152 x gjra global journal for research analysis of abrus precatorius, showed in vitro and in vivo antitumor properties by the induction of apoptosis. 3. alzheimer's disease: abrus precatorius l. lectinhave been used to identify glycohistochemically the microglial cells (mgc) activation in autoptic brain samples from alzheimer's disease subject. abrus precatorius agglutinin recognizes mgc in the cerebral white matter from all ad patients studied. 4. antimalarial: an isoavaquinoneabruquinone was isolated from the extract of aerial parts and exhibited antimalarial activity. conclusion: abrus precatorius is very potent herbal plant used as various purposes. it has different synonym according various archarya's. according to its action it gives various effect. as per modern science it is organic irritant vegetable poison. but according to acharaya priyawat shrama it is vishgna activity. sometimes made into pills and sold as birth control pills. references: 1. dravyguana vidnayan dravyaguna vidnyan , volume 2, acharya priyvat sharma choukhambha bharati academy-varanasi, 2011 pg.no.—770 2. https://www.pharmatutor.org/articles/review-abrus-precatorius 3. kaviraj ambika datta shastri;’’ayurved tatvasandipika “hindi commentary ;’’ “sushrut samhita’’ edition2005, part ii. 4. dr v.v. pillay ‘’modern medical toxicology’’ 5. dr phadke and dr deshmukh pratakshik pustikaagadtantra volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 11.vedula r. aditya chainulu.cdr introduction acute kidney injury (aki) is a complex condition that manifests in a number of clinical scenarios with it manifestations ranging from modest plasma creat inine escalation to anuric renal failure.it is often under-recognized 1–4and has severe consequences . recent epidemiological studies show the wide variation in 1,5–7etiology and risk factors , identify the increased mortality associated with this disease (especially when dialysis is 1,4,6,8,9required) , and indicate a relationship to the subsequent development of chronic kidney disease (ckd) and 1,4,8, 10 –12development of dialysis dependence . emerging evidence suggests that even minor serum creatinine changes are associated with higher in-patient 13–15mortality . over the past decades, aki has been the focus of extensive clinical and basic research. a major limitation has been the absence of a universally recognized denition of aki. despite signicant progress in understanding the biology and mechanism of aki in animal models, there has been limited translation of this knowledge into improved patient management and outcomes. acute kidney injury network (akin) is an independent collaborative network of experts selected by the participating societies to represent their eld of expertise as well as their sponsoring organization. akin seeks to promote global, interdisciplinary and intersocietal partnerships in order to ensure success in the area of aki and achieve the best results for patients with or at risk of aki. aims and objectives to study and analyze the etiology of aki and sepsis as a mortality indicator in aki patients in icu. sample size : 100 inclusion criteria : all patients admitted to icu with aki and those who developed aki after admission to icu. exclusion criteria : ÿ patients with pre-existing renal disease and with renal transplant. ÿ patients with abnormal kidney size and abnormal corticomedullary differentiation. results and discussion 100 patients have been analyzed in our research. there were 52 males and 48 females. the mean age was 59.5 years. in the sixth to eighth decade, the highest number of cases were reported. mehta et al., in her study analysed a sample population which had 59% males and 41% were females with 46mean of 59.5years. sepsis was found to be the leading cause of acute kidney injury in the current study (40%) as has been time and again proven by multiple studies in the past like muthusethupathi et 47al in chennai. this study has shown that among 40 patients with sepsis, 18 patients expired (p<0.001) and sepsis was hence found to be an indicator of higher mortality rates than those without sepsis. mortality due to septicemia was observed to be 75%. this was identical to the ndings of 48qutub ho, saeed ia in their three-year long prospective study (1996 to 1999) in which sepsis emerged as the leading cause of acute kidney injury and also a major contributor for mortality. they also stated that prevention of sepsis would improve the prognosis of patients who got admitted into icu due to any other cause. 49in another study conducted by agarwal et al at cmc vellore in 2004, similar observations were made in pediatric population vis-a-vis septicemia. it was found that mortality due to septicemia was 83% among icu patients who had acute kidney injury and was a major contributor to morbidity and mortality. figure 1 : proportion of cases with sepsis sepsis as a mortality indicator in acute kidney injury patients in icu original research paper dr . v. r. aditya chainulu junior resident, department of general medicine, sree balaji medical college and hospital, chennai x 29gjra global journal for research analysis general medicine sepsis is an extreme and dysregulated inammatory response to infection that is distant from the primary site of infection resulting in end-organ damage. appearance of acute kidney injury (aki) during sepsis raises patient morbidity, predicts higher death rates, has a signicant effect on functions of multiple organs, is associated with a prolonged duration of stay in the intensive care unit, and hence warrants appropriate healthcare resources. pathophysiology, diagnostic procedures and appropriate therapeutic interventions in sepsis are still highly debatable despite impressive advances in several medical elds. the overwhelmingly high mortality rate of sepsis is not reduced despite multiple immunomodulatory agents showing promise in preclinical studies. major obstacles to progress in understanding, early diagnosis, and implementing effective therapeutic modalities in sepsis-induced aki comprise minimal histopathological data, few animal models closely emulating human sepsis, and a relative lack of specialized diagnostic tools. here we analyse 100 icu patients who developed aki and sepsis as a major etiological factor as well as mortality indicator. abstract keywords : sepsis, acute kidney injury, mortality, intensive care unit, etiology. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. v. padma* professor, department of general medicine, sree balaji medical college and hospital, chennai *corresponding author dr. indhuja senior resident, department of general medicine, sree balaji medical college and hospital, chennai. 30 x gjra global journal for research analysis table 1 : outcome based analysis of sepsis references: 1. mehta rl, pascual mt, soroko s, savage br, himmelfarb j, ikizler ta, paganini ep, chertow gm, program to improve care in acute renal disease (picard. spectrum of acute renal failure in the intensive care unit: the picard experience. kidney international. 2004 oct 1;66(4):1613-21. 2. palevsky pm. epidemiology of acute renal failure: the tip of the iceberg. 3. ympa yp, sakr y, reinhart k, vincent jl. has mortality from acute renal fai lure decreased? a systematic review of the literature. the american journal of medicine. 2005 aug 1;118(8):827-32. 4. metnitz pg, krenn cg, steltzer h, lang t, ploder j, lenz k, le gall jr, druml w. effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. critical care medicine. 2002 sep 1;30(9):2051-8. 5. waikar ss, curhan gc, wald r, mccarthy ep, chertow gm. declining mortality in patients with acute renal failure, 1988 to 2002. journal of the american society of nephrology. 2006 apr 1;17(4):1143-50. 6. uchino s, kellum ja, bellomo r, doig gs, morimatsu h, morgera s, schetz m, tan i, bouman c,macedo e, gibney n. acute renal failure in critically ill patients: a multinational, multicenter study. jama. 2005 aug 17;294(7):813-8. 7. liangos o, wald r, o’bell jw, price l, pereira bj, jaber bl. epidemiology and outcomes of acute renal failure in hospitalized patients: a national survey clinical journal of the american society of nephrology. 2006 jan 1;1(1):43-51. 8. clermont g, acker cg, angus dc, sirio ca, pinsky mr, johnson jp. renal failure in the icu: comparison of the impact of acute renal failure and endstage renal disease on icu outcomes. kidney international. 2002 sep 1;62(3):986-96. 9. thakar cv, worley s, arrigain s, yared jp, paganini ep. inuence of renal dysfunction on mortality after cardiac surgery: modifying effect of preoperative renal function. kidney international. 2005 mar 1;67(3):1112-9. 10. druml w. long term prognosis of patients with acute renal failure: is intensive care worth it?. 11. liano f, junco e, madero r, pascual j, verde e. the spectrum of acute renal failure in the intensive care unit compared with that seen in other settings. kidney international -supplements. 1998 may 1(66):16-24. 12. mehta rl, pascual mt, soroko s, chertow gm, picard study group. diuretics, mortality, and nonrecovery of renal function in acute renal failure. jama. 2002 nov 27;288(20):2547-53. 13. chertow gm, burdick e, honour m, bonventre v, bates dw. acute kidney injury, mortality, length of stay, and costs in hospitalized patients. journal of the american society of nephrology. 2005 nov1;16(11):3365-70. 14. gruberg l, mintz gs, mehran r, dangas g, lansky aj, kent km, pichard ad, satler lf, leon mb. the prognostic implications of further renal function deterioration within 48 h of interventional coronary procedures in patients with pre-existent chronic renal insufciency. journal of the american college of cardiology. 2000 nov 1;36(5):1542-8. 15. lassnigg a, schmidlin d, mouhieddine m, bachmann lm, druml w, bauer p, hiesmayr m. minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. journal of the american society of nephrology. 2004 jun 1;15(6):1597-605. 16. qutub ho, saeed ia. acute renal failure in intensive care unit. saudi med j 2001;22:999-1003. 17. agarwal i, kirubakaran c, markandeyulu v. clinical prole and outcome of acute renal failure in south indian children. journal of the indian medical association. 2004 jul;102(7):353-4. 18. macedo e, malhotra r, bouchard j, wynn sk, mehta rl. oliguria is an early predictor of higher mortality in critically ill patients. kidney international. 2011 oct 1;80(7):760-7. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction despite advances in antenatal and intrapartum care, stillbirth 1 continues to be a major burden. currently, 98% of stillbirths 2 occur in low-to-middle-income countries. estimated proportion is 10% in developed regions and who estimated rate is 22 per 1000 total births. government of india has developed an indian newborn action plan which includes 3 efforts to reduce stillbirths to <10 per 1000 births by 2030. stillbirth is dened as (who) baby born with no signs of life at or after 28 weeks of gestation. risk factors are women with > 35 years of age, prolonged pregnancy, low socioeconomic status, smoking habit in pregnancy, women with certain medical conditions such as high blood pressure and diabetes, multifetal gestation like triplets or quadruplets. stillbirth at term in an otherwise low risk pregnancy devastates parents with its unexpectedness. a modest reduction in india's sbr would translate into thousands of lives saved. the indian government recognizes the need to improve pregnancy care and inst i tut ional del ivery among disadvantaged socioeconomic groups who have a higher risk of maternal and 4 fetal death. since 2005, the government has made several efforts including cash assistance and dedicated services through community health workers with a stronger focus in the 4 states with poor health and development indicators. objectives to study all the cases of stillbirths in last one year at tertiary care health center and to review its etiology, pregnancy complications & associated risk factors. materials & methods this is a retrospective observational study, conducted at a government medical college and hospital over a period of one year (november 2018 to november 2019). written informed consent from subjects was obtained for participation. women who delivered at our labour room with stillborn baby over the study period were included. antenatal history was recorded, clinical examination ndings, laboratory parameters, complications studied, obstetric managements as well as the managements of complications and fetal outcomes were recorded. results total cases of stillbirth were 102 out of 9624 total births during study period. stillbirth rate was 11 per 1000 total births. table 1: demographic prole of cases under study out of 102 cases 67% were >30 years of age, 57% were grandmultipara, 49 % were in between 36-42 weeks of gestation, 77% were from rural area and 59% belonged to lower socioeconomic group. table 2: associated risk factors for stillbirth understanding stillbirth: a retrospective study original research paper dr. gauri nagnath jagdale assistant professor, department of obstetrics &gynaecology, b.j.g.m.c pune. x 25gjra global journal for research analysis obstetrics & gynaecology introductionstillbirth is an important global health problem affecting over 7000 families every day and is associated with emotional, social & economic consequences. objectivesto study all the cases of stillbirths in last one year at tertiary care center in view of its etiology, pregnancy complications & associated risk factors. methodsretrospective observational study of all cases in last one year (nov. 2018 to nov. 2019) at tertiary care center. all cases are assessed in aspect of history, clinical ndings, laboratory parameters, complications and outcome. results: total cases of stillbirth were 102 out of 9624 total births during study period. stillbirth rate was 11 per 1000 total births. conclusion: targeting at risk population groups, recording all stillbirths and improving quality of health care provided can reduce the rate further. abstract keywords : stillbirth, complications, congenital anomalies. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. pradip w. sambarey* professor & head, department of obstetrics & gynaecology, b.j.g.m.c pune. *corresponding author demographic variable frequency percentage age <20 years 13 13 20-30 20 20 >30 years 69 67 parity primipara 12 12 multipara 32 31 grandmultipara 58 57 gestational age(weeks) 28-32 12 12 32-36 40 39 36-42 50 49 place of residence urban 23 23 rural 79 77 socioeconomic status upper 12 12 middle 30 29 lower 60 59 associated risk factor frequency percentage number of anc visits 4 or more 05 05 less than 4 58 57 missing 39 38 timing of rst anc visit < 3 months 38 37 3 months or later 64 63 place of delivery institution 31 30 home 71 70 sex of baby female 43 42 male 59 58 26 x gjra global journal for research analysis stillbirth rate was 57% in women with less than 4 anc visits and women who visits health care facility rst time in rdpregnancy after 3 month of gestation have stillbirth rate of 63%. home delivery is an important factor contributing for 70% of total stillbirths. out of all stillborn babies 58% were male babies. there was higher rate of stillbirth in spontaneous vaginal deliveries (74%) than cesarean section (18%). table 3: complications in pregnancy associated with stillbirth preeclampsia, eclampsia & other hypertensive disorders in pregnancy contribute for 21%, child birth complications for 18% of total stillbirths. out of total stillborn babies 11% were having congenital anomalies. maternal diabetes contribute for 10% of total stillbirths and remaining 10% were due to abnormal fetal presentation and position. discussion the overall rate of stillbirth was found to be 11 per 1000 total births. the above ndings show the impact of inequality on stillbirth, as women in the most deprived groups were at highest risk. this was identied across a number of variables which capture different aspects of deprivation; for example, poorer women, those with little education, those living in rural areas were at increased risk of stillbirth compared to more afuent and advantaged women. pregnancy complications, including anemia, eclampsia, other hypertensive disorders, antepartum hemorrhage, abnormal fetal position and obstructed labour signicantly increased the risk of stillbirth. we found a signicant disparity in the risk of stillbirth by socioeconomic status which is consistent with previous research. a systematic review of studies from developing countries showed that low socioeconomic status was signicantly associated with stillbirth with a population 5 attributable fraction ranging between 2% and 75%. maternal education and employment may act through promoting high selfesteem and empowering women to make decisions about 6 healthcare utilization. our ndings related to timing and number of anc visits conforms to the results of other studies. improving the quality of pregnancy care with specic measures to prevent stillbirth are important in addition to increasing coverage of antenatal care. male sex of fetus to be 7 associated with higher risk of stillbirth. abnormal fetal presentation and obstructed labour operate through similar 8 mechanisms causing fetal hypoxia and stillbirth. however, a stillbirth could be prevented if these complications are detected timely and managed appropriately. conclusion our study showed that targeting at risk population groups, recording all stillbirths and improving quality of health care provided can reduce the rate further. improving uptake of anc and timely identication and effective management of maternal and fetal complications could reduce preventable stillbirths. asha's and anganwadi workers could play an important role in timely identication of danger signs through frequent interactions with pregnant women. progress towards goals of poverty eradication and female education could help to reduce stillbirths. limitations there may be possibility of misclassication of stillbirth as miscarriage/ abortion or neonatal death as stillbirth. conflict of interest-nil funding source-nil references 1. flenady v, wojcieszek am, middleton p, ellwood d , erwich jj, coory m, et al. stillbirth: recall to action in high income countries. lancet 2016; 387:691-702. 2. lawn je, blencowe h, waiswa p, et al. stillbirths: rates, risk factors and acceleration towards 2030. lancet 2016; 387: 587-603. 3. sharma d. india newborn action plan. j res med sci 2015; 2:58. 4. ministry of health and family welfare (mohfw) gol. national health portal: janani suraksha yojana (jsy) new delhi: national institute of health and family welfare (nihfw), mohfw. (cited 18 dec 2018). 5. mcclure em, saleem s, pasha o, et al. stillbirth in developing countries: a review of causes, risk factors and prevention strategies. j matern fetal neonatal med 2 009; 22:183-90. 6. pincus t, callahan lf. associations of low formal education and poor health status: behavioral, in addition to demographic and medical explanations. j clin epidemiol 1994; 47: 355-61. 7. mondal d, galloway ts, bailey tc, et al. elevated risk of stillbirth in males: systematic review and metaanalysis of more than 30 million births. bmc med 2014; 12:220. 8. lawn j, shibuya k, stein c. no cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths. bull world health organ 2005; 83: 409-17. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra mode of delivery spontaneous vaginal 76 74 assisted vaginal 08 08 cesarean section 18 18 complications in pregnancy prevalence percentage preeclampsia & other hypertensive disorders in pregnancy 22 21 child birth complications 18 18 fetal growth restriction 31 30 congenital anomalies of baby 11 11 maternal diabetes 10 10 abnormal fetal presentation and position 10 10 introduction the falciform ligament, which is located on the left of the midline of the abdomen, runs through the anterior wall of the abdomen and diaphragm. it is one of the anatomical structures which attaches the liver to the remnants of the umbilical veins. the length of the falciform ligament may vary individually and it contains the ligamentum teres and obliterated umbilical vein. pathologic conditions of the falciform ligament are extremely rare; one particularly rare condition is the torsion of a fatty appendage of the falciform ligament leading to fat infarction. this type of torsion and/or infarction occurs more commonly in the greater omentum or epiploic appendages. the condition causes abdominal pain and associated raised inammatory markers, and it can be identied on ultrasound and ct scan. in this paper, we present a case that underwent urgent surgery due to acute abdomen, which was secondary to primary falciform ligament torsion. case presentation a 56-year-old female patient was admitted with the complaints of pain in the right upper quadrant and the epigastric region. the patient's history revealed an abdominal pain for past 2 days with an increasing severity. patient is a known hypertensive on treatment. physical examination suggested a systolic blood pressure of 110/70� mmhg, pulse rate of 108 bpm. the patient was afebrile and was not jaundiced. guarding & tenderness was present in the right hypochondrium & epigastric region of abdomen, picture that of an acute abdomen. laboratory test results showed a leukocyte count of 10,500/mm3 (4000–10,000/mm3). serum chemistry tests and electrolyte measurements did not indicate any pathology related to acute abdomen. abdominal ultrasonography did not demonstrated any abnormality like free uid or any gall bladder pathology. abdominal computed tomography showed oval shaped fat dense structure lying adjacent to the falciform ligament with focal inammatory changes in the local fat (figure 1). it has an enhancing margin with mild stranding of the fat around it, features suggestive of torsion of falciform ligament with focal fat necrosis. based on these ndings, the patient was immediately scheduled for laparotomy which revealed torsion of falciform ligament around its axis (gure 2), a focal necrotic patch with early gangrenous changes noted in the falciform ligament towards the abdominal wall with minimal omental adhesions, no free uid noted. all other organs were found to be normal. the falciform ligament was resected. the histopathological examination of surgical specimens revealed congested capillaries and necrosis seen compatible with torsion of falciform ligament. the postoperative period was uneventful. patient was discharged on the seventh postoperative day and also after 6-month follow-up, no complaints were found out. figure  1cect abdomen figure 2 torsion of falciform ligament around its axis discussion the term “intra-abdominal focal fat infarction”, or iffi, has been used to describe focal fatty tissue necrosis or in various anatomical locations. iffi are most often due to torsion and/or infarction of the greater omentum or epiploic appendages but have also been reported to involve the lesser omentum and the appendage of the hepatic falciform ligament which is very [1]rare. the falciform ligament is a double fold of peritoneum that torsion of a fatty fringe of the falciform ligament, a rare cause of acute abdomen: a case report original research paper dr. magesh kumar. j* assistant professor, department of general surgery, sree balaji medical college & hospital, bharath university, chromepet, chennai *corresponding author x 75gjra global journal for research analysis general surgery the falciform ligament is a double fold of peritoneum that marks the anatomical division between the right and left lobes of the liver. pathologic conditions of the falciform ligament are extremely rare; one particularly rare condition is the torsion of a fatty appendage of the falciform ligament leading to fat infarction. in this article, we present a case of an isolated falciform ligament torsion, a rare primary pathology of the falciform ligament. a 56-year-old female patient was admitted with the complaints of abdominal pain for 3 days. imaging studies demonstrated torsion of facliform ligament. exploratory laparotomy revealed a torsion and necrotic mass of the falciform ligament. abstract keywords : falciform ligament; acute abdomen; torsion p. suresh babu associate professor sree balaji medical college & hospital, bharath university, chromepet, chennai – 600044 k.s. ravishankar professor & hod, department of general surgery,sree balaji medical college & hospital, bharath university, chromepet, chennai – 600044 volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 76 x gjra global journal for research analysis anatomically divides the liver into the right and left lobes. it extends from the superior surface of the liver to the inferior surface of the diaphragm and to the posterior surface of the anterior abdominal wall. it contains the ligamentum teres, paraumbilical veins, and variable amount of extra peritoneal fat. [3] it is extremely rare to see pathologic conditions of the falciform ligament which include ligament cysts, tumours, abnormal vascularisation due to portal hypertension, iatrogenic internal hernia of bowel loops through the ligament, and gangrene related to acute necrotising pancreatitis, along with torsion of the falciform ligament as described in this case. additionally, the most recognized abnormalities of the falciform ligament are congenital pathologies including derivation and partial ligament defects [3][4][5]. both ultrasound and ct can be used to visualise a torted fatty appendage of the falciform ligament. it is not possible to use plain lm radiography to diagnose this condition, as the falciform ligament is only evident on abdominal plain lms in the setting of pneumoperitoneum. in that situation, the “falciform ligament sign” is produced, which consists of gas outlining the falciform ligament. on ultrasound, a torted fatty appendage of the falciform ligament appears as a hyperechoic, noncompressible, slightly heterogeneous mass in the area of maximal abdominal tenderness. further, on real-time sonography, the lesion does not move with underlying intraperitoneal structures while breathing, which indicates its extra peritoneal position. on ct, a torted fatty appendage of the falciform ligament appears as an area with increased fat density, associated with surrounding inammatory changes in the adjacent fat planes [1]. to our knowledge, there has been no previous description of the appearance of a twisted infarcted fatty appendage of the falciform ligament on mri. however, mri would be a valid alternative form of imaging to diagnose this condition, because it would distinguish adipose tissue from oedema or bleeding, it avoids radiation exposure particularly in the case of a paediatric patient, and it avoids contrast medium administration and its associated nephrotoxicity. coulier reported that the contrast-enhanced abdominal computed tomography is the gold standard for diagnosis of intraperitoneal fat necrosis as well as the follow-up of the disease. in recent years, the number of patients faced with the intraperitoneal fat tissue necrosis including the falciform ligament has been increasing parallel to the development in [3][4][5]the eld of radiology . the primary falciform ligament torsion & necrosis is often diagnosed during surgery. coulier proposed that patients diagnosed with falciform ligament necrosis could be treated medically after excluding other disorders with a detailed history, whereas most writers still put forward to surgical treatment in patients with falciform ligament necrosis. in such patients, laparoscopy is another treatment option. wider uses of diagnostic laparoscopy in acute abdomen have also picked up many such cases. but only a few cases of falciform ligament infarction have been reported. laparoscopy or laparotomy is indicated when the diagnosis is not clear or [2][4][5] when there is no improvement on conservative measures. conclusion in conclusion, falciform ligament torsion is an extremely rare cause of acute abdomen. always a surgeon should have this diagnosis in mind and conrm it with a radiological imaging. if conservative management fails, surgery is the only treatment of choice. laparoscopy or laparotomy can be performed according to the preference and experience of the surgeon as well as the overall condition of the patient. conflict of interests the authors declare that there is no conict of interests regarding the publication of this paper. references 1. b. coulier, “contribution of us and ct for diagnosis of intraperitoneal focal fa t in fa rc t ion ( iff i ) : a p ic to r ia l rev iew, ” journa l be lge de radiologie—belgisch tijdschrift voor radiologie, vol. 93, no. 4, pp. 171–185, 2010. 2. ozkececı z. t., ozsoy m., celep b., bal a., polat c. a rare cause of acute abdomen: an isolated falciform ligament necrosis. case reports in emergency medicine. 2014;2014:3. doi: 10.1155/2014/570751.570751 3. li x. p., xu d. c., tan h. y., li c. l. anatomical study on the morphology and blood supply of the falciform ligament and its clinical signicance. surgical and radiologic anatomy. 2004;26(2):106–109. doi: 10.1007/s00276-003-01840. 4. lloyd t. primary torsion of the falciform ligament: computed tomography and ultrasound ndings. australasian radiology. 5. webber c. e., jr., glanges e., crenshaw c. a. falciform ligament, a possible tw is t? a rch ives o f surger y. 1977 ;112 (10 , a r t i c le 1264 ) do i : 10.1001/archsurg.1977.01370100118027 volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra review of literature the increased cardiovascular risk associated with esrd has been well established, and estimated cardiovascular mortality rates are ten to one hundred fold higher among dialysis patients than ageand sex-matched individuals in the general population. the cardiovascular risk associated with renal impairment increases earlier in the course of renal disease progression than was initially hypothesized. more specically, there are evidences that even mild to moderate degrees of renal impairment are associated with increased cardiovascular risk. many traditional cardiovascular risk factors, documented in the general population, contribute to cardiovascular risk in ckd patients. in fact, many framingham risk factors are more prevalent among (3)individuals with ckd than those with normal kidney function. hypertension is cardiovascular risk factor which contributes to the cardiovascular risk associated with ckd. szcech and colleagues demonstrated that patients with hypertension are susceptible to increased risk for new or recurrent (7) cardiovascular events in individuals with stage 2–3 ckd. systolic blood pressure is more strongly associated with cardiovascular death in esrd patients on dialysis than either pulse or diastolic pressure. however, a u-shaped relationship found between systolic blood pressure and mortality in which high or low systolic blood pressures appear to be associated with increased mortality rates in stage 5 ckd patients. the presence of left ventricular hypertrophy (lvh) is also a cardiovascular risk determinant in ckd patients. anemia and hypertension are two ckd associated complications hypothesized to play a signicant role in the development of (8)lvh. in a cohort of 2,423 patients with stage 3–4 ckd, investigators noted an independent risk of lvh for the composite endpoint of myocardial infarction and fatal coronary heart disease. patients were followed over a period of 102 months. in adjusted analysis, lvh was associated with increased risk for composite and cardiac outcomes hazard ratio (hr 1.67; 95% ci 1.34 to 2. 07).addictions like tobacco use is also associated with increased mortality and incidence of (24)heart failure among patients with stage 5 ckd. results in our study of esrd patients out of 140 patients 68 (48.6%) were male and 72 (51.4%) were female. in our study maximum patient were between 41 to 50 years of age 52 (37%) out of 140. table no.1 distribution patients according to the age figure no.1 distribution patients according to the age in our study out of 140 patients lvh was present 64(45.7%) patients, 2 decho was normal in 60(42.9%),reduced ejection fraction in 4(2.9%), valvular heart disease in 4(2.9%). table 2: findings on 2d echo figure no.2: percentage of 2d echo ndings in esrd echocardiographic findings in patients with end stage renal disease undergoing hemodialysis original research paper shilpa gadade junior resident, department of general medicine, d.y. patil medical college and hospital, navi mumbai general medicine introduction: chronic kidney disease (ckd) has emerged as a major public health problem .most (1)common causes of ckd are diabetes and hypertension. hypertension is cause as well as effect of ckd.ckd is risk for adverse cardiovascular events .criteria for ckd (either of the following present for >3 months) is as follows: markers of kidney damage (one or more) albuminuria (aer >or equal to30 mg/24 hours; acr >or equal to30 mg/g >or equal (2)to 3 mg/mmol]) aims and objectives: to asses echocardiographic changes in patients of end stage renal disease undergoing hemo dialysis materials and methods: this prospective observational study was conducted in department of general medicine, d.y patil hospital, nerul, navi mumbai. the study was started after the approval of institutional ethics committee. a written signed informed consent was taken prior to enrolling the subjects in the study. a total of 140 patients presenting with symptoms of esrd on hemodialysis was taken. detailed history and through examination was done. abstract keywords : esrd (end stage renal disese)/echocardiography/lvh (left ventricular hypertrophy volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra smita patil* professor, department of general medicine ,d.y. patil medical college and hospital, navi mumbai *corresponding author age group (years) number of patients percentage 21 to 30 20 14.3 31 to 40 28 20.0 41 to 50 52 37.1 51 to 60 28 20.0 61 to 70 8 5.7 above 70 4 2.9 total 140 100.0 findings no. of patients percentage lvh 64 45.7 normal 60 42.9 minimal pe ,lvh 8 5.7 lvh,ef 35% 4 2.9 severe mr ef 35% 4 2.9 total 140 100.0 30 x gjra global journal for research analysis discussion in our study of esrd patients out of 140 patients 68 (48.6%) were male and 72 (51.4%) were female in a similar study by rajapurkar et al. 2012 on rst report of indian ckd registry ,the mean age was 50.1 ± 14.6 years, with m:f ratio of 70:30. patients from north zone were younger and those from the (4)east zone older. comparing to this study in our study percentage of female patients more than that of male . in our study maximum patient were between 41 to 50 years of age 52 (37%) out of 140. study by p.p. verma et al 2015 published from a rural belt of karnataka. the population had a mean age of 39.88 ± 15.87 years. study by agraval et al mean age was 42+/-13, singhal et al. was 45 +/-15 .the age group of our study was more or less similar to that of agraval et (5)al study. in our study out of 140 patients lvh was present 64(45.7%) patients, 2decho was normal in 60(42.9%),reduced ejection fraction in 4(2.9%), valvular heart disease in 4(2.9%). dhamija jp, saxena n, et al in their study out of 35 esrd patients, echocardiography revealed lv dilatation and dias tolic dysfunction in 18 patients (51.2%) , lv hypertrophy in 17 patients (48%), systolic dysfunction and pericardial effusion in (6) 10 patients (28.57%) and 6 patients (17.14%) respectively. the percentage of lvh more or less similar to our study .in their study hypertensive patients were 27 of 35 esrd patients, 13 out of 27 had higher prevalence of lvh (51.85%). systolic dysfunction and rwma was absent in normotensive group. concluding that lv diastolic dysfunction and hypertrophy (6)were most common echocardiographic ndings. conclusion esrd causes structural and functional abnormality contri buting to major cardiovascular events.most common nding was lvh. hypertension and anemia are the other risk factor to aggravate this condition .hence lvh is having prognostic importance detects early changes in cardiac parameters. screening of patients with esrd adds a therapeutic as well as prognostic importance. references: 1. k/doqi clinical practice guidelines for chronic kidney disease: evaluation, classication, and stratication.national kidney foundation.am j kidney dis. 2002 feb; 39(2 suppl 1):s1-266.) 2. denition and classication of ckd. kidney int suppl (2011). 2013;3(1):19–62. doi:10.1038/kisup.2012.64 3. prim care. 2008 jun; 35(2): 329–vii.robert thomasabbas kansojohn r. sedor“chronic kidney disease and its complications.” primary care vol. 35,2 (2008): 329-44, vii. 4. rajapurkar, m.m., john, g.t., kirpalani, a.l. et al. what do we know about chronic kidney disease in india: rst report of the indian ckd registry. bmc nephrol 13, 10 (2012) doi:10.1186/1471-2369-13-1. 5. varma pp. prevalence of chronic kidney disease in india where are we heading?. indian j nephrol. 2015;25(3):133–135. 6. dhamija jp, saxena n, saxena s. evaluation of 2-d echo ndings in chronic kidney disease: case study of 35 end stage renal disease patients. iaim, 2016; 3(9): 61-65. 7. muntner p, he j, astor bc, folsom ar, coresh j j am soc nephrol. 2005 feb; 16(2):529-38. 8. levin a, singer j, thompson cr, ross h, lewis m am j kidney dis. 1996 mar; 27(3):347-54. 9. chronic kidney disease in india: challenges and solutions.agarwal sk1, srivastava rk.) volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 31gjra global journal for research analysis introduction chronic kidney disease (ckd) worldwide health problem causing progressive decline in renal function. higher prevalence of ckd is due to obesity, hypertension diabetes etc. on ultrasonography, cortical echogenicity is also increased with progression of disease, and is due to interstitial inammation, oedema, sclerosis or brosis. previous studies have suggested that progressive decrease in renal length and cortical thickness could predict possibility of renal failure later 1in course of disease . the resistive index (rri) is commonly used as an index of intrarenal arterial resistance caused by various intrarenal pathologies. rri increases in various kidney diseases including ckd. some previous studies have shown the associations of ri with renal function and patient prognosis. therefore, we planned to study the relationship between ultrasonographic renal parameters and renal impairment in patients with chronic kidney disease. aims and objectives to assess the role of renal resistive index, renal cortical thickness, renal length, and cortical echogenicity in ckd patient. material and method it was hospital based cross-sectional study conducted in department of radiodiagnosis, mgm medical college, indore, after getting approval from institutional scientic review board. a total of 86 patients with ckd, age more than 18 years were undergone ultrasonographic examination for kidney evaluation in b-mode grey scale using 2.5 to 5 mhz transducer after taking written consent. bipolar renal length, cortical thickness and renal resistive index (rri) were measured. documentation of cortical echogenicity was done by comparing with liver echogenicity. a detailed clinical history, serum creatinine and egfr using cockroft-gualt equation were recorded. exclusion criteria: congenital renal diseases, acute kidney disease, renal malignancy, traumatic injury; and unwilling patients to consent for study were excluded. appropriate statistical tests were applied for renal cortical thickness, renal length, cortical echogenicity, renal resistive index and egfr values. pearson correlation analysis was done between renal length and renal cortical thickness measurements against serum creatinine and egfr. p-values of <0.05 was considered to be statistically signicant. results & discussion out of total 86 ckd patients, 48 were male and 38 were females. in our study, age range was 18-82 year, with mean age 53.11 years. common age group was 45-55 years (40%). the mean serum creatinine was 4.02mg/dl. the mean egfr was 43.27 ml/min/1.73m2. these results were correlated with 2the studies done by siddappa jk et al in 2013 . the mean bipolar renal length in ckd patients was 8.12cm. the mean renal cortical thickness in ckd patients was 6.25 mm (table 11) . 78 out of 86 patients with ckd had increased cortical echogenicity. majority of them had grade 2 cortical echogenicity (36). 48 patient out of 86 patients had maintained corticomedullary differentiation, 29 patients had poorly maintained cmd and 9 patients had lost cmd on ultrasonography. the results were in concordance with study 4conducted by singh a et al in 2016 . in our study, serum creatinine was signicantly higher in higher grades of echogenicity (p< 0.01) and mean egfr was also signicantly decreased with increasing grades of echogenicity (table 2). these ndings were consistent with the 2ndings of siddappa jk et al (2013) . in our study, bipolar renal length and cortical thickness were decreased signicantly with increasing grades of cortical echogenicity in ckd patients (p<0.01) (table 2). our results 5were in accordance with study by ahmed s et al (2019) . the mean renal resistive index (rri) was 0.92 in our study. it was signicantly higher in higher grades of increased cortical echogenicity (p=0.024) and also in advanced stages of ckd (p<0.01) (table 2). thus rri had increased with progression of disease and it was well correlated with renal function (table 3 & figure 3). our ndings were in accordance with study done 9by hanamura k et al 2012 . role of renal parameters in assessment of renal impairment in ckd patients original research paper dr alka agrawal professor & head of department, department of radiodiagnosis, mgm medical college & m y hospital, indore. radiodiagnosis aim & objectives: to study the role ultrasonographic renal parameters to assess renal impairment in ckd patients. method: total 86 patients with ckd were undergone ultrasonographic examination for evaluation kidneys. renal length, cortical thickness, segmental artery doppler and cortical echogenicity were documented on b-mode gray scale using 2-5 mhz probe. results: 2 mean renal length was 8.12cm, mean cortical thickness was 6.25mm and mean egfr was 43.27 ml/min/1.73m . serumcreatinine showed negative correlation with cortical thickness and renal length. egfr showed positive correlation with cortical thickness and renal length. cortical echogenicity positively correlated with serum creatinine (r=0.7102, p<0.01) and negatively with renal function (r=-0.4681, p<0.01). rri was higher in advanced stages of ckd. conclusion: cortical thickness and cortical echogenicity showed signicant correlation with serum creatinine and renal function. rri can be used as marker in ckd and to assess the risk of adverse renal outcome in ckd. abstract keywords : ckd, cortical thickness, renal length, cortical echogenicity, serum creatinine and egfr, rri. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr dharmendra singh thakur pg resident, department of radiodiagnosis, mgm medical college & m.y. hospital, indore. dr amit shankhwar* associate professor, department of radiodiagnosis, mgm medical college & m.y. hospital, indore. * corresponding author 88 x gjra global journal for research analysis in our study, serum creatinine showed signicant negative correlation with cortical thickness (r=-0.6504, p<0.01), renal length (r=-0.3745, p<0.05) and cortical echogenicity (r=0.7102, p<0.01). the renal function (egfr) was positively correlated with cortical thickness (r=0.5781, p<0.01), renal length (r=0.3248, p<0.01) and negatively with cortical echogenicity (r=-0.4681, p<0.01). thus, in our study, cortical thickness was more strongly related to serum creatinine and egfr (table 3). these ndings were in concordance with 3results of yamashita sr et al (2015) . this correlation between serum creatinine and egfr with cortical echogenicity can be explained by the fact that echogenicity of kidneys was due to glomerular sclerosis, tubular atrophy interstitial brosis and 6inammation . these ndings, on biopsy, were clinically associated with decreased renal function thereby decreasing egfr and higher serum creatinine level. these ndings were 7further supported by moghazi s et al (2005) and gareeballah 8et al (2015) . table 1: mean values of renal parameters in ckd patients: table 2: comparison of various parameters according to grades of cortical echogenicity in ckd patients: table 3: statistical correlation of serum creatinine and egfr with renal parameters in ckd patients: figure 1: scatter plot showing relationship between cortical thickness and serum creatinine: figure 2: scatter plot showing relationship between renal length and serum creatinine: figure 3: scatter plot showing relationship between egfr and resistive index. conclusion finally, we conclude that, ultrasonographic renal parameters such as renal cortical thickness, renal length and cortical echogenicity were well correlated with serum creatinine and renal function (egfr) in ckd patients. cortical thickness and cortical echogenicity had shown strong correlation with serum creatinine and renal function. these parameters can be used to assess the status of renal function and for follow-up to predict the progression of disease over the time in patients with ckd. rri was signicantly higher in ckd patients and was more in advanced stages of ckd. therefore, it can be used as marker in ckd and as a risk factors for adverse renal outcome in ckd. references 1. beland md, walle nl, machan jt, et al. renal cortical thickness measured at ultrasound: is it better than renal length as an indicator of renal function in chronic kidney disease? ajr am j roentgenol. 2010; 195:w146–9 2. siddappa jk, singla s, al ameen m, rakshith sc, kumar n. correlation of ultrasonographic parameters with serum creatinine in chronic kidney disease. j clin imaging sci 2013;3:28 3. yamashita sr, von atzingen ac, iared w, bezerra asa, ammirati al, canziani mef, d’ippolito g. value of renal cortical thickness as a predictor of renal function impairment in chronic renal disease patients. radiol bras. 2015 jan/fev;48(1):12–16. 4. singh a, gupta k, chander r, et al. sonographic grading of renal cortical echogenicity and raised serum creatinine in patients with chronic kidney disease. j. evolution med. dent. sci. 2016;5(38):2279-2286, doi: 10.14260/jemds/2016/530. 5. ahmed s, bughio s, hassan m, et al. (march 12, 2019) role of ultrasound in the diagnosis of chronic kidney disease and its correlation with serum creatinine level. cureus 11(3): e4241. doi 10.7759/cureus.4241 6. roseneld at, siegel nj. renal parenchymal disease: histopathologic sonographic correlation. am j roentgenol 1981;137(4):793-8 7. moghazi s, jones e, schroepple j, et al. correlation of renal histopathology with sonographic ndings. kidney int 2005;67(4):1515-20. 8. gareeballah, a., gameraddin, m., mustafa, h., alshabi, s., alagab, f.e., tamboul, j. and salih, s. sonographic findings in renal parenchymal diseases at sudanese. open journal of radiology, (2015); 5, 243-249. 9. hanamura k, tojo a, kinugasa s, asaba k, and fujita t. the resistive index is a marker of renal function, pathology, prognosis, and responsiveness to steroid therapy in chronic kidney disease patients. international journal of nephrology volume 2012, article id 139565, 9 pages doi:10.1155/2012/139565. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra parameters mean 1.serum creatinine (mg/dl) 4.02 2.egfr (ml/min/1.73m2) 43.27 3.cortical thickness (mm) 6.25 4.renal length (cm) 8.12 5.renal resistive index (rri) 0.92 serum creatinine (mg/dl) egfr (ml/min/1.73 m2) renal length (cm) cortical thickness (mm) rri echogenicity mean mean mean mean grade 0 1.45 66.41 12.54 11.86 0.73 grade 1 1.96 45.78 10.78 9.75 0.81 grade 2 3.24 28.75 8.81 7.31 0.89 grade 3 4.87 21.63 7.27 5.68 0.93 grade 4 6.91 15.65 6.68 3.46 0.98 p-value <0.01 <0.01 <0.05 <0.01 0.024 renal parameters serum creatinine egfr correlation (r) p-value correlation (r) p-value cortical thickness -0.6504 <0.01 0.5781 <0.01 renal length 0.3745 <0.01 0.3248 <0.01 echogenicity 0.7102 <0.01 -0.4681 <0.01 rri 0.4321 0.038 -0.5017 0.041 x 89gjra global journal for research analysis introducton development of agricultural sector is important but more emphasis should be placed on the development of industrial sector as it is only this sector which can help in solving numerous problems confronting our economy. rural industry occupies an important position in the industrial structure of our country. in a country like india, wherein on one hand there is the acute problem of unemployment and on the other hand scarcity of capital, it is only the rural industries which are best suited under these conditions. developing countries are characterized as labor abundant and capital scarce. india is no exception to this phenomenon and is undergoing an acute unemployment syndrome. large scale industries with their stress on latest technical know-how requiring enormous capital investment cannot absorb all the growing number of unemployed masses in the country. on the other hand, village and cottage crafts which employ labor intensive techniques of manufacture can provide immense employment opportunities to the masses. with any given investment, employment possibilities would be many times greater in rural industries than those in large scale industrial sector. developing economies have to determine the priority of their scarce capital allocation among various activities such as the setting up of consumer goods industries, basic industries, transportation and power. basic industries, transportation and power are highly capital intensive and there is no alternative to them. in the case of consumer goods industries , these economies can make a choice between small industries of a capital sparing nature and large industries which are generally capital intensive. underemployment is a serious problem in agrarian economies. agriculture does not provide full employment to the rural population. this keeps majority of them in the mire of poverty. the nation is also at a loss as it is not able to make use of the available manpower resources. rural industries make use of local know-how. but large scale industries generally necessitate the import of machinery, materials and technical guidance from advanced countries. this results in the outow or precious foreign exchange. the tight foreign exchange position experienced by the developing nations goad them to turn towards village, cottage and small industries. a decentralized set up in the industrial development of a nation ensures more or less equitable distribution of national cake and thus preserves the economic equality among all. in view of the above mentioned features of developing economies like india, giving weightage to rural industries for their industrial development will be appropriate. the government of india has been taking a number of measures to promote and develop the village and cottage industries since independence. i t had established all india organizations to advise the government on measures to be taken for their proper development. steps were also initiated to protect them from competition by the large organized sector. in order to ensure the ow of nance to artisans, schematic lending like differential rate of interest scheme, composite loan scheme etc. were formulated and are being implemented. for upgrading the quality and quantity of goods produced, the government had helped the formation of a number of research institutes. to improve the skill of artisans, training programs were being held frequently. industries such as coir, handloom and handicrafts belonging to village and cottage industries sector in tamilnadu have a hoary past. local availability of the skill and raw materials were the factors responsible for their development in the state. the constitution of khadi and village industries board speeded up the setting up of new ventures in many other areas of this sector. in addition to this, various other institutions were established in the state for village and cottage industries to enable the government implement its programs of development. regulatory measures have been initiated to ensure availability of raw materials to these industries. the state level organizations were also concerned with the modernizing of the techniques of manufacture. with the object of liberating artisans from the clutches of middleman in marketing, the government had helped the formation of a number of retail outlets. today, the village and cottage crafts along with modern small scale industries account for a major portion of the industrial employment in tamilnadu. the indian concept the concept as it has developed in india also shows confusion and lack clarity. before independence, the term small scale industry was meant to denote the village based and / urban cottage industry, manufacturing handicrafts. in the industrial policy resolution 1948 and the document of the first five year plan, the only criterion to dene small scale was their nonregistration under the factory act. thus ssi meant all units which used power and employed less than 10 workers / without power and employed up to 20 workers. later on, during the first five year plan the distinction between ssi and village industry was made. from then on, capital, employment and use of power criteria were adopted. rural industries the terms "village industries" and "cottage industries" are used interchangeably and sometimes simultaneously to mean traditional industries by the present day planners and administrators. they do not provide any clear cut denition for these terms. the national planning committee (1948) has dened cottage industry as ‗‗an enterprise or series of operations carried on by a workman skilled in the craft on his own responsibility, the nished product of which he markets himself. he works in his own home with his own tools and materials and provides his own labour and at most the labour of such members of his an overview of rural and village industries original research paper dr. a. venkatachalam principal gtn arts college dindigul. commerce keywords : k. sangeetha* ph.d., research scholar pg & research centre department of commerce gtn arts college, dindigul.*corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 42 x gjra global journal for research analysis family as are able to assist. the workers work mostly by hand and personal skill with little or no aid from modern power driven machinery and in accordance with the traditional technique. such supplementary energy as is provided by animal power may add to the economy and efciency of the industry. he works, nally, for a market in the immediate neighborhood that is to say in response to known demand with reference to quality as well as quantity.” the denition is very comprehensive and it points out the characteristics of cottage industries such as limitation of employment to family members, the place of work as the cottage of artisan, avoidance of power operated equipment and production for local markets only. village industries have not been dened in a comprehensive manner. the planning commission has dened them as "those concerned with the processing of local raw materials for local markets and with simple techniques". all these are characteristics are common to the cottage industries as well. the only difference is on the stipulation of the place of work by the artisan in the case of cottage industries which of course has been changed now. the khadi and village industries commission or the act that resulted in the creation of the kvic had not tried to give a comprehensive denition for village industries. instead, it lists a few industries under its jurisdiction and treated them as village industries. according to section 2(h) of the khadi and village industries commission act of 1956, village industries mean all or any of the industries specied in its schedule. the act imposed certain restrictions on the industries under its purview such as avoidance of power, utilization of village raw materials, location in rural areas etc. in fact, these industries can belong to the category of cottage industries also. with the object of enlarging the area of operation of village industries and permitting the use of power-operated equipment, the kvic has put forward a new denition for village industries in response to khadi and village industries review committee report 1987. as per the new denition, village industry meant any industry located in a rural area having a population which does not exceed ten thousand, which produces any goods or renders any service with or without the use of power and in which the per capita xed capital investment does not exceed fteen thousand rupees. according to the new denition, village industries under the purview of kvic are no longer conned to traditional industries category. khadi and village industries commission the gandhian concept of decentralized structure of the kvic envisioned a structure of decentralized production processes with small units widely scattered and dispersed over large areas. kvic as an organization had emerged over the years based on production and other processes dispersed over small villages with marketing of khadi largely carried out in urban areas. there are eleven standing committees, which assist the commission in the formulation of policies and problems relating to different aspects of implementation. in other words, the commission is assisted by the following standing committees: 1) certication committee 2) standing finance committee 3) cotton purchase advisory committee 4) training committee 5) standardization of khadi and saranjam committee 6) khadi experiments grants committee 7) government supplies committee 8) cooperative advisory committee support organizations most of the institutions have a feeling that the support organizations such as the kvic, kvibs and dics, over the years, had developed more as a bureaucratic organization than a facilitating agency of the khadi programme there seems to be no linkages between supporting organisations and institutions regarding marketing, research and development ® &d), training and exports. it is reported that the institutions had misutilised the supporting organisations only as a disbursement instrument of loans, grants and rebates. there had been no effort on the part of the institutions to pressurize the kvic to cater to their needs as and when required. the dissemination of the information regarding r & d activities and exports, by the support organisations was also lacking. the same could have been done by the large institutions through their state federations for expansion of khadi with the changing times. but this was not implemented. conclusion development of these rural industries is the responsibility of the state governments under the framework of the indian constitution. therefore, the state governments along with the central government had taken steps for developing rural industries on sound lines. references: 1. reddy j.p. ―problems and development of small scale industries in indiaǁ asia publishing house, p.122 2. mukesh gulati, ―the changing complexion of small industry in indiaǁ liberal times, february 1994. 3. www.kvic.com volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 43gjra global journal for research analysis introduction pregnancy is a unique, exciting and often joyous time in a woman's life, as it highlights the woman's amazing creative and nurturing powers while providing a bridge to the future. from 1990 to 2015, the global maternal mortality ratio declined by 44 % – from 385 deaths to 216 deaths per 100,000 2 live births, according to un inter-agency estimates. in india it was reported that the mmr among indian women national average of mmr is 212 per 100,000 live births (srs 20072009) which in itself is very high compared to the international scenario like sweden (5), usa (24), and brazil (58) and even in neighboring countries such as sri lanka (39) and thailand 3 th(48). health outcome goals established in the 12 5-year plan are to reduce infant mortality rate to 25 per 1000 live births, to reduce maternal mortality ratio to 100 per 100,000 live births 4by 2017 . kerala, which has always had a well-implemented public healthcare system, has an mmr rate of 46, the best in the country. this is followed by maharashtra at 61 and tamil nadu at 66. a study was conducted in pune, maharashtra on knowledge of antenatal care among pregnant women attending antenatal clinic at a tertiary care hospital reveals that about 58% women had poor knowledge regarding anc. the investigator have selected this study because she noticed that the pregnant mothers in clinical setting and community having doubts related to pregnancy, labor, postnatal and newborn care. investigator also noticed lack knowledge on stmaternal and child health services such as, antenatal care (1 ndtrimester, 2 trimester, and 3rd trimester), danger signs during pregnancy, intranatal period, postnatal period and new born care. so, the investigator has selected this study to create awareness regarding maternal and child health care and services available in government. hence the present study is undertaken to assess the knowledge on availability of stmaternal and child health services, antenatal care (1 nd rdtrimester, 2 trimester, 3 trimester), danger signs during pregnancy, labor, postnatal and new born care. in order to develop an appropriate strategies to overcome and to enhance knowledge regarding utilization of maternal and child health care and services in government sector by providing mother craft classes and informative module. materials and methods a descriptive study was conducted using a quantitative approach. the setting chosen for the present study was obstetrics and gynaecological outpatient department of women and children government hospital thycaud, trivandrum. it is a 750 bedded, hospital with obstetrics gynaecological and peadiatric departments and with twenty four hours casualty. this hospital was selected for the study due to sample availability coupled with the investigator's familiarity and easy access to the hospital. in the present study the sample size consists of 210 primi gravida mothers who are in rst trimester and attending obg opd of women and children government hospital, trivandrum selected purposively. the study includes pregnant women primi gravida mothers who are in rst trimester. the study excludes the pregnant women those who are mentally challenged and illiterate. the tools consist of section a: socio personal variables, it consist of eight items including age in years, education, occupation, religion, family income per month, area of residence , color of your ration card ,rsby card and registration done for any maternity benet scheme. section b: clinical variables it consists of 7 items. including obstetrical score, gestational age, lmp, edd, height (cm), weight (kg) and bmi. section c: structured knowledge questionnaire structured questionnaire was used to assess level of knowledge on health information regarding maternal and child health. it includes antenatal 33 items, intranatal 3 item and postnatal and new born 12 items. total score is 48. 1-16: poor knowledge 17-32: average knowledge 33-48: good knowledge formal permission was obtained from directorate of health service and district medical ofce after obtaining no objection certicate from woman and children government hospital thycaud and also obtain permission from obstetrics and gynaecological department of the hospital. data were collected over a period of four weeks from 31.12 .2018 to 26.1.2019. two hundred and ten subjects satisfying the inclusion criteria were selected by purposive sampling technique from obstetrics and gynecology outpatient department of the hospital .the purpose of the study was well explained to the study subjects and informed written consent knowledge of health information regarding maternal and child health among antenatal mothers: a cross sectional study original research paper mrs. akhila s nair msc (n) student department of obstetrics and gynaecological nursing sree gokulam nursing college x 1gjra global journal for research analysis nursing a descriptive study was conducted on knowledge of health information regarding maternal and child health among antenatal mothers. purposive sampling technique was adopted and 210 primi gravida mothers who were selected. the tool used for data collection consisted of socio-personal variables, clinical variables and structured questionnaire to assess the knowledge of health information regarding maternal and child health. the data was collected by self-reporting and interview method. result showed that majority 51% of the subjects had average knowledge, 39.5% of subjects have poor knowledge and only 9.5% of subjects have good knowledge. there was an association between knowledge of health information regarding maternal and child health and socio personal variables such as education of subjects is statistically signicant (p<0.001), family income of subjects is statistically signicant (p<0.05) and clinical variables such as body mass index is statistically signicant (p<0.05). abstract keywords : knowledge; health information; primi gravida mothers. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra mrs. malathi. d* professor department of obstetrics and gynaecological nursing sree gokulam nursing college venjaramoodu *corresponding author 2 x gjra global journal for research analysis was obtained from the pregnant women. the investigator maintained good interpersonal relationship with the subjects and condentiality was maintained for each subjects. tool 1 were used to collect socio personal and clinical variable. tool 2 was a structured questionnaire to assess the knowledge of health information regarding maternal and child health. the investigator was able to collect data from 8-20 subjects per day by spending six to eight hours. results socio demographic data ÿ majority of the subjects, 45.2% belongs to the age group of 21-25 years, 24.8% of the subjects belongs to the age group of 26-30years, 15.2% of the subjects belongs to the age group of ≤ 20 years and 14.8% of the subjects were belongs to >30 years of age group. ÿ among the total subjects majority of the subjects, 32% were graduate / postgraduate, 29.5% of the subjects were educated up to high school education, 25.7% of the subjects were educated up to post high school diploma, 7.1% of the subjects were educated up to professionals, 3.8% of the subjects were educated up to have middle school education and only 1.9% of the subjects have educated up to primary school education. ÿ most of the subjects, 59% were unemployed, 12.3% of the subjects were professionals, 6.2 % of the subjects were have elementary occupation, 5.2% of the subjects were technician and associated professionals, 4.8% of the subjects were clerk, 3.3% of them are craft and related trade workers, 2.9% of subjects were both skilled agricultural, shery workers and skilled worker, shop, market sales workers and only 1% of the subjects were legislators, senior ofcer and manager. ÿ majority of the subjects, 51 % were belongs to hindu religion, 29.5% of the subjects were belongs to christian religion and 19.5% of the subjects were belongs to muslim religion. ÿ majority of the subjects, 26.7 % were have monthly income of rupees ≤ 6326 , 24.8% of subjects have monthly income of rupees 6327-18952, 15.2% of subjects have monthly income of rupees ≥126360, 8.1% of subjects have monthly income of rupees 31591-47265 and only 5.2% of subjects have monthly income of rupees 63182-126359. ÿ findings shows that, majority 51.9% of the subjects live in urban area and 48.1% of the subjects are live in rural area.. ÿ more than half of the subjects, 55.7% of the subjects do not have an rsby card and only 44.3% of the subjects have rsby card. ÿ majority of the subjects, 46.2% have pink color of ration card, 30% of subjects have blue color ration card, 13.3% of subjects have yellow color ration card, only 10.5% of subjects have white color ration card. ÿ more than half of the subjects, 55.2% were done registration for maternity benet scheme and only 44.8% of subjects were not done registration for maternity benet scheme. knowledge on health information regarding maternal and child health among antenatal mothers. figure: 1 percentage distribution of subjects based on knowledge the gure 1 shows that majority 51% of the subjects have average knowledge, 39.5% of subjects have poor knowledge and only 9.5% of subjects have good knowledge discussion majority; that is 51% of the subjects have average knowledge, 39.5% of subjects have poor knowledge and only 9.5% of subjects have good knowledge. the ndings of the present study were consistent with the result of previous study, to assess knowledge of antenatal care services among pregnant mothers and nursing mothers in southwest nigeria. the study result showed that knowledge of about 61.1% moderate, 15% was good and12.9% was low. the ndings of the present study were consistent with the result of previous study to assess knowledge regarding antenatal care among mothers in an urban area of amritsar, punjab. the study result showed that the knowledge about the antenatal care 22.0% mothers had poor knowledge while 45.6% and 32.4% had average and good knowledge respectively. present study ndings showed that there was an association between knowledge of health information regarding maternal and child health and socio personal variables such as education of subjects is statistically signicant (p<0.001), family income of subjects is statistically signicant (p<0.05) and clinical variables such as body mass index is statistically signicant (p<0.05). the ndings of the present study were consistent with the result of previous study to assess knowledge regarding antenatal care among pregnant women in rural area of lahore. the study result showed that there was signicant association between qualication and knowledge of expectant women about prenatal care. references 1. everet j. introduction to pregnancy. centersite.net. [internet] 2006 [cited on 2009 aug]; issn: (614) 448-4055. available from https://www.centersite.n et/poc/view_doc.php?type=doc&id=6129 2. unicef data. (2018). maternal mortality unicef data. [online] available at: https://data.unicef.org/topic/maternal-health/maternal-mortality/ [accessed 26 jun. 2018]. 3. bongaarts j. who, unicef, unfpa, world bank group, and united nations population division trends in maternal mortality: 1990 to 2015 geneva: world health organization, 2015. population and development review. 2016;42(4):726-726. [online] available at : https://niti.gov.in/content/maternalmortality-ratio-mmr-100000-live-births 4. planning commission, government of india. twelfth five year plan (2012–2017). new delhi. sage publications, india pvt ltd. 2013. [online] available at: http://planning commission.go v.in/plans/plan rel/12thplan/pd f/12fyp_vol3.pdf 5. thenewsminute.com. 2018 [cited 26 june 2018]. available from: https://then ewsminute.com/article/maternal-mortality-rate-dips-130-167-kerala-bestindia-82646 6. barun bhai patel, pranaya gurmeet1, datttreyaramkrishnasinalkar, kapil h. pandya, ajoymahen, neha singh. a study on knowledge and practices of antenatal care among pregnant women attending antenatal clinic at a tertiary care hospital of pune, maharashtra. medical journal of dr. d.y. patil universi ty ; mayjune 2016 ; vol 9 : issue 3 available from: http://www.mjdrdypu.org/article.asp?issn=0975-2870;year=2016;vol ume =9;issue=3;spage=354;epage=362;aulast=patel 7. [internet]. who.int. 2019 [cited 16 june 2019]. available from: https://www.who .int/pmnch/media/publications/aonsectioniii_2.pdf 8. population census 2011. available at https://www.census2011.co.in 9. yohannes b, tarekegn m, paulos w. mothers' utilization of antenatal care and their satisfaction with delivery services in selected public health facilities of wolaita zone, southern ethiopia. intj scien technol res. 2018 feb;2(2):74-85. available at : http://citeseerx.ist.psu.edu/viewdoc/ download?doi=1 0.1.1. 300.8427&rep=rep1&type=pdf 10. rozilza am, muhamad hj. knowledge, attitude and practices on antenatal care among orang asli women of jempol, negeri sembilan, malaysian. j public health med. 2011;11(2):13-21. available at: https://www. mjphm.org. my/mjphm/journals/volume%2011:2/188-knowledge,% 20attitude% 20and% 20practice%20on%20antenatal%20care%20among%20orang%20asli%20w omen%20in%20jempol,%20negeri%20sembilan.pdf 11. bhatia, j.c., (1988): 'a study of maternal mortality in anantpur district, andhra pradesh, india', indian institute of management, bangalore. available at: https://www.ncbi.nlm.nih.gov/pubmed/8296332 volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 23.dr abhay kumar.cdr background diabetes mellitus is a group of clinical syndrome charac terized by hyperglycemia due to defects in insulin action, insulin secretion, or both causing diabetes mellitus. the chronic hyperglycemia of diabetes leading to long-term damage, dysfunction and failure of various organs, especially the kidneys, eyes, heart, nerves, and blood vessels. type 2 diabetes mellitus has quickly become a global health problem due to rapidly increasing population growth, urbanization, aging and increasing prevalence of physical inactivity and obesity .these complications are due to long lasting effects of diabetes mellitus on the glomerular microvasculature of the kidney causing diabetic nephropathy. diabetic nephropathy (dn) develops in patients with several years of medical history of diabetes and uncontrolled hyperglycemia. diabetes is the leading cause of end-stage renal disease (esrd) in most countries of the world . type 2 dm showed that intensive blood glucose control early in the course of disease exhibits a long-lasting favorable effect on the risk of diabetic kidney disease development. in diabetes, the cells do not receive glucose and most of it is accumulated in the blood causing hyperglycemia. creatinine, urea, uric acid, are the parameters to diagnose functioning of the kidney. however, changes in serum creatinine concentration more reliably reect changes in glomerular ltration rate than changes in serum urea concentrations. as diabetes mellitus is the major cause of renal dysfunction, so a good control over the sugar level can halt the progression of renal damage. serum bun has a negative relationship with serum triglycerides in patients with diabetes mellitus, therefore a decrease in serum bun may increase serum triglycerides. in the other hand, serum creatinine has a positive relationship with serum triglycerides, thus the increase in serum creatinine can also increase serum triglycerides in patients with diabetes mellitus. aim and objectives : 1. to determine the frequency of abnormal kidney function test in patients with diabetes mellitus type 2 . 2. to study the relationship between abnormal kidney function test and glycemic prole. 3. to study the relationship between abnormal kidney function test and sociodemographic variable in patient with diabetes mellitus type 2. materials and method : this is prospective study which will be conducted on 83 patients of type 2 diabetes mellitus with age > 18 year. it will be collected with meticulous detailed history and thorough physical examination as indicated for a particular case will be done along with appropriate investigations. relevant blood investigation will be performed and kidney function test will be performed for each patient. other investigation as needed for a patient will also be performed . each patient in the study group will be followed till discharge. the following parameters will be looked in: a. blood investigations cbc, rbs,hba1c , urine complete examination, abnormal kidney function test which include s.creatinine, b.urea ,s.uric acid ,s.electrolytes, bun , estimated glomerular ltration rate (e gfr) by cockcroft gault formula. inclusion criteria : all patient of diabetes mellitus type 2 on treatment either insulin or hypoglycaemic drugs. , newly diagnosed diabetes mellitus , patient aged more than 18 year of age , patient admitted in ward and patient or relatives who sign an informed consent . exclusion criteria : gestational diabetes mellitus patients , drug induce diabetes mellitus patient and patients admitted in icu. results : with 83 no of cases ,the mean age with standard deviation was 56.45±13.397 years. the mean and standard deviation hb for all patients 12.4804±2.03323 .the mean creatinine with standard deviation was 1.453±1.337 ,.the mean urea with standard deviation was 57.54±42.14 , the mean uric acid with standard deviation was 6.06±1.377 , the mean bun with standard deviation was 26.909±19.705 ,the mean egfr with standard deviation was 71.912±41.16 , the mean hba1c with standard deviation was 10.211±2.72 and the mean rbs with standard deviation was 240.70±97.64. there was no statistically signicant difference among the mean of normal frequency of abnormal kidney function tests in patients with diabetes mellitus type 2 original research paper dr. abhay kumar resident, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india medicine background : in this study, we determined frequency of abnormal kidney function tests in patients with diabetes mellitus type 2 and its glycemic prole . method : this is an prospective study on patients diagnosed with diabetes mellitus type 2 in geetanjali medical college and hospital, udaipur.83 cases were included in the study.kidney function tests along with other blood routine tests were done. results : the mean creatinine with standard deviation was 1.453±1.337 .the mean uric acid with standard deviation was 6.06±1.37 . the mean rbs with standard deviation was 240.70±97.64 . there was no statistically signicant difference among the mean of normal and abnormal kft patients for hb, tlc, pc, na, k, cl and rbs as their p value was >0.05. however, there was statistically signicant difference among the mean values of normal and abnormal kft patients as the p value for the following was <0.05. conclusion : this study concludes that biochemical parameters of kidney functions are associated with a worsening in insulin action and predicts the development of type 2 diabetes. the study also revealed that in order to prevent the progression of diabetes mellitus to diabetic nephropathy, vigilant monitoring of serum urea and creatinine would help in the early diagnosis of renal failure and could make treatment possible. abstract keywords : kidney function tests, diabetes mellitus type 2 volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. damodar parikh* associate professor, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india *corresponding author 8 x gjra global journal for research analysis and abnormal kft patients for hb, tlc, pc, na, k, cl and rbs as their p value was >0.05. however, there was statistically signicant difference among the mean values of normal and abnormal kft patients as the p value for the following was <0.05 . out of 51 patients with normal kft, 19 were male and the remaining 32 were female. furthermore, out of 32 patients with abnormal kft, 14 were female and 18 were male. there was no statistically signicant difference between gender of the normal and the abnormal kft patients p value was >0.05 out of 51 patients with normal kft, majority of them belonged to 61-70 years of age group. furthermore, out of 32 patients with abnormal kft majority of them belonged to 51-60 years of age group. there was no statistically signicant difference between age group of the normal and the abnormal kft patients p value was >0.05. discussion : in the current study the number of males was 50 and the number of females was 33. this implied that the study showed male predominance. similarly according to the study of caramori et al, (2013) and al salhen, (2016) also showed that the number of males was greater than that of the females depicting that males were more affected as compared to females. in the current study the mean age with standard deviation was 56.45±13.397 years. it was identied that the current mean age was higher than that of the study conducted by caramori et al, (2013) where it was 35.0±9.9 years. however, the current mean age was at par with that of al salhen, (2016) where the mean age was 56.10±7.82 years. in the current study it was identied that majority of the diabetic patients had the disease from 0-5 years. similar results were found in the study of al salhen, (2016) where the majority of the diabetic patients had the disease for <5 years. furthermore, in the current study the mean create with standard deviation was 1.453±1.337, the mean urea with standard deviation was 57.54±42.14 and the mean uric acid with standard deviation was 6.06±1.377. therefore, it was identied that there was a statistically signicant correlation among these factors and diabetes. similar results were found in the study of bamanikar et al, (2016)13 where a strong positive correlation between the serum urea levels and blood sugar levels. however, the study contrasted the current ndings as it was found in the study that there was a weak positive correlation between serum creatinine levels and blood sugar. conclusion : it has been identied in the current study that biochemical parameters of kidney functions are associated with a worsening in insulin action and predicts the development of type 2 diabetes. the study also revealed that in order to prevent the progression of diabetes mellitus to diabetic nephropathy, vigilant monitoring of serum urea and creatinine would help in the early diagnosis of renal failure and could make treatment possible. references : 1. steinke jm, sinaiko ar, kramer ms, suissa s, chavers bm, mauer m. the early natural history of nephropathy in type 1 diabetes: iii. predictors of 5year urinary albumin excretion rate patterns in initially normoalbuminuric patients. diabetes. 2005 jul 1;54(7):2164-71. 2. rossing p, rossing k, gæde p, pedersen o, parving hh. monitoring kidney function in type 2 diabetic patients with incipient and overt diabetic nephropathy. diabetes care. 2006 may 1;29(5):1024-30. 3. alicic rz, rooney mt, tuttle kr. diabetic kidney disease: challenges, progress, and possibilities. clinical journal of the american society of nephrology. 2017 dec 7;12(12):2032-45. 4. keane wf, zhang z, lyle pa, cooper me, de zeeuw d, grunfeld jp, lash jp, mcgill jb, mitch we, remuzzi g, shahinfar s. risk scores for predicting outcomes in patients with type 2 diabetes and nephropathy: the renaal study. clinical journal of the american society of nephrology. 2006 jul 1;1(4):761-7. 5. bamanikar sa, bamanikar aa, arora a. study of serum urea and creatinine in diabetic and nondiabetic patients in a tertiary teaching hospital. the journal of medical research. 2016;2(1):12-5. 6. najaan b, kim y, crosson jt, mauer m. atubular glomeruli and glomerulotubular junction abnormalities in diabetic nephropathy. journal of the american society of nephrology. 2003 apr 1;14(4):908-17 7. sulaiman mk. diabetic nephropathy: recent advances in pathophysiology and challenges in dietary management. diabetology & metabolic syndrome. 2019 dec 1;11(1):7. 8. al salhen ks, mahmoud ay. determinants of abnormal kidney function tests in diabetes patient type 2 in libya. international journal of scientic study. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra kft n mean std. deviation p-value hb normal 51 12.8033 1.96285 >0.05 abnormal 32 11.9656 2.06782 tlc normal 51 9.0033 2.74426 >0.05 abnormal 32 9.5063 2.76766 pc normal 51 2.1025 .73371 >0.05 abnormal 32 1.9584 .62853 create normal 51 0.8927 0.19134 <0.05 abnormal 32 2.3466 1.82522 urea normal 51 36.4853 15.11315 <0.05 abnormal 32 91.0994 49.38233 u. acid normal 51 5.8224 1.01920 <0.05 abnormal 32 6.4469 1.76031 na normal 51 136.84 6.754 >0.05 abnormal 32 134.94 7.080 k normal 51 5.1216 5.44949 >0.05 abnormal 32 6.0625 7.66848 cl normal 51 99.494 5.8100 >0.05 abnormal 32 101.469 11.0512 bun normal 51 17.0561 7.06063 <0.05 abnormal 32 42.6141 23.07431 egfr normal 51 81.3441 31.64191 <0.05 abnormal 32 56.8816 49.87343 rbs normal 51 229.351 93.5787 >0.05 abnormal 32 258.800 102.6894 kft total p-value normal abnormal sex female count 19 14 33 >0.05 % within kft 37.3% 43.8% 39.8% male count 32 18 50 % within kft 62.7% 56.3% 60.2% total count 51 32 83 % within kft 100.0% 100.0% 100.0% kft n mean std. deviation p-value hba1c normal 51 9.6639 2.25479 <0.05 abnormal 32 11.0844 3.19325 kft total p-value normal abnormal age group (years) 31-41 count 8 4 12 >0.05 % within kft 15.7% 12.5% 14.5% 41-50 count 11 8 19 % within kft 21.6% 25.0% 22.9% 51-60 count 9 10 19 % within kft 17.6% 31.3% 22.9% 61-70 count 18 6 24 % within kft 35.3% 18.8% 28.9% 71-80 count 2 3 5 % within kft 3.9% 9.4% 6.0% >80 count 3 1 4 % within kft 5.9% 3.1% 4.8% total count 51 32 83 % within kft 100.0% 100.0% 100.0% x 9gjra global journal for research analysis 2016 sep 1;4(6):99-103. 9. perrone rd, madias ne, levey as. serum creatinine as an index of renal function: new insights into old concepts. clinical chemistry. 1992 oct 1;38(10):1933-53. 10. judykay t. nutrition for reducing urea and creatinine in the blood. diabetes care. 2007;27:2191-2. 11. kodama s, saito k, yachi y, asumi m, sugawara a, totsuka k, saito a, sone h. association between serum uric acid and development of type 2 diabetes. diabetes care. 2009 sep 1;32(9):1737-42. 12. del prato s, bonadonna rc, bonora e, gulli g, solini a, shank m, defronzo ra. characterization of cellular defects of insulin action in type 2 (noninsulindependent) diabetes mellitus. the journal of clinical investigation. 1993 feb 1;91(2):484-94 13. cordonnier dj, zmirou d, benhamou py, halimi s, ledoux f, guiserix j. epidemiology, development and treatment of end-stage renal failure in type 2 diabetes. the case of mainland france and of overseas french territories. diabetologia, 1993;36:1109-12 14. olivarius nd, andreasen ah, keiding n, mogensen ce. epidemiology of renal involvement in newly-diagnosed middle-aged and elderly diabetic patients. cross-sectional data from the population-based study “diabetes care in general practice”, denmark. diabetologia. 1993 oct 1;36(10):1007-16 15. gulab k, neelam j, nidhi s, monika s, juber a, rahul k. signicance of serum urea and creatinine levels in type 2 diabetic patients. iosr j dent med sci. 2015;14:65-7. 16. caramori ml, parks a, mauer m. renal lesions predict progression of diabetic nephropathy in type 1 diabetes. journal of the american society of nephrology. 2013 jul 1;24(7):1175-81. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 10 x gjra global journal for research analysis introduction: neuroendocrine carcinomas (necs) of the stomach, although rare, deserve particular attention as they are aggressive and have an extremely poor prognosis [1–6]. in addition, the concept of this disease and its diagnostic criteria have been changed recently. the world health organization (who) proposed new diagnostic criteria in 2010 that mainly depend on the rate of cellular proliferation [7]. this is a case series of the case admitted in sree balaji medical college and hospital for a period of two year and to nd out the incidence of the neuroendocrine tumor and its various modalities of presentation and its management materials and methodology: ÿ this is a case series of the case admitted in sree balaji medical college and hospital for a period of two year and to nd out the incidence of the neuroendocrine tumor and i ts various modali t ies of presentat ion and i ts management. ÿ inclusion criteria ÿ all cases of nec biopsy proven ÿ exclusion criteria ÿ associated with other malignancy ÿ after thorough clinical examination patient is examined systematically and necessary investigations sent such as usg abdomen, cect andomen, mri contrast a case series of neuroendocrine tumours of gi tracta increase incidence in recent days original research paper dr. magesh kumar. j* assistant professor, department of general surgery, sree balaji medical college & hospital, bharath university, chromepet, chennai *corresponding author general surgery gastric neuroendocrine carcinomas are rare and have a poor prognosis and the diagnostic criteria for this disease have recently changed. this is a case series of the case admitted in sree balaji medical college and hospital for a period of two year and to nd out the incidence of the neuroendocrine tumor and its various modalities of presentation and its management. abstract keywords : gastric neuroendocrine carcinoma, sporadic gastric p. suresh babu associate professor sree balaji medical college & hospital, bharath university, chromepet, chennai – 600044 k. s. ravishankar professor & hod, department of general surgery,sree balaji medical college & hospital, bharath university, chromepet, chennai – 600044 volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra s no age and sex clinical presentation investigations treatment 1 60/f nonspecic abdominal pain ugi scopy – moderate dysplasia consequent scopy biopsy leading to nec total gastrectomy with gj and jj 2 50/m acute pain abdomen features suggestive of gastric perforation cect – gastric perforation with perigastric nodes (growth in pylorus) bilroth ii surgery hpe nec 3 45/f dyspepsia for evaluation ugi scopy revealed – polyp in the d1 biopsy –nec endoscopic removal of the polyp. patient is in observation 4 45/m presenting with gastric outlet obstruction cect, ugi revealed the pathology hpe antral growth palliative gastrectomy with gj and jj 5 52/m rectal growth, bleeding pr for evalauation hpe proven – nec pelvic evisceration with prostatectomy as it was inltrating with ileal conduit. case series pictures: intra op picture showing tumour intraop picture showing perforated tumou 72 x gjra global journal for research analysis slide showing normal mucosa &tumour site salt and pepper nuclei appearenace peripheral palisading of cells for all the mentioned cases immunohistochemistry helped in nalising the diagnosis.the patients are still in followup stusy and doing well.still larger scale of study is in progress. discussion: neuroendocrine neoplasm (nen) is an epithelial neoplasm with predominant neuroendocrine differentiation and is an uncommon tumor with multiple sites of occurrence [5]. nens are commonly divided by origin as located in the foregut (lung, bronchus, stomach or duodenum), midgut (jejunum, ileum, appendix or proximal colon) and hindgut (distal colon or rectum). the percentage of foregut cases is 34%, midgut 30% and hindgut 36% [6]. gastric neuroendocrine neoplasms (nens) embrace a group of tumors that exhibit a spectrum of histopathologic variations, ranging from clearly benign tumors to highly malignant ones. recently, the concept of this disease and its diagnostic criteria have been changed. in the 2010 who criteria, nens of the stomach are dened as neoplasms with neuroendocrine differentiation, including neuroendocrine tumors (nets) and necs arising in the stomach [7]. synonyms for gastric nets include carcinoid, welldi f ferent iated endocrine tumor/ carcinomas, and enterochromafn-like cell nets, and synonyms for necs include poorly differentiated endocrine carcinomas and small cell and large cell endocrine carcinomas. nens are classied i n t o n e t g 1 ( c a r c i n o i d ) a n d g 2 , n e c s , m i x e d adenoneuroendocrine carcinomas, enterochromafn cells, serotonin-producing nets, and gastrin-producing nets [7]. gastric nen is classied into neuroendocrine tumor (net), n e u r o e n d o c r i n e c a r c i n o m a ( n e c ) , m i x e d adenoneuroendocrine carcinoma, enterochromafn cells, serotonin-producing nets and gastrinproducing nets. nets include net g1 (carcinoid) and net g2 (well-differentiated neuroendocrine tumor/carcinoma). necs include nec g3 (poorly differentiated neuroendocrine carcinoma small cell type/large cell type) [4]. nen is positive for synaptophysin and chromogranina [7]. nen is classied based on the level of cellular proliferation, including the mitotic and ki-67 indices [4]. in our case, the mitotic index was 16/10 hpf and the ki-67 labeling index was 26%-50%. thus, she was diagnosed with nec. we suspected jumping metastasis from the main lesion to the proximal margin. in the japanese classication of gastric carcinoma, nens are classied into carcinoid tumors and endocrine carcinomas (small cell type and large cell type) [8]. although the prevalence of gastric nens has recently risen, they are thought to be relatively rare tumors that account for less than 1% of all gastric tumors [9]. in general, the majority of these tumors are nets, whose courses are indolent and not life threatening. concerning nets, more than 100 years have passed since oberndorfer proposed the term “carcinoid” in 1907 [10]. in 1993, rindi et al. advocated a classication system with three subtypes of gastric carcinoid tumors according to the clinicopathological features [1], and this classication system is reected in the 2010 who criteria. on this background, gilligan et al. advocated a treatment algorithm for gastric carcinoid tumors, including the abovementioned subtypes as well as the size and number of tumors [11]. recently, less invasive therapeutic options, such as endoscopic resection of the tumor, have been reported for small nets [12]. necs of the stomach are also rare, representing less than 10% of gastric nens [2, 13], and such rarity has made it difcult to understand precisely their biological nature and to establish optimal treatment options. the nec of our case was a difcult diagnosis to establish, and the immunohis tochemis t r y p layed a major ro le . microscopically, the patient's tumor was uniform in shape and arranged in small microtubular structures (rosette-like arrangement) to form solid nests, with medium-sized, roundto-cuboid-shaped tumor cells on hematoxylin and eosin staining. onimmunohistochemistry, the tumors are usually positive for synaptophysin and neuronal-specic enolase, but are rarely positive for the chromogranina staining observed in our patient. in the 2010 who criteria, nens are classied into nets or necs on the basis of the level of cellular proliferation, including the mitotic and ki-67 indices. the mitotic index was 46/10hpf and the ki-67 labeling index was 70–80% in our case, so he was diagnosed as nec. lymphatic invasion was widely observed and lymph node involvement was seen in many nodes, suggesting the high-grade malignant nature of this tumor and showing the compatibility of the diagnosis. aggressive surgery and chemotherapy should be considered for any nec [3].gastric nen is classied into neuroendocrine tumor (net), neuroendocrine carcinoma (nec), mixed adenoneuroendocrine carcinoma, enterochromafn cells, serotonin-producing nets and gastrinproducing nets. nets include net g1 (carcinoid) and net g2 (well-differentiated neuroendocrine tumor/carcinoma). necs include nec g3 (poorly differentiated neuroendocrine carcinoma small cell type/large cell type) [4]. nen is positive for synaptophysin and chromogranina [7]. nen is classied based on the level of cellular proliferation, including the mitotic and ki-67 indices [4]. in our case, the mitotic index was 16/10 hpf and the ki-67 labeling index was 26%-50%. thus, she was diagnosed with nec. we suspected jumping metastasis from the main lesion to the proximal margin. gastric nen has different prognoses volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 73gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra and treatments depending on type. the prognosis of net g1 is good and the 5 year survival rate is high. net g2 has a favorable prognosis but is aggressive. nec has the highest malignant potential but the 5 year survival rate is 75%-80%; however, the prognosis is poor. net can be removed by endoscopic resection, whereas nec requires surgical resection and lymph node dissection [8]. the best choice adjuvant chemotherapy for nec is cisplatinum-based chemotherapy [9]. however, in this case we used a 5fu oral agent because of the patient's nancial status and compliance. in conclusion, a neuroendocrine tumor can be removed by endoscopic resection but it must be a radical surgical resection in accordance with a malignant tumor, due to its aggressive tendency and high malignant potential. diagnosis protocol ÿ 24 hr urinary measurement of 5hiaa ÿ serum chromogranin a ÿ nt – probnp ( n-terminal pro-brain natriuretic peptide) ÿ used in surveillance & as a prognostic marker. ÿ cect scan – investigation of choice – solid mass with spiculated borders & radiating surrounding strands that is associated with linear strands within the mesenteric fat & kinking of the bowel ÿ mri – useful in liver metastasis ÿ nuclear imaging somatostatin receptor positivity – identication of extra abdominal metastatic disease or in cases where primary cannot be identied by ct scan. ÿ ga-dotatate pet/ct – localize primary tumor in patients with neuroendocrine metastasis of unknown origin & to dene the extent of metastatic disease . ÿ pet scan using f-dopa(dihydroxyphenylalanine) used in identing nets medical and surgical treatment: ÿ multidisciplinary ÿ surgical debulking, hepatic artery embolization, chemoembolization, or radioembolization and medical therapy ÿ treatment of patients with small bowel net – based on tumor size, site & presence or absence of metastatic disease. ÿ lesion <1cm with no evidence of regional ln metastasis – segmental intestinal resection. ÿ lesion >1cm, multiple tumors or with regional ln metastasis , regardless of size of primary tumor – wide excision of bowel & mesentery needed. ÿ lesion of terminal ileum – right hemicolectomy. ÿ small duodenal tumorslocally excised , whereas more extensive tumors needs pancreatoduodenectomy. ÿ liver metastasis – trans arterial chemoembolization or arterial embolization. ÿ octreotide & lanreotide & pasireotide – relieves symptoms ÿ peptide receptor radionuclide therapy yttrium & leuticium isotopes conjugated with somatostatin analogues – advanced nets ÿ interferon alpha &pegylated interferon alpha-2b – ce l l cyc le inh ib i t ion a t g1/s & antiangiogenesis effects through downregulation of vegf. ÿ cytotoxic chemotherapystreptozotocin, 5fu & cyclophosphamide – well differentiated & metastatic nets. ÿ ketanserin & cyproheptadine – controls symptoms. ÿ telotristat etiprate – inhibits serotonin synthesis. ÿ bevacizumab – inhibits angiogenesis. ÿ targeting of multiple signaling pathways is a treatment strategy that may provide better tumor control & overcome resistance mechanisms involved with targeting of a single pathway. conclusion we described a case series of sporadic nec. an adequate description of necs should be globally and historically discussed in relation to the real manifestation of this tumor group, considering the evaluation of the consensus conference. the diagnosis and treatment of these tumors should be evaluated in large clinical studies. references 1. g. rindi, o. luinetti, m. cornaggia, c. capella, and e. solcia ; three subtypes of gastric argyrophil carcinoid and the gastric neuroendocrine carcinoma: a clinicopathologicstudy, gastroenterology,1993,104 [4], 994–1006. 2. g. rindi, c. bordi, s. rappel, s. la rosa, m. stolte, and e. solcia : gastric carcinoids and neuroendocrine carcinomas: pathogenesis, pathology, and behavior : world journal of surgery, 1996, 20 [2],168–172. 3. g. rindi : clinicopathologic aspects of gastric neuroendocrine tumors,: american journal of surgical pathology, 1995.19 (1), s20–s29, 3. j. waisberg, l. l. de matos, a. m. d. a. a. mader et al., neuroendocrine gastric carcinoma expressing somatostatin: a highly malignant, rare tumor,: world journal of gastroenterology, 2006,12 (24),3944–3947. 4. k. matsui, x. m. jin, m. kitagawa, and a. miwa, : clinicopathologic features of neuroendocrine carcinomas of the stomach: appraisal of small cell and large cell variants: archives of pathology and laboratory medicine, 1998,122 (11),1010–1017. 5. j. y. yu, l. p. wang, y. h. meng, m. hu, j. l. wang, and c. bordi : classication of gastric neuroendocrine tumors and its clinicopathologic signicance ; world journal of gastroenterology, 1998, 4 [1–6],158–161. 6. f. t. bosman, f. carneiro, r. h. hruban, and n. d. theise, eds., who classication of tumors of the digestive system, international agency for research on cancer, lyon, france, 4th edition, 2010. 7. japanese gastric cancer association, japanese classication of gastric carcinoma (in japanese), kanehara publishing, tokyo, japan, 14th edition, 2010. 8. i. m. modlin, k. d. lye, and m. kidd : carcinoid tumors of the stomach: surgical oncology, 2003, 12 [2],153–172. 9. s. oberndorfer ; karzinoidetumoren des duendarms ; frankfurter zeitschriftfürpathologie, 1907, 1,426–432. 10. c. j. gilligan, g. p. lawton, l. h. tang, a. b. west, and i. m. modlin, gastric carcinoid tumors: the biology and therapy of an enigmatic and controversial lesion, ; american journal of gastroenterology,1995,90 (3), 338–352. 11. s. simoyama, m. fujishiro, and y. takazawa; successful type-oriented endoscopic resection for gastric carcinoid tumors: a case report ; world journal of gastrointestinal endoscopy, 2010,2 [12], 408–412. 12. n. chiba, t. suwa, m. hori, m. sakuma, and m. kitajima : advanced gastric endocrine cell carcinona with distant lymph node metastasis: a case report and clinicopathological characteristics of the disease : gastric cancer, 2004,7(2),122–12 . 74 x gjra global journal for research analysis introduction atherosclerotic disease is projected to become the leading 1cause of global morbidity and mortality by 2020 ; this trend 2has grave implications for countries in south asia . rates of coronary artery disease (cad) are higher in south asians who have migrated and some studies suggest that rates of disease in the indian subcontinent parallel those in the industrialized 3,4 5world . cvd accounting for 32% of all death in 2000 . located in south asia, bangladesh has a population of 160 million. in 1975, the incidence of ihd in bangladesh was reported to be 6 73.3 per thousand and it was 14 per thousand in 1985 . so surveys in bangladesh indicate very high prevalence rates of cardiovascular disease and prevalence of ihd has progressively increased in bangladesh during the last decade of twentieth century, particularly among the urban population. this calls for aggressive preventive strategies. however, setting goals for preventive initiatives necessitates the denition of the risk factor prole of a population but, for the bangladeshi population, absence of relevant data makes this difcult. the traditional risk factors namely hypertension (htn), diabetes mellitus (dm), hypertriglyceridaemia (high) tg, low level of high density lipoprotein (ldl-c), smoking, low levels of antioxidants (vitamin a, e, beta carotene), rising afuence, rapid modernization associated with sedentary but stressful life style in summation are suggested as additional risk factors for ihd. all aspects of cholesterol are important hdl, ldl and triglycerides so therefore; all aspects of it should be treated and managed properly. the reason having low hdl is dangerous is because of the protective function it performs. hdl cleans the walls of blood vessels, removing excess cholesterol, which would have been used to make plaque, pattern of dyslipidaemia in patient with angiographically documented coronary artery disease original research paper md. shahimur parvez* dr. md. shahimur parvez, assistant professor, department of cardiology, enam medical college & hospital, savar, dhaka, bangladesh. e mail: dr.parvez.dmc@gmail.com * corresponding author x 85gjra global journal for research analysis cardiology background: dyslipidaemia contributes to substantial increased risk of premature extensive and accelerated atherosclerosis leading to cad, pvd and mi etc. patients derive most benet from treatment with lipid-lowering agents. objective: to evaluate the pattern of dyslipidaemia in patients with angiogram documented signicant coronary artery disease (lesion ≥70 % stenosis). methods: this cross sectional analytical study was carried out in the department of cardiology, dhaka medical college hospital, dhaka; university cardiac centre (ucc), bangabandhu sheikh mujib medical university, shahbag, dhaka and department of cardiology, ibrahim cardiac hospital & research institute, shahbag, dhaka (march 2011 to august 2011). a total number of 50 patients with angiogram documented coronary artery disease were included in this study. stenosis ≥ 70% in any of the three major epicardial vessels was considered signicant cad. total cholesterol ≥200 mg/dl or ldlc ≥130 mg/dl or hdlc ≤40 mg/dl or triglyceride ≥200 mg/dl were considered as dyslipidaemia. considering the inclusion & exclusion criteria the study population were divided into two groups. group-i: patients with dyslipidaemia (n=43) and group-ii: patients without dyslipidaemia (n=07). results: th almost one third (32.0%) of the patients were in 6 decade and male to female ratio was 5.3:1. eighty percent of the patients had typical chest pain and 16.0% had shortness of breath. regarding the traditional risk factors, dyslipidaemia (86.0%) was more common followed by hypertension (66.0%), diabetes (42.0%), smoking (40.0%) and family history of ihd (28.0%). mean bmi of the group-i was 25.46±3.69 and group-ii was 24.65 ± 4.21. left main involvement was found in 4.0% and most of the patients (60.0%) had signicant proximal lesion involvement that were 40.0% in lad, 18.0% in lcx and 22.0% in rca. the mean difference of fasting lipid prole was not statistically signicant between smoker and non-smoker patients, hypertensive and normotensive, diabetic and non-diabetic patients with angiogram documented coronary artery disease (p>0.05). conclusion: most of the patients with coronary artery disease had low hdl (84.0%) irrespective of taking lipid lowering medication. abstract keywords : dyslipidaemia, coronary angiography, coronary artery disease volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra mohammad arifur rahman mohammad arifur rahman, consultant cardiology, sheikh fazilatunnesa mujib memorial kpj specialized hospital, tetuibari, gazipur, dhaka, bangladesh md. moniruzzaman md. moniruzzaman, associate professor & consultant cardiology, sheikh fazilatunnesa mujib memorial kpj specialized hospital, tetuibari, gazipur, dhaka, bangladesh arin islam lita arin islam lita, resident medical ofcer, department of medicine, holy family red crescent medical college & hospital, eskaton, dhaka, bangladesh. tamal peter ghosh tamal peter ghosh, registrar, department of cardiology, enam medical college & hospital, savar, dhaka, bangladesh. abdul wadud chowdhury abdul wadud chowdhury, professor & head, department of cardiology, dhaka medical college hospital, dhaka, bangladesh. 86 x gjra global journal for research analysis causing coronary artery disease. hdl then brings the excess cholesterol to liver, where it is processed and removed. having low hdl cholesterol increases risk of coronary artery disease, regardless of good ldl and triglycerides level. and sadly, hdl cholesterol is something people overlook when managing their cholesterol. epidemiologic studies have shown a strong inverse 8, 9association between hdl-c and cv events . low hdl-c is becoming increasingly common in south east asian populations, most likely due to the increasing prevalence of 10type ii diabetes and metabolic syndrome . materials and methods this cross sectional study was done among the patients of department of cardiology, dhaka medical college hospital, dhaka, university cardiac centre (ucc), bangabandhu sheikh mujib medical university, shahbag, dhaka and department of cardiology, ibrahim cardiac hospital & research institute, shahbag, dhaka. patient undergoing cag and those who fullled the selection criteria was taken as study population. patient who fullled the following criteria for clinical indications of cag was included. stenosis ≥70% in any of the three major epicardial vessels was considered signicant cad. extent of cad was dened as signicant single, two or three vessel cad. total cholesterol ≥200 mg/dl or ldlc ≥130 mg/dl or hdlc ≤40 mg/dl or triglyceride ≥200 mg/dl were considered as dyslipidaemia. considering the inclusion & exclusion criteria the study population was divided into two groups. group-i: patients with dyslipidaemia (n=43) and group-ii: patients without dyslipidaemia (n=07). diagnostic coronary angiography was performed via either the trans-femoral or trans-radial approach using standard techniques. cine angiographic lms were analyzed independently by two experienced operators. signicant cad was dened as ≥70% stenosis in any of the three major epicardial coronary arteries or a left main coronary artery stenosis ≥50%. branch vessel cad was dened as ≥70% stenosis in a major side branch of an epicardial artery (if >2 mm in diameter). angiograms revealing coronary artery stenosis <70% in major epicardial coronary arteries were termed as non-obstructive cad. extent of cad was dened as signicant single, two or three vessel cad involvement. purposive sampling was done. the collected data were analyzed with the aid of computer software statistical package for social sciences version 20 (spss inc., chicago, illinois). quantitative data were expressed as mean ± sd and student's “t” test was employed for analysis. qualitative data were analyzed with �2 test. comparison between groups were made by unpaired t-test. p value < 0.05 was considered. data was collected through a structured case record form. data were collected from all respondent by direct facetoface interviews. informed written consent was obtained from all participants. a proforma was designed to record patient demographics including cardiac risk factors, ischaemic ecg changes, values of cardiac troponin i levels and the different coronary artery segments for stenosis documentation. results: table-1: baseline characteristics of patients according to the cardiac troponin i level status. (n=50) figure 1: coronary angiographic prole among the study population (n=50) figure 2: bar diagram showing the association between smoking and fasting lipid prole in study patients (n=50). figure 3: bar diagram showing the association between hypertension and fasting lipid prole in study patients (n=50) figure 4: bar diagram showing the association between diabetes and fasting lipid prole in study patients (n=50) discussion: this cross sectional study was carried out with an aim to evaluate the pattern of dyslipidaemia in patients with angiogram documented coronary artery disease and to determine the relative importance of different components of cholesterol in patients with coronary artery disease. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra variables p value age 59.40 ± 9.81 59.30 ± 12.18 ns0.968 30-44 03 (2.8%) 16 (13.4%) 45-59 54 (48.6%) 40 (33.6%) 60-74 50 (45.0%) 56 (47.1%) 75-89 04 (3.6%) 07 (5.9%) gender male 82 (73.9%) 87 (73.1%) ns0.621 female 29 (26.1%) 32 (26.9%) bmi 25.07 ± 3.55 24.65 ± 4.21 ns0.417 cardiac risk factors diabetes mellitus 55 (49.5%) 60 (50.4%) ns0.595 hypertension 76 (68.4%) 84 (70.5%) ns0.235 cigarette smoking 27 (24.3%) 37 (31.0%) ns0.784 positive f/h of cad 25 (22.5%) 26 (21.8%) ns0.690 dyslipidaemia 78 (70.2%) 69 (57.9%) ns0.294 ecg ischemic abnormality 74 (66.6%) 75 (63.0%) ns0.235 the present study observed the mean age was 55.84±10.28 and 54.30±12.18 years ranging from 35 to 75 years and thmaximum number of the patients was found in the 6 decade. in the current study it was observed that 84.0% patients were male and 16.0% were female. male was predominant in this study and male to female ratio was 5.3:1 in the whole study population. in this current study it was observed that eighty percent patients had typical chest pain and 16.0% had shortness of breath. in this current study the traditional risk factors was evaluated and found that 40.0% patients were smoker, 66.0% hypertension, 42.0% diabetes, 86.0% dyslipidaemia and 28.0% had family history of ihd among the study patients. family history of premature cad was present in about one fth of the whole study patients. mean bmi was 25.46±3.69 and 24.65±4.21. as regards to the relationship between bmi>25 with coronary artery disease, a number of investigators studied and found signicant relationship with coronary artery disease but in this study we did not nd any correlation between bmi & extent of coronary artery disease. smoking is a well-known risk factor for coronary artery disease. in this present study it was observed that the mean difference of fasting lipid prole was not statistically signicant (p>0.05) between smoker and non-smoker patients with angiogram documented coronary artery disease. low hdl was found 95.0% and 76.7% in smoker and nonsmoker patients respectively. hypertension is a very well recognized risk factor for coronary artery disease. in this study it was observed that hypertension did not signicantly affect the extent of coronary artery disease among the study groups. the reason may be due to most of the patients were taking anti-hypertensive medication and their blood pressure was well controlled. in this current study it was observed that low hdl was found 81.8% and 88.2% in patients with hypertensive and normotensive patients respectively. the mean difference of fasting lipid prole between hypertensive and normotensive patients with angiogram documented coronary artery disease was not statistically signicant (p>0.05). regarding the ecg change among the study groups it was also statistically non-signicant. even with cag documented coronary artery disease patients, 28.0% had apparently normal ecg. regarding the fasting lipid prole it was observed that in this present study high tc (≥200mg/dl) level was found in 09 (18.0%), high ldl (≥130 mg/dl) in 08 (16.0%), low hdl (≤40 mg/dl) in 42 (84.0%) and high tg (≥200mg/dl) in 19 (38.0%) patients with angiogram documented coronary artery disease. percentage of patients having high ldl & high cholesterol is low, may be due to most of patients taking lipid lowering medication. despite taking lipid lowering medication, most of their hdl is below 40 mg/dl. in this current series it was observed that left main involvement was found in 4.0% and most of the patients (60.0%) had signicant proximal lesion involvement, which were 40.0% in lad, 18.0% in lcx and 22.0% in rca. this is more prevalent in group-i patients than in group-ii patients. statistical signicance was found among the groups (p=0.002). the mean difference of fasting lipid prole was not statistically signicant (p>0.05) between diabetic and non diabetic patients with angiogram documented coronary artery disease. low hdl was found 81.0% and 89.7% in patients with dm and patients with non dm respectively. conclusion this study was undertaken to evaluate the pattern of dyslipidaemia in patients with angiographically documented coronary artery disease. most of the people with coronary artery disease (cad) identied by coronary angiography had low hdl (84.0%). the percentages of other parameters of lipid prole are not as high as that of hdl. treating the condition effectively, therefore, would have a considerable impact on the outcome of the cad patients. a signicant proportion of patients with coronary disease could benet from interventions aimed at increasing hdl-cholesterol and reducing triglycerides. limitation of the study ÿ the sample size is small. ÿ patients with dyslipidaemia either getting lipid lowering medication or not has not been categorized. ÿ low total cholesterol and low ldl may be due to lipid lowering medication. references 1. reddy, k.s., yusuf, s., et al., 1998. “emerging epidemic of cardiovascular disease in developing countries”. circulation; 97: pp. 596-601. 2. nishtar, s. et al., 2002. “prevention of coronary heart disease in south asia”. lancet; 360: pp. 1015-18. 3. yusuf, s., reddy, s., ounpuu, s., anand, s., et al., 2002. “global burden of cardiovascular diseases: part ii: variations in cardiovascular disease by specic ethnic groups and geographic regions and prevention strategies”. circulation; 104: pp. 2855-64. 4. enas, e.a., garg, a., davidson, m.a., nair, v.m., huet, b.a., yusuf, s., et al., 1996. “coronary heart disease and its risk factors in rst-generation immigrant asian indians to the united states of america”. indian heart journal; 48: pp. 343-53. 5. gahaffar, a., reddy, k.s., singhi, m.e., et al., 2004. “burden of noncommunicable disease in south asia”. british medical journal; pp. 234:807. 6. malik, a., islam, m.n. zafar, a., khan, a.k., et al., 1976. “clinical patterns of ischaemic heart disease and its association with some known risk factors”. bangladesh heart journal; 2: pp.1-9. 7. amanullah, m., et al., 1994. “intravenous thrombolytics in acute myocardial infarction”. bangladesh heart journal; 9: pp.1-4. 8. gordon, t., castelli, w.p., hjortland, m., kannel, w.b., dawber, t.r., et al., 1977. “high density lipoprotein as a protective factor against coronary heart disease. the framingham study”. american journal of medicine; 62: pp. 707714. 9. jacobs, d.r., jr, mebane, i.l., bangdiwala, s.i., criqui, m.h., tyroler, h.a., et al., 1990. “high density lipoprotein as a predictor of cardiovascular disease mortality in men and women: the follow-up study of the lipid research clinics prevalence study”. american journal of epidemiology; 131: pp. 32-47. 10. tan, c., emmanuel, s.c., tan, b., jacob, e., et al., 1999. “prevalence of diabetes and ethnic differences in cardiovascular risk factors”. diabetes care; 22: pp. 241–247. x 87gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: the aim of anesthesiology as a science is the removal of pain temporarily, started initially with pain relief for surgeries, extending now on to postoperative pain relief, chronic pain and cancer pain. spinal anaesthesia plays a major role in alleviating pain intraoperatively extending sometime into postoperative period also. spinal anesthesia for cesarean section has always enjoyed popularity as it eliminates the complication of pulmonary aspiration and avoids the problem of difcult airway observed with general anesthesia. the other advantages of this technique are its simplicity, rapidity in onset and dependability. the advantages of neuraxial opioids over neuraxial local anaesthetics are that, it produces prolonged, intense, selective, segmental analgesia without motor blockade and sympathetic dysfunction. opiods and local anesthetics administered together have a potent synergistic analgesic effect(1). intrathecal opioids enhance analgesia from sub therapeutic dose of local anaesthetic and make it possible to achieve successful spinal anaesthesia using otherwise inadequate doses of local anaesthetic(2). hence, the present study has been undertaken to combine “sufentanil” an opioid and “bupivacaine” a long acting local anaesthetic for intrathecal administration to provide anaesthesia for cesarean section. aim of the study : to evaluate the effect of intrathecal sufentanil in improving the quality of anesthesia with 0.5% hyperbaric bupivacaine in low dose for lower segment cesarean section, to evaluate the efcacy of intrathecal sufentanil in providing postoperative pain relief for lower segment cesarean section, to assess the duration of pain relief, to assess the incidence of side effects. materials and methods : the study was conducted in 80 patients undergoing elective and emergency cesarean section after getting consent and explaining the procedure details to the patients. term parturients aged 18 to 35 years classied under asa physical status i and ii, i and ii who were termed t for subarachnoid e e block were selected. patients with coexisting medical diseases were excluded. patients who were converted to general anesthesia were excluded later. after preoperative assessment, the pregnant patients were premedicated with inj. metaclopromaide 10mg & inj. ranitidine 50mg – intramuscularly 45 minutes before induction of anesthesia. patients were randomly allotted into two groups. group i: inj bupivacaine (0.5%) heavy 1.5cc + 0.1cc of normal saline. group ii: inj bupivacaine (0.5%) heavy 1.5cc + sufentanil 5μg procedure details: in the preoperative visit, patients were explained of the procedure details. then baseline preoperative pulse rate and blood pressure were recorded. all patients were preloaded with 15-20ml/kg of normal saline/ ringer lactate. patients were put in lateral position and with strict aseptic precautions lumbar puncture was done with quincke babcock's standard spinal needle – 23 g. after ensuring free ow of cerebrospinal uid, the drug was injected as per the group assigned. the assigned amount of sufentanil(5,6,7) and normal saline were taken in sterile tuberculin syringe(8). after injection patient was put up in supine position with left lateral tilt and 100% oxygen given through mask until delivery of the baby. parameters observed : time of subarachnoid injection, hemodynamics, bradycardia, maximal level of sensory block, nausea and vomiting, pruritus, two segment regression time,sedation score, fetal outcome, total duration of analgesia are observed. in the post operative period total duration of analgesia was taken as that period from the time of induction (subarachnoid block) till patient's rst requirement for analgesic medication. pain was evaluated using linear visual analogue scale(3). also in the post operative period every mother and baby were followed up for any complication like respiratory depression, postoperative nausea and vomiting, pruritus(4), urinary retention and hypotension. statistical signicance was brought out by student's t – test. observation and results : in this randomised single blinded study, conducted in 80 patients, the subjects were allocated into 2 groups group i: inj bupivacaine (0.5%) heavy 1.5cc + 0.1cc of normal saline group ii: inj bupivacaine (0.5%) heavy 1.5cc + sufentanil 5μg(5). evaluation of efficacy of intrathecal sufentanil with low dose bupivacaine in lower segment cesarean section original research paper dr. muthu vijayasankar m.d, associate professor, tamilnadu government multi super speciality hospital, chennai, tamilnadu. anaesthesiology background: spinal anesthesia for cesarean section is the preferred technique over general anesthesia due to various advantages. bupivacaine is the common drug which is used in those surgeries. we want to evaluate the effectiveness of low dose bupivacaine with sufentanil and low dose bupivacaine alone. study design: it is a prospective randomised study conducted in 80 patients undergoing cesarean section. patients are randomised into 2 groups. group i: inj bupivacaine (0.5%) heavy 1.5cc + 0.1cc of normal saline group ii: inj bupivacaine (0.5%) heavy 1.5cc + sufentanil 5μg(5). local anesthetic effect, hemodynamics, post operative analgesia, complications and fetal outcome are compared.statistical signicance was brought out by student's t – test. results: all the patients who received 1.5ml of hyperbaric bupivacaine with sufentanil were comfortable during the intra operative period(12). about 52.5% of the patients who received bupivacaine alone had intraoperative discomfort signicantly. conclusion: it has been found out by this study that addition of 5μg of sufentanil to low dose (7.5mg) of 0.5% of bupivacaine intrathecally in cesarean section provides improved quality of surgical anaesthesia and analgesia abstract keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. sankaran chockalingam* m. d, senior assistant professor, thirunalveli medical college and hospital, tamilnadu. *corresponding author 22 x gjra global journal for research analysis demographic data both groups were comparable in age, height and duration and nature of surgery. figure 1. comparison of age there was no statistically signicant variation in age of the patients in both the group. both the groups were comparable. figure 2. comparison of height there was no statistically signicant variation in height of the patients in both the groups. both the groups were comparable. maximal level of sensory blockade maximal sensory level achieved for pin prick sensation t6 in group i and t4 in group ii. highest level of blockade achieved was t4 in group i&t2 in group ii. lowest level of blockade achieved was t10 in group i and t6 in group ii. a signicant variation noted in maximal level of sensory blockade in both the groups. figure 3. two segment regression time two segment regression time duration of analgesia as measured by two segment regression time were 44.75min in group i with standard deviation of 10.12, 64.25min in group ii with standard deviation of 13.51. a signicant variation noted in two segment regression time in both the groups. figure 4. total duration of anesthesia total duration of analgesia was 76.5 minutes in group i with standard deviation of 19.12 (around one hour and fteen minutes). 150.37 minutes in group ii with a standard deviation of 25.5, (around two hour and thirty minutes). figure 5. hemodynamics with regard to blood pressure, a fall in blood pressure more than 20% from the baseline value was considered hypotension. in group i, 5% of patients had hypotension. in group ii, 17, 5 % of patients had hypotension. the hypotension in the study group required either intravenous uids or injection ephedrine and oxygen supplementation. none of them required any further intervention. with regard to pulse rate, a fall in pulse rate below 60 per minute was considered bradycardia. about 5% of patients had bradycardia in group ii and it was treated with inj. atropine 0.6 mg intravenously. none of them required any further intervention. no bradycardia noted in group i patients. sedation intraoperative sedation was excellent in group ii patients. in group ii 47.5 %of patients had sedation score of 2. 2.5% of patients had sedation score of 3. in group i all patients had sedation score of 1. nausea and vomiting in group ii 15% of patients had nausea and vomiting. eventually all responded to inj.metaclopromaide 10mg intravenously. in group i no patients had nausea or vomiting. pruritus in group ii 40% of patients had pruritus. all responded to inj. diphenhydramine. in group i no patient had pruritus. respiratory depression and urinary retention no respiratory depression and urinary retention was noted in both the groups. intraoperative discomfort in group ii 100% of the patients were comfortable. in group i 52.5% of the patients had intraoperative discomfort(15). we had to necessarily manage them with analgesics and intravenous anaesthetics. fetal outcome apgar was calculated at 1 minute and 5 minutes after deliver of baby. there was no neonatal respiratory depression noted. apgar score was comparable in both the group. it did not show statistically signicant variation among the two groups. the st thscore was 6.9 ±0.659 at the 1 minute and 8.725 ± 0.75 at the 5 minute in the sufentanil group. the score was 7.22 ± 0.65at st ththe1 minute and 8.95 ± 0.75 at the 5 minute in the control group. none of the babies had any further neurological complications. discussion: 80 patients undergoing cesarean section with the physical status of asa i, ii, i & ii were taken up for the study. they were e e randomly allocated into two groups, 40 patients in each group. variables like age, height were standardized in both groups. group i (control group) received 1.5 cc of 0.5% bupivacaine with 0.1 ml of normal saline intrathecally(13). group ii (study group) received 1.5 cc of 0.5 % bupivacaine volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra sensory level group i group ii t2 7 t3 1 t4 10 22 t5 1 1 t6 22 9 t7 1 t8 5 t9 t10 2 x 23gjra global journal for research analysis with 5 �g of sufentanil intrathecally. the quality of intra operative surgical anaesthesia was excellent in (100 %) of patients in sufentanil group as compared to 47.5 % in control group. all the patients who received 1.5ml of hyperbaric bupivacaine with sufentanil were comfortable during the intra operative period(12). about 52.5% of the patients who received bupivacaine alone had intraoperative discomfort signicantly. they had to be necessarily maintained with adjuvant analgesic or intravenous anaesthetics. addition of opioids aid in relieving the discomfort that could be caused by visceral handling. this is well brought out in other studies done by peach. m.j. et al in 1994 & m.s. batra et al. total duration of analgesia: the total duration of analgesia evaluated was signicantly prolonged in sufentanil group(11); 150.38± 25.5 minutes compared to 76.5±19.12 minutes in control group. the requirement for the rst dose of analgesia was signicantly prolonged in sufentanil group. this value was statistically signicant as calculated by student's t-test. (p<0.001). the results of our study goes in consistent with the study by braga ade f,braga f.s.et al at s c h o o l o f m e d i c a l s c i e n c e s , c a m p i n a s , s a o paolo,brazil.(eur.j.anaesthesiol.2003 aug;20(8):631-5) 2-segment regression time: 2-segment regression of anesthesia took longer;64.25±13.52 min in sufentanil group(14) as compared with 44.75±10.12 in control group. this was proved statistically signicant. this value was statistically signicant as calculated by student's t-test. (p<0.001) hemodynamic variables: the incidence of hypotension was about 17.5% in the study group compared with 5% in control group. the hemodynamics after 5 minutes was 93.5±16.41 mm of hg in sufentanil as compared with 101.75±18.5 in control group. nausea & vomiting: opioids produce nausea and vomiting by direct stimulation of chemoreceptor trigger zone(10). this effect is dose related and can be treated with anticholinergic or phenothiazines, those are antagonistic at dopamine receptor. route of opioid administration does not inuence the occurrence of vomiting. the incidence of vomiting in our study is 15%. pruritus: this is a common side effect especially with obstetric population. incidence from previous studies showed result of 0-100%. this effect is dose dependent as shown by gilmcmorland, 1990, (personal communication), this effect is centrally mediated due to cephalad migration of the opioid to brain stem and fourth ventricle. it is self limiting, can also be antagonized by anti-histamines. no patients required treatment in our study. 40% of patients in our study had pruritus, which was dose related. consistent with the study conducted by braga ade et al concluded pruritus was the most common side effect and had the signicantly higher incidence when a dose of sufentanil 7.5mic was used(eur j anaesthesiol.2003 aug;20(8):631-5) sedation: intra operative sedation was excellent in sufentanil group. in control group patients required sedative supplementation whereas no sedation was required in the sufentanil group. about 47.5 % had sedation score of 2& 2.5% had sedation score of 3. fetal outcome: apgar was calculated at 1 minute and 5 minutes after deliver of baby. there was no neonatal respiratory depression noted. apgar score was comparable in both the group.it did not show statistically signicant variation stamong the two groups. the score was 6.9±0.659 at the1 thminute and 8.725±0.75 at the 5 minute in the sufentanil st group. the score was7.22±0.65at the1 minute and 8.95±0.75 that the 5 minute in the control group. none of the babies had any further neurological complications. so far varied numbers of studies have been conducted showing the efcacy of sufentanil in providing comfortable intraoperative period and prolonged post operative pain relief with minimal complication.this study delineates that the acceptable dose range without much morbidity in hospitals with moderate post operative care and without high dependency unit with 5 �g of sufentanil intrathecally. it has been found out by this study that 5�g of intrathecal sufentanil with 1.5ml of 0.5% hyperbaric bupivacaine provides an improved quality of intraoperative surgical anesthesia. increase in the duration of two segment regressions (64.25 ± 13.51). increase in the total duration of analgesia (150.375 ± 25.50). the occurrence and intensity of side effects were so minimal and not signicant. the benet associated with administration of intrathecal sufentanil in a dose of 5μg outweighs the disadvantages of it. conclusion it has been found out by this study that addition of 5μg of sufentanil to low dose (7.5mg) of 0.5% of bupivacaine intrathecally in cesarean section provides improved quality of surgical anaesthesia and analgesia without signicantly increasing maternal and fetal side effects than using bupivacaine alone. references 1. cousins mj, mather le, intrathecal and epidural administration of opioids. anaesthesiology 1984; 61:276-310 2. dahlgren g.jacobson j. morman .m et al,intrathecal sufentanil, fentanyl or placebo added to bupivacaine for cesarean section. anaesthesia and analgesia 85(6)1288-93, 1997 december 3. collins sl moore, ra mcquayhj, the visual analog pain score. pain 1997, 72: 95-97 4. fameuo ce naguibbb scott p.v fisher, intraspinal narcotics and itching. british journal of anaesthesilogy 1982; 284:105 5. gordon k, lima rj, yamashita am, spinal anaesthesia for caesarean section with 0.5%. hyperbaric bupivacaine associated with fentanyl and sufen-tanil. brazilians journal of anaesthesia, international issue vol, 9, 1998. 6. jose francisco, giovani alves, joao rosa de almeida association of fentanyl or sufentanil and 0.5% bupivacaine in spinal anaesthe-sia. a comparative study. brazilian journal of anesthesiology vol. 52 n05, sep-oct 2002 7. ngiam sk, chong jl,the addition of sufentanil and fentanyl to bupivacaine for cesarean section. 8. parlow jl, noneu p, chan ps et al, addition of opioids alters the densi-ty and spread of intrathecal local anaesthetics. an invitro study. canadian journal of anaesthesia, 199; 6 : 66-70. 9. michael j. cousins and lawrence e motler, intrathecal and epidural administration of opioids, anaesthesiology, 1992; 61 :276-310. 10. y a k s h a n d r u d y : s i t e o f a c t i o n o f s p i n a l o p i o i d s (1976)(bja;1989,63,165,volume-192). 11. cousins mj, mather le, intrathecal and epidural administration of opioids, anaesthesiology 1984, 61, 276-310. 12. honet je arkoosh va, norris mc et al comparison among in-trathecal fentanyl, meperdine and sufentanil for labour analgesia. anae. anal. 1992; 75, 734-9 13. dahlgren gunnar md, et al intrathecal sufentanil, fentanyl, or placebo added to bupivacaine for caesarean section, anaes anal. 1997; 85:1288-93. 14. ngiam sk, chong jl, the addition of intrathecal sufentanil and fen-tanyl to bupivacaine for cesarean section singapore med j 1998 jul; 39(7);290-4 15. chung cj, baqe sh, et al anaesthesia with 0.25% hyperbaric bupivacaine for caesarean section effects of volume, bja 1990; aug 77(2);145-49 volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 24 x gjra global journal for research analysis introduction carcinoma of the breast is the most common nonskin malignancy in women. breast cancer is more than 100 times more common in women than in men. in our country incidence of breast cancer is second only to that of cancer cervix (jemal a [1]et al 2003) . breast cancer is proportionately on the increase in a few metropolitan areas of india. this appear to be related to late marriage, late birth of rst child, fewer children, shorter period of breast feeding, which are common among the educated urban women. common denominator for most of these factors is strong and prolonged estrogen stimulation, operating on a genetically susceptible background. genetic predisposition with familial breast carcinoma ÿ brca-1 gene located on chromosome 17q ÿ brca-2 gene located on chromosome 13q other risk factors are familial relative like mother and sister, menstrual and reproductive history. other physical and chemical factors are exogenous estrogens, contraceptive agents and ionizing radiation. commonest neoplasm of breast is tumour arising from epithelial component of glandular element of breast. inltrative ductal carcinoma being the most common type of carcinoma'(70%), lobular carcinoma is the second most common followed by smaller groups such as medullary, mucinous, comedo carcinoma, paget's disease, papillary, [2]tubular and inammatory carcinoma (berg and hutter 1995 ). in recent years, interest in prognostic factors has been stimulated by the success of systemic adjuvant therapy for early stage, cancer breast. the important pathological prognostic factors in invasive breast carcinoma include [3]patient's age, tumor size (chervallier et at 1990 , galea et at [4]1992 ), lymph node involvement + distant metastasis (du-toit [5] [6] [7]et at 1990 , pisansky et al 1993 , ravdin et at 1994 ), beside it nuclear grade, histological grade, histological type, proliferative capacity, microvessel density, hormone receptors [8] [9]status her2-neu, (cohen 1978 ). (ullrich and yamamoto, et [10]al ). cells have receptors on their surface and inside the cytoplasm and nucleus. chemical messengers such as hormones bind to these receptors, causing changes in the cell. breast cancer cells may or may not have three important receptors: estrogen receptor (er), progesterone receptor (pr), and her2/neu. her2+ breast cancer had a worse prognosis, but her2+ cancer cells respond to drugs such as the monoclonal antibody, trastuzumab, (in combination with conventional chemotherapy) and this has enhanced the prognosis signicantly. cells with none of these receptors are called basal-like or triple negative. aims and objectives present study has been conducted with following aims and objective: 1. to nd out the incidence of invasive breast carcinoma in bundelkhand region 2. to assess the overexpression of her2neu in breast carcinoma by immunohistochernistry and its correlation with (a) diagnosis (b) prognosis (histological grade) in invasive breast carcinoma. materials and methods the present study has been conducted in pathology department, mlb medical college, jhansi. the tissue material has been obtained from patients admitted in surgery department for breast conservation surgery or modied radical mastectomy and tissue blocks present in pathology department has been utilized. ÿ biopsies and mastectomy specimens were xed in 10% formalin. ÿ detailed history about age, residence, clinical diagnosis and chief complaints was enquired. ÿ gross appearance of mastectomy specimen/biopsy was overexpression of her2/neu gene: correlation with histological grading in breast carcinoma original research paper dr. renu sahay associate professor , department of pathology , maharani laxmi bai medical college, jhansi x 41gjra global journal for research analysis pathology background: carcinoma of the breast is the most common nonskin malignancy in women. prognosis and management of breast cancer are inuenced by variables such as stage, grade, hormone receptor status of oestrogen(er), progesterone(pr) and human epidermal growth factor receptor2 (her2/neu) overexpression. aim to correlate grade of tumour with her2/neu receptor status of breast carcinoma. methods: the present study has been conducted in pathology department, mlb medical college, jhansi. the tissue material has been obtained from patients admitted in surgery department for breast conservation surgery or modied radical mastectomy and tissue blocks present in pathology department has been utilized. all samples were subjected for routine histological examination and immunohistochemical analysis. results: the patients were >20 years of age; 56% of tumours were right sided; 51% tumours were histopathologically grade 2 and 98% were invasive breast carcinoma. by immunohistochemistry, out of 45 cases, 19 was her2/neu positive; out of which the 6 cases (31.57%) with the score of 2+ (grade ii), 9 cases (47.37%) with score 3+ (grade iii) and 4 cases (21.06%) score of 0/1+ (negative) (grade i). conclusions: assessment of hormone receptors for clinical management of breast cancer patients is strongly advocated to provide prognostic information and best therapeutic options. a signicant correlation was observed between her2/neu immunoreactivity and the histological grade of tumour. abstract keywords : breast cancer, histological grade, her2/neu overexpression, immunohistochemistry (ihc). volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. vikas goyal* lecturer, department of pathology, maharani laxmi bai medical college, jhansi *corresponding author dr. shailza junior resident, department of pathology, maharani laxmi bai medical college, jhansi 42 x gjra global journal for research analysis noted. ÿ parafn blocks after through tissue processing were prepared. ÿ sections were cut 3-4 micron thick and subjected to following: ÿ routine haematoxylin and eosin staining has been done for histomorphological typing according to who and grading of all cases. ÿ immunohistochemistry has been done using monoclonal antibodies obtained from 'biogenex' company. her2/neu (clone ep3) immunohistochemistry marker was used. histological grading of invasive carcinoma: inavasive ductal carcinomas and all other invasive tumors are graded based on an assessment of tubule/gland formations, nuclear pleomorphism and mitotic counts. assessment of histological grade has become more objective with modications of the patley and scarff method rst by bloom and richardson (1957) and more recently by elaston and ellis (1991. examples of assignment of points for mitotic counts for 3 different eld areas. the three values are added together to produce score of 3 to 9, which the grade in assigned as follows: i m m u n o h i s t o c h e m i c a l d e t e c t i o n o f h e r 2 / n e u immunoreactivity: representative sections of tumour were further processed for immunohistochemistry using immunoperoxidase technique. sections were taken on readymade poly-l lysine coated slide. antigen retrieval was done in pressure cooker using citrate buffer solution at ph 6.0-6.2 with washing using pbs (phosphate buffer solution) at ph=7.2-7.6 and slides were stained with monoclonal antibodies obtained from ' b i o g e n e x ' c o m p a n y. h e r 2 / n e u ( c l o n e e p 3 ) immunohistochemistry markers were used. her2/neu positivity was interpreted and reported using asco 2007 guidelines (american society of cancer oncology) which takes into account the cytoplasmic membrane staining and the proportion of immuno-positive tumour cells. reuslts: discussion: lesions of the breast constitute a very important chunk of the causes of morbidity and mortality in women worldwide. recently there has been increasing interest in the early detection of the malignant breast lesions as early therapeutic intervention improves survival. one of the most fundamental aspects of oncologic pathology has been the recognition that the morphologic appearance of tumour can be correlated with their degree of malignancy. her2 amplied breast cancers have increased sensitivity to certain cytotoxic agents such as doxorubicin, relative resistance to hormonal agents, and propensity to metastasize to the brain and viscera. her2-amplied tumors have an increased sensitivity to doxorubicin possibly due to coamplication of the topoisomerase-2 gene which is near the her2 locus on chromosome 17 and is the target of the drug. half of her2-positive breast cancers are er-positive but they generally have lower er levels, and many have p53 alterations. these tumors have higher proliferation rates, more aneuploidy, and are associated with poorer patient prognosis. the poor outcome is dramatically improved with appropriate chemotherapy combined with the her2-targeting [11] [12]drug trastuzumab. (ross js 2003 ; gabos z 2006 ; villman [13]k 2009 . in the present study 45 cases of malignant lesions of the breast were included. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra feature score tubule and gland formation majority of tumor (>75%) 1 moderate degree (10-75%) 2 little or more (<10%) 3 nuclear pleomorphism small, regular uniform cell 1 moderate increase in size and variability 2 marked variation 3 mitotic counts per 10 high power elds dependent on microscopic eld area 1-3 field diameter (mm) 0.44 0.59 0.63 2field area (mm ) 0.152 0.274 0.312 mitotic count 1 point 0-5 0-9 0-11 2 point 6-10 10-19 12-22 3 point >11 >20 >23 grade i well differentiated 3-5 points grade ii moderately differentiated 6-7 points grade iii poorly differentiated 8-9 points parameters [n=45] no. of cases percentage table 1: age wise distribution of cases 21-30 02 4.44% 31-40 03 6.67% 41-50 16 35.55% 51-60 14 31.11% >60 16 22.22% table 2: clinical presentation wise distribution of cases left breast lump 25 55.56% right breast lump 06 13.33% pain 07 15.56% axillary mass 06 13.13% nipple discharge 01 02.22% biopsy 05 11.11% table 3: distribution of cases according histological type invasive ductal carcinoma (not otherwise specied) 41 91.12% mucinous 02 04.44% medullary 01 2.22% sarcoma phylloidis 01 2.22% table 4: distribution of invasive ductal carcinoma according to tubular components >75% (score 1) 12 29.27% 10-75% (score 2) 26 63.41% <10% (score 3) 03 7.32% table 5: distribution according to nuclear pleomorphism small, uniform cells (score 1) 15 36.59% moderate variation (score 2) 16 39.02% marked variation (score 3) 10 24.39% table 6: distribution according to mitotic counts/10hpf 0-5/10hpf (score 1) 05 12.20% 6-10/10hpf (score 2) 26 63.41% >10/10hpf (score 3) 10 24.39% table 7: histological grade wise distribution of cases grade 1 (score 3-5) 8 19.51% grade 2 (score 6-7) 21 51.22% grade 3 (score 8-9) 12 29.27% table 8: correlation of her2/neu immunoreactivity with histological grade grade 1 04 21.06% grade 2 06 31.57% grade 3 09 47.37% out of the 45 cases studied, maximum patients were in age group more than 41-50 years (35.55%) followed by 31.11% patients from 51-60 years. 22.22% patients were >60 years and 6.67% patients from 31-40 years of age group (table i), 4.44% cases in age group 21-30.this is in accordance with [14]study of (hussain et al 1994 ). out of 45 cases maximum 31 cases (68.89%) clinically presented with lump in breast followed by pain in 7 cases (15.56%), 6 cases (13.33%) presented with axillary lump and only 1 case (2.22%) presented with nipple discharge (table ii). these ndings are in accordance with the study of (blarney et [15]al 1998 ). in our study out of 31 cases presented with breast lump 25/31(55.56%) localized in left side and 6/31 (13.33%) localized in right side (table ii). this was accordance with the [16]study of (haagensen 1986 ). out of 45 cases these 44 invasive carcinomas (epithelial), 41 (91.12%) were invasive ductal ca (nos), 2 case( 4.44%) of mucinous carcinoma,) case(2.22%) of medullary carcinoma ,1 case (2.22%) of sarcoma phylloidis (table iii). similar ndings [2]were noted by (berg and hutter 1995 and hussain et at [14]1994 ). in this study, all invasive epithelial tumours were graded according to the modied bloom richardson grading by [17](elaston and ellis et al 1991 ). out of the 41 cases of invasive ductal carcinomas, 51.22% were grade ii, 29.27% were grade iii while 19.51% were grade i (table vii). our results closely [18]matched with the study of doussal et al 1989 and zubair [19]ahmad et al, 2009 . for all carcinomas, her2/neu was also studied using immunoperoxidase method and scoring was done. the immunostaining was read in a semiquantitative manner and graded as follows: 0, 1+, 2+ and 3+. intensity scores of 0 or 1+ were designated as negative expression and 3+ were designated as positive expression for her-2/neu. scores of 2+ were taken as equivocal cases, which were further recommended for fish analysis. kalal iravathy goud et al [20]2012 . out of 45 cases her2 positive immunostaining is seen in 19 cases. out of those 6 cases (31.57%) were seen with the score of 2+ (grade ii), 9 cases (47.37%) with score 3+ and 4 cases (21.06%) score of 0/1+ (negative) (table viii). our results [20]closely matched with the study of kalal iravathy goud et al . however the number of cases in present study is small and long follows up is required to reach any denitive conclusion. ultimate goal of each study is how it can be benecial to the society. any research by itself on breast carcinoma is useful because of the sheer numbers of women worldwide who suffer morbidity & mortality due to this disease. hence there is relevance of search for new prognostic markers which may help in stratifying patients. conclusions the present study entitled " overexpression of her2/neu gene: correlation with histological grading in breast carcinoma" shows the conclusion, that her2/neu immunoreactivity is directly related to histological grade. staining is more intense in higher grade of malignancies. the number of cases in present study is small to reach any denitive conclusion. however results of present study did show concurrence with those of other researchers. references: 1. ghafoor a, jemal a, ward e, cokkinides v, smith r, thun m. trends in breast cancer by race and ethnicity. ca cancer j clin. 2003 nov-dec;53(6):342-55. erratum in: ca cancer j clin. 2004 may-jun;54(3):181. 2. berg jw, hutter rv. breast cancer. cancer. 1995 jan 1;75(1 suppl):257-69. pubmed pmid: 8001000. 3. chevallier b, roche h, olivier jp, chollet p, hurteloup p. inammatory breast cancer. pilot study of intensive induction chemotherapy (fec-hd) results in a high histologic response rate. am j clin oncol. 1993 jun;16(3):223-8. pubmed pmid: 8338056. 4. galea mh, blamey rw, elston ce, ellis io. the nottingham prognostic index in primary breast cancer. breast cancer res treat. 1992;22(3):207-19. pubmed pmid: 1391987. 5. r. s. du toit mr a. p. locker i. o. elis c. w. elston r. w. blarney.evaluation of the prognostic value of triple node biopsy in early breast cancer.first published: february 1990 6. thomas m. pisansky m.d. james n. ingle m.d. daniel j. schaid ph.d.patterns of tumor relapse following mastectomy and adjuvant systemic therapy in patients with axillary lymph node-positive breast cancer. impact of clinical, histopathologic, and ow cytometric factors.volume72, issue4 15 august 1993 pages 1247-1260. 7. ravdin pm, de laurentiis m, vendely t, clark gm. prediction of axillary lymph node status in breast cancer patients by use of prognostic indicators. j natl cancer inst. 1994 dec 7;86(23):1771-5. 8. carpenter, g., king, l. jr & cohen, s. epidermal growth factor stimulates phosphorylation in membrane preparations in vitro. nature 276, 409–410 (1978) 9. ullrich, a. et al. rat insulin genes: construction of plasmids containing the coding sequences. science 196, 1313–1319 (1977). 10. yamamoto, t., hihara, h., nishida, t., kawai, s. & toyoshima, k. a new avian erythroblastosis virus, aev-h, carries erbb gene responsible for the induction of both erythroblastosis and sarcomas. cell 34, 225–232 (1983). 11. ross js, fletcher ja, linette gp, stec j, clark e, ayers m, symmans wf, pusztai l, bloom kj. the her-2/neu gene and protein in breast cancer 2003: biomarker and target of therapy. oncologist. 2003;8(4):307-25. review. pubmed pmid: 12897328. 12. gabos z, sinha r, hanson j, chauhan n, hugh j, mackey jr, abdulkarim b. prognostic signicance of human epidermal growth factor receptor positivity for the development of brain metastasis after newly diagnosed breast cancer. j clin oncol. 2006 dec 20;24(36):5658-63. epub 2006 nov 13. pubmed pmid: 17102066. 13. villman k, nilsson g, lahtela sl, lehtiö k, pajunen m, study investigators. a d j u v a n t c a p e c i t a b i n e i n c o m b i n a t i o n w i t h d o c e t a x e l a n d cyclophosphamide plus epirubicin for breast cancer: an open-label, randomised controlled trial. lancet oncol. 2009 dec;10(12):1145-51. doi: 10.1016/s1470-2045(09)70307-9. epub 2009 nov 10. 14. hussain ma, ali s. tyagi sp, reza h. incidence of cancer breast at aligarh. j indian med asso, 1994 sep, 92(9): 296-7. 15. r.w. blarney, f. boccardo, t. tominaga, w. jonat, m. kaufmann, l. beex,a new standard treatment for advanced premenopausal breast cancer: a metaanalys is o f the combined hormonal agent tr ia l i s t s group (chat).september 1998volume 34, supplement 5, page s90 16. haagensen cd. disease of the breast (third ed.) w.b. saunders, philadelphia;1986, pp250-266 17. elston cw, ellis io. pathological prognostic factors in breast cancer. i. the value of histological grade in breast cancer: experience from a large study with long-term follow-up. histopathology. 1991 nov;19(5):403-10. pubmed pmid: 1757079. 18. doussal v, tubiana m, friedman s, hace k, burnet m. prognostic value of histologic grade nuclear components of scarf bloom richardson (sbr) an improved score modication based on multivariate analysis of 1262 idcs. cancer 64: 1914-1921, 1989 19. zubair ahmad, amna khurshid, asim qureshi, romana idress, nasira asghar, naila kayani.breast carcinoma grading, estimation of tumor size, axillary lymph node status, staging, and nottingham prognostic index scoring on mastectomy specimens.year : 2009 | volume : 52 | issue : 4 | page : 477-481 20. goud ki, dayakar s, vijayalaxmi k, babu sj, reddy p v. evaluation of her2/neu status in breast cancer specimens using immunohistochemistry (ihc) & uorescence in-situ hybridization (fish) assay. indian j med res 2012;135:312-7 x 43gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: orthopedic upper arm surgeries forms a signicant group of orthopedic trauma.the surgeries can be done under general anaesthesia or regional anaesthesia. regional anaesthesia has several advantages over general anaesthesia like improved postoperative pain, decreased post operative 1opioid administration and reduced recovery time anaesthesiologist has a choice of technique for providing anaesthesia and analgesia during upper extremity surgery by brachial plexus block through various routes like interscalene, supraclavicular infraclavicular and axillary. systematic reviws has shown that infraclavicular block is a safe and simple technique with efcacy comparable to other brachial plexus block. the advantage of infraclavicular block includes a lower likelihood of tourniquet pain during surgery and more reliable blockade of the musculocutaneous and axillary nerve and signicantly shorter block performance 2time. ropivacaine the single s isomer long acting amide local anaestheticis is well tolerated regional anaesthetic, effective for surgical anaesthesia as well as relief of post operative pain. the efcacy of ropivacaine is similar to that of racemic 3bupivacaine and levobupivacainr for peripheral nerve blocks. levobupivacaine, another single s isomer amide local anaesthetic has similar efcacy but an enhanced safety prole when compared to bupivacaine, a major advantage in 4regional anaesthesia. both drugs are useful in clinical situation where risk of systemic toxicity related to overdosing or unwanted intravascular injection is high as during 5peripheral nerve block. ropivacaine and laevobupivacaine in peripheral nerve block provide comparable clinical prole and post operative analgesia while other studies show that levobupivacaine produce approximately 30% longer duration in each modality 6and long lasting analgesia. clonidine , an alpha 2 adrenergic agonists helps to improve 7the reliability and efcacy of regional anaesthesia 8 prolonging duration of block and perineural use is 9recommended. the rationale of the study was to nd out efcacy and safety of ropivacaine and laevobupivacaine with clonidine as an adjuvant when used in infrac;lavicular block for lower arm surgeries. material and methods: this was a prospective ,randomized, double blind study. institutional ethical committee approval was taken. source of study population was patients posted for elbow and forearm surgeries. sample size calculated was 60. convenient sample was used. screening of patient done and patient fullling inclusion criteria like age 20-60yrs of either gender, height of 150-170 cm,weight 50-70kg,asa grade i and ii were included. exclusion criteria was allergy to local anaesthetics, history of drug abuse, neurological disease, cardiac disease, chronic obstructive disease, diabetes mellitus and local infection at puncture site. after taking informed consent, patients were randomized by computer generated random number table into two groups, group a-inj ropivacaine 0.5%, 30cc and inj. clonidine 1ug/kg and group b-inj. laevobupiacaine 0.5%, 30 cc and inj. clonidine 1ug/kg. group allocation concealment done by opaque sealed envelope technique.the drugs syringes were prepared by a resident who did not take part part in further study. asenior resident performed all the blocks. the principal investigator who was blind to group allocation recorded the study parameters. on day of surgery,infraclavicular brachial plexus bolck was given by coracoid approach. a 10cm 20g insulated needle attached to nerve stimulator (nsml 100,inmed)was inserted. initial stimulating current was set at 0.6-0.8ma.the brachial plexus was reached at 4cm-6cm and stimulating current was than decreased to elicit motor response at 0.3ma.only motor comparative study of ropivacaine and laevobupivacaine with clonidine as an adjuvant in infraclavicular brachial plexus block for lower arm surgeries original research paper dr srihari gutte senior resident department of anaesthesiology government medical college aurangabad x 51gjra global journal for research analysis anaesthesiology introduction: infraclavicular block is a safe and simple technique for providing surgical anaesthesia of the lower arm with an efcacy comparable to other brachial plexus block ropivacaine and levobupivacaine has similar efcacy to bupivacaine with enhanced safety prole. clonidine improves the reliability and efcacy of peripheral nerve block. aims and objectives: to compare the block characteristics of ropivacaine and laevobupivacaine with clonidine as an adjuvant in infraclavicular brachial plexus block. material and methods: for this prospective study ,60 patients were randomized into two groups ,group a-0.5% ropivacaine 30 cc and inj. clonidine 1ug/kg and group b-0.5% laevobupivacaine 30cc and inj.clonidine 1ug/kg and infraclavicular brachial plexus block was given.the onset of sensory block, motor block, the duration of sensory block and motor block, the quality of surgical anaesthesia, the duration of postoperative analgesia, vas score, haemodynamic parameters and side effects were observed. results: onset of sensory block and motor block was earlier with laevobupivacaine. duration of sensory and motor block was longer in laevobupivacaine group. quality of surgical analgesia was excellent in 100% in both groups. duration of post operative analgesia was same in both groups.. haemodynamically patients were stable and there were no signicant side effects seen in either groups. conclusion: laevobupivacaine with clonidine and ropivacaine with clonidine are comparable in infraclavicular brachial plexus block for lower arm surgeries. abstract keywords : infraclavicular brachial plexus block, ropivacaine, laevobupivacaine,clonidine volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr rajashri b. sonwane* associate professor department of anaesthesiology government medical college aurangabad *corresponding author 52 x gjra global journal for research analysis response (twitches)from the triceps, forearm muscles were accepted prior to local anaesthetic injection. aspiration was performed and loading dose administered incrementally. the patient was withdrawn from study in case of failure of onset of block. sensory block assessed by 23g hypodermic needle by hollmen scale,1-normal sensation of pinprick, 2-weaker sensation of pinprick, 3-pinprick recognized as touch by blunt object, 4no perception of pinprick. motor block evaluated by bromage scale, grade1-ability to ex and extend the forearm, grade 2-ability to ex and extend only the wrist and ngers, grade3-ability to extend only the ngers, grade 4-inability to move the forearm, wrist and ngers. quality of surgical block assessed by need of supplemental anaesthesia.excellent-no supplementary sedative and analgesic required,good-only sedative required,fair-both sedative and analgesic required,poor-general anaesthesia required. postoperative analgesia was assessed by using visual analogue scale (0mm-no pain to100 mm-worst pain imaginable). duration of analgesia taken from inj. of local anaesthetic to need of rescue analgesia. patients heart rate, systolic blood pressure, respiratory rate, oxygen saturation monitored. also patient observed for accidental intravascular injection of drug, pleural puncture,anaphylaxis to local anaesthetic drugs. patient observed for postoperative side effects like nausea, vomiting, shivering, pruritus, dysthesia , peripheral neuropathy. statistical analysis: for analysis of this data spss (statistical software for social sciences) software version 20th was used.. demographic data was represented in form of meam, sd and percentages. it was analyzed using chi-square test to check association between two drugs, chi square test for trend and fisher exact test depending on type of data. for comparison of quantitative variables of two groups, unpaired t-test was used and it was also represented in form of mean and sd etc. the duration of surgery and duration of analgesia was analyzed and evaluated by one way anova. vital parameters like pulse rate, systolic blood pressure, respiratory rate, oxygen saturation were analyzed by unpaired t test. statistical signicance was indicated by conventional symbols: p <0.05: statistically signicant, p >0.05: statistically non-signicant. results: demographic parameters like age, gender, weight, height, bmi,asa grade,duration of surgery were comparable in the two groups.(table 1) table 1: demographic characteristics there was statistically signicant difference between group a and group b when onse t t ime o f sensor y b lock considered(p<0.0001). there was statistically signicant difference in mean time of onset of motor block when group a and b compared(p<0.0001). regarding duration of sensory block the difference was statist ically signicant( p<0.0001).the duration of motor block was statistically signicantwhen group a and group b compared(p<0.0001). a statistically non-signicant difference was observed amongst the groups regarding duration of analgesia th(p=0.08). at 10 hr, mean vas scores was more than 3 in both groups and statistically not signicant (p = 0.746).( table 2) table 2: nerve block characteristics the quality of surgical anaesthesia in group a and group b was excellent in 100% of patients .(table 3) table 3: quality of surgical anaesthesia on comparison, no statistically signicant difference was found in both the groups with respect to pulse rate (p value >0.05) (chart 1) or with respect to systolic blood pressure (p value >0.05).( chart 2) chart 1: heart rate at different time intervals (beats per minute) chart 2: systolic blood pressure at different time intervals (mm hg) volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra demographic parameters group a (n=30) mean ± s.d. group b (n=30) mean ± s.d. p value age (years) 34.37 ± 10.516 36.87±11.74 0.38 male (%) female (%) 22 (73.3%) 08 (26.7%) 21(63%) 09(27%) weight (kg) 60.00± 6.878 58.80±7.540 0.52 height (cm) 159.27 ± 6.40 159.27±6.400 0.99 bmi 23.73±3.085 23.14±2.40 0.41 grade i asa grade ii 25 (83.3%) 26(86.70%) > 0.05 05 (16.7%) 04 (13.3%) duration of surgery 118±31.55 119.83±43.51 0.91 block characteristics group a mean ± sd group b mean ± sd tvalue pvalue onset of sensory block 3.58 ± 0.631 1.07±0.173 21.012 0.0001 onset of motor block 7.53± 0.571 2.33±0.467 38.88 0.0001 duration of sensory block 426±24.011 507.33±19.46 -18.37 0.0001 duration of motor block 393±20.536 488.67±17.76 -19.30 0.0001 duration of analgesia 618±27.96 634±40.73 -1.77 0.08 thvas score at 10 hr 2.67+0.547 2.63+0.490 0.30 0.746 scale group a (%) (n=30) group b (%) (n=30) p value excellent 30(100%) 30(100%) >0.05 good 00 00 fair 00 00 poor 00 00 two patient in each group complained of nausea and vomiting. two patient in group a and one patient in group b complaint of vomiting. one patient of each group had pruritus. incidence was found to be statistically insignicant amongst the groups (p > 0.05). discussion: in our study,demographic parameters like age, gender, height, weight, bmi, asa grade, duration of surgery were comparable and similar to many other studies. in congruence to our study,sensory block onset was earlier with 10 levobupivacaine in one study, early with ropivacaine in 11, 12another study but few studies had equal onset in both 13,14,15,16groups similar to our study, motor block onset was early 10with laevobupivacaine but in other study early with 11,17ropivacaine and equal in both groups in remaining 12,14,15studies onset is related to the intrinsic physiochemical properties of individual local anaesthetic agents. physicochemical propert ies include the pka and hydrophobicity of local anaesthetics. ropivacaine is about 10 times less lipophilic than levobupivacaine and is resistant to 18rapidly penetrating myelinated nerve bres. when onset time compared for sensory and motor block , it was earlier with sensory block as small myelinated axons, a gamma and a delta sensory bres are most susceptible to block followed 18by large myelinated a alpha and a beta bres similar to our study, sensory block duration was longer with 14-17levobupivacaine, but equal duration in both groups seen in 19 one study similar to our study, duration of motor block was 14,16longer with levobupivacaine while other studies found 15,19,20equal duration in both groups. .duration of block is inuenced by the peripheral vascular effects of local anaesthetic drugs. many local anaesthetic drugs have a biphasic action on vascular smooth muscle. they cause vasoconstriction at lower concentration and vasodilatation at higher concentration. effect of local anaesthetics on vascular tone and regional nblood ow are complex and vary according to concentration, time, particular vascular bed, 18among other factors. similar to our study quality of surgical anaesthesia was 12,1,17,19comparable in few studies but high success with 11ropivacaine seen in one study. dissimilar from our nding one study needed intraoperative supplementation of 19analgesics. small diameter axons such as c bres concerned with touch, pain are often stated to be more susceptile to local anaesthetic block than large diameter bres such as a bres, concern wi th motor and 18proprioception. duration of analgesia was found to be of 10-12,15,19,20equal duration similar to our study but other studies 13,14,16found prolonged analgesia with laevobupivacaine . 10,15,19,20similar to our study vas score was equal in other studies it is widely believed that benet of adding clonidine is to improve the quality of block. studies comparing ropivacaine and ropivacaine with clonidine has shown advantage in few 21,22block characteristics while other studies did not found 22advantage in some block parameters. by adding clonidine studies comparing laevobupivacaine and laevobupivacaine 23with clonidine found advantage of clonidine but other study 24 found no advantage. study with clonidine added to both groups showed prolonged duration of analgesia and delayed need of rescue analgesics in laevobupivacaine-clonidine 25group which did not agree with our study. in a study comparing intravenous versus perineural clonidine there was no difference in onset but duration of analgesia prolonged with intravenous clonidine. clonidine acts on alpha 2 receptors in the central nervous system that is locus coeruleus and dorsal horn of spinal cord. alpha 2 receptors 26are not present in the normal peripheral nerves. data regarding effect of peripheral clonidine on quality of surgical anaesthesia is inadequate. in our study we think clonidine in dose of 1ug/kg contributed to excellent quality of surgical anaesthesia. haemodynamic parameters stable and comparable in both 14groups similar to our study. in our study minimal side effect 14,16seen while other studies did not show side effects. conclusions: laevobupivacaine with clonidine and ropivacaine with clonidine provides comparable brachial plexus block by infraclavicular route for lower arm surgeries. 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feng s. ropivacaine versus levobupivacaine in peripheral nerve block: a prisma-compliant meta-analysis of randomized controlled trials. medicine. 2017 apr;96:14. 7. pöpping dm, elia n, marret e, wenk m, tramèr mr. clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocksa meta-analysis of randomized trials. anesthesiology. 2009 aug 1;111(2):406-15. 8. kirksey ma, haskins sc, cheng j, liu ss. local anesthetic peripheral nerve block adjuvants for prolongation of analgesia: a systematic qualitative review. plos one. 2015 sep 10;10(9):e0137312. 9. brummett cm, williams ba. additives to local anesthetics for peripheral nerve blockade. international anesthesiology clinics. 2011;49(4):104-116. 10. mageswaran r, choy yc. comparison of 0.5% ropivacaine and 0.5% levobupivacaine for infraclavicular brachial plexus block. med j malaysia. 2010;65(4):300–305. 11. palmisani s, arcioni r, di benedetto p, de blasi ra, mercieri m, ronconi p. ropivacaine and levobupivacaine for bilateral selective ankle block in patients undergoing hallux valgus repair. acta anaesthesiologica scandinavica. 2008;52(6):841–844 12. messina m, magrin s, bignami e, maj g, carozzo a, mennella r, landoni g, zangrillo a. prospective randomized, blind comparison of ropivacaine and levobupivacaine for supercial plexus anesthesia in carot id endoarterectomy. minerva anestesiologica. 2009;75(1-2):7-12. 13. casati a, vinciguerra f, santorsola r, aldegheri g, putzu m, fanelli g. sciatic nerve block with 0.5% levobupivacaine, 0.75% levobupivacaine or 0.75% ropivacaine: a double-blind, randomized comparison. european journal of anaesthesiology. 2005;22(6):452–456. 14. fournier r, faust a, chassot o, gamulin z. levobupivacaine 0.5% provides longer analgesia after sciatic nerve block using the labat approach than the same dose of ropivacaine in foot and ankle surgery. anesthesia & analgesia. 2010;110(5):1486–1489. 15. dang cp, langlois c, lambert c, nguyen j-m, asehnoune k, lejus c. 0.5% levobupivacaine versus 0.5% ropivacaine: are they different in ultrasoundguided sciatic block? saudi journal of anaesthesia. 2015;9(1):3. 16. malav k, singariya g, mohammed s, kamal m, sangwan p, paliwal b. comparison of 0.5% ropivacaine and 0.5% levobupivacaine for sciatic nerve block using labat approach in foot and ankle surgery. turkish journal of anaesthesiology and reanimation. 2018 feb;46(1):15-20. 17. puig mm, gonzález-suárez s, pacheco m, roigé j. comparative study of ropivacaine 0.5% and levobupivacaine 0.33% in axillary brachial plexus block.reg anesth pain med 2009;sep-oct;34(5):414-9 18. ronald miller, lars eriksson,lee feisher et al. miller’s anaesthesia 8th edition, philadelphia elseiver-health sciences division 2014 chapter 36. local anaesthetics; pages 1028-1055 19. hanna m, sloan p. a comparison of levobupivacaine and ropivacaine for interscalene and femoral nerve blocks: a randomized, double-blind, prospective clinical trial. journal of anesthesia and clinical research. 2011 may;2(5):135. 20. watanabe k, tokumine j, lefor ak, moriyama k, sakamoto h, inoue t, et al. postoperative analgesia comparing levobupivacaine and ropivacaine for brachial plexus block: a randomized prospective trial. medicine. 2017;96(12). 21. patil kn, singh nd. clonidine as an adjuvant to ropivacaine-induced supraclavicular brachial plexus block for upper limb surgeries. journal of anaesthesiology, clinical pharmacology. 2015 jul;31(3):365. 22. bafna u, yadav n, khandelwal m, mistry t, chatterjee cs, sharma r. comparison of 0.5% ropivacaine alone and in combination with clonidine in supraclavicular brachial plexus block. indian journal of pain. 2015 jan 1;29(1):41. 23. wilson e, kabade sd, sebastian s. clonidine as an adjuvant to levobupivacaine in supraclavicular brachial plexus block-a randomized double-blind control study.j evid based med health 2018;5(25)1893-1897 24. fournier r, faust a, chassot o, gamulin z. perineural clonidine does not prolong levobupivacaine 0.5% after sciatic nerve block using the labat x 53gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra approach in foot and ankle surgery.regional anaesthesia and pain medicine,vol37,issue 5, 2012 25. senapati s, basu a, bhattacharya d, hazra s, sarkar d, dandapat p. comparison of analgesic effect of intra-articular administration of levobupivacaine and clonidine versus ropivacaine and clonidine in day care knee arthroscopic surgery under spinal anesthesia. indian journal of pain. 2016 jan 1;30(1):38. 26. mannion s, hayes i, loughnane f, murphy db, shorten gd. intravenous but not perineural clonidine prolongs postoperative analgesia after psoas compartment block with 0.5% levobupivacaine for hip fracture surgery. anesthesia & analgesia. 2005 mar 1;100(3):873-8. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 54 x gjra global journal for research analysis introduction 1. more than 40 percent of the world`s population, in more than 100 countries is under the risk of infection . 2. every year 2500 million people worldwide get infected with various mosquito born diseases. 3. scientists had studied the insecticidal properties in the plants ocimum sanctum, azardirachta indica, vitex negundo and eucalyptus globulus. 4. synthetic chemicals are hazardous to the environment and human health hence we have selected plants with insecticidal properties to prepare mosquito repellent. material and methods the selection of the plants was based on their local availability and their insecticidal properties. the selected plants ocimum sanctum (tulsi), azardirachta indica (neem), vitex negundo (nirgudi), eucalyptus globulus (nilgiri) were collected from local areas in two months august and september ,2018. ÿ the fresh leaves of the selected plants were collected, washed with distilled water, dried in shed and powdered . ÿ the dried powder of leaves of o. sanctum, a. indica, and v. negundo as 30 gram each and e. globulus 10 gram as total 100 gram powder was extracted in ethanol by soxhlet method. ÿ the extraction was ltered and then ltrate was evaporated under reduced pressure yielding crude. ÿ the repellent extract was prepared with 5%, 10%, 15%, 20% and 25% concentrations in 70 % ethanol. ÿ these concentrations were tested in the closed glass jars against mosquitoes for 30 min. twenty mosquitoes were used in each jar. then percentage mortality was observed. observation table result and discussion different concentrations such as 5%, 10%, 15%, 20% and 25% were used in different glass jars and 10%,20%,60%,75% and 100% mortality of mosquito was observed at different concentrations after 30 min. of exposure. from these observations it is found that 25% concentration of mosquito repellent spray is more effective and shows 100% mortality. the spray was reported to be eco-friendly and not toxic to human being. similar type of results were observed by jang et al. (2002), cavalcanti et al., (2004), arunpandiyan (2011), marimuthu and rajamohan (2011) and injal et al. (2017) also reported that the repellent sprays were good insect repellents and excellent results were found against mosquitoes. in our results mortality is due to insecticidal property of the plant extract. hence the repellent prepared by extract of leaves of plants o. sanctum, a. indica, v. negundo and e. globulus. found more effective due to there synergistic action in the control of mosquito. it is also found that this repellent is nausea and irritation free. conclusion 1. herbal mosquito repellent spray prepared from the local plants is a best source of protection from mosquitoes in college campus. 2. there is no skin irritations observed during it's a spray time. 3. the study revealed that this mosquito repellent plant extract has no side effect on human health. besides this, the repellent is very cheap and can be easily prepared by common man. 4. hence the herbal spray is a promising product to protect everybody from mosquitoes and disease caused due to bite of mosquitoes. acknowledgement authors are thankful to prin. dr. r.v.shejawal lal bahadur shastri college of arts and science and commerce , satara and head of department of zoology for constant support during this research work. use of various plant extracts as herbal mosquito repellent spray original research paper s. m. pawar p.g. dept. of zoology, lal bahadur shastri college of arts, science and commerce. satara x 33gjra global journal for research analysis medicine the present study is conducted to determine the mosquito repellent activity in some indigenous plants ocimum sanctum (tulsi), azadirachta indica ((neem), vitex negundo (nirgudi) and eucalyptus globulus (nilgiri) which are known for insecticidal property. whereas mixture of powder of leaves of these plants is used in 30:30:30:10 proportion respectively. different concentrations of this mixture such as 5%, 10%, 15%, 20% and 25% are used to prepare ethanol extract. it is observed that 25 % concentration is more effective. it is also observed that the smell of this repellent is pleasant and there is no any nausea or skin irritation. this extract can be used in preparation of repellent sprays and sticks to control mosquito. abstract keywords : ocimum sanctum, azadirachta indica, vitex negundo, eucalyptus globulus and mosquito repellent m. p. gujar* p.g. dept. of zoology, lal bahadur shastri college of arts, science and commerce. satara *corresponding author p. p. yadav p.g. dept. of zoology, lal bahadur shastri college of arts, science and commerce. satara volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra v. b.supugade p.g. dept. of zoology, lal bahadur shastri college of arts, science and commerce. satara r. g. patil p.g. dept. of zoology, lal bahadur shastri college of arts, science and commerce. satara concentration % time of exposure in hrs mortality % 5 6 10 10 6 20 15 6 60 20 6 75 25 6 100 34 x gjra global journal for research analysis references 1. al-sharook z, balan k, jiang y, rembold h (1991): insect growth inhibitors from two tropical meliaceae. effect of crude seed extracts on mosquito larvae, j. appl. ent. 111, 425–430. 2. cavalcanti esb, de morais sm, ashley alm, william pse. (2004): larvicidal activity of essential oils from brazilian plants against aedes aegypti l. memo´ rias do instituto oswaldo cruz 99, 541–544. 3. jang ys, kim mk, ahn yj, lee hs (2002) : larvicidal activity of brazilian plants against aedes. aegypti and culex pipiens pallens (diptera: culicidae). agric. chem. biotechnol. 44, 23–26. 4. g. arunpandiyan (2011) : toxicity of aqueous crude neem leaf extract against culexmosquitoes, int j pharm biomed sci, 2(1), 1-3. 5. marimuthu g. and rajamohan s. (2011): mosquito adulticidal and repellent activities of botanical extracts against malarial vector, anopheles stephensi liston (diptera: culicidae). asian pacic journal of tropical medicine.; 4(12):941-947. 6. a. s. injal, a. p. sagar, s. s. kshirsagar and t. kulkarni (2017): technical approach to prepare mosquito repellents using different natural plants extracts, international journal of innovative and applied research, 5 (12), 2026. 7. rajkumar s, jebanesan a. (2005), oviposition deterrent and skin repellent activities of solanum trilobatum leaf extract against the malarial vector anopheles stephensi. j insect sci, 5, 15. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction hyponatremia is the most common electrolyte abnormality in hospitalized patients and is frequently encountered in the intensive care setting. treatment varies signicantly according to the timing of onset and etiology of the disorder. inadequate or improper treatment may lead to brain edema or demyelination with life-threatening consequences. hyponatremia, or low blood sodium, is frequently dened as serum sodium concentration < 135 meq/l, and it represents a 1, 2relative excess of total body water to sodium. hyponatremia is common in hospitalized patients, occurring .3in 30% to 40% of patients with a serum sodium of <135 meq/l devita et al found that approximately 25% to 30% of patients admitted to an intensive care unit (icu) had hyponatremia 4dened as serum sodium <134 meq/l. the clinical presentation has a wide spectrum and varies from patient to patient, from being asymptomatic, to ones having seizures and coma. most of the patients with hyponatremia have either non-specic symptoms or symptoms due to underlying system involved. although majority of cases are mild and asymptomatic, hyponatremia is important clinically because acute severe hyponatremia can cause substantial morbidity and mortality. the aim of this study is to evaluate the clinical features and etiology of hyponatremia in patients admitted a tertiary care hospital. materials and methods the present 1-year cross-sectional observational study included 100 adult patients with moderate-to-severe hyponatremia admitted under the department of medicine from october 2012 to april 2014. patients aged ≥18 years with moderate-to-severe hyponatremia (≤125 mmol/l) admitted to the micu were included in the study. the exclusion criteria comprised of cases with hyperglycemia, hyperlipidemia, and proteinemia. ethical clearance was obtained from the institutional ethical committee and after explaining the purpose of the study. written consent from all the participants was obtained before data collection. instrumentation demographic data, including age and sex, were obtained from the patients. a history of other comorbid conditions along with presenting complaints was noted. further, these patients were subjected to a physical examination for evaluating the clinical signs. the patients underwent the investigations including, complete blood count, random blood sugar, liver function tests, renal function tests, serum osmolality, urine osmolality, serum sodium, and urine sodium. based on the investigations, the type of hyponatremia was determined as euvolemic hypoosmolar, hypervolemia hypoosmolar, and hypovolemic hypoosmolar. following this categorization, the etiology was determined and evaluated in different types of hyponatremia. all data thus obtained was entered in a structured proforma. results a total of 100 patients were studied who were admitted with hyponatremia to hospitals under kasturba medical college, mangalore between october 2012 and april 2014. the maximum numbers of patients were in the age group of 6170(28%).there were more males than females in the study. the total of 30% was asymptomatic with documented hyponatremia. the lowest serum sodium amongst asymptomatic patients was 109. among those who were symptomatic (symptoms pertaining to hyponatremia) most of them had a combination of symptoms. about 40% had lethargy, 19% had disorientation, 19% had vomiting, 12% had anorexia, 5% patients had seizure, 2 % patients had coma, 1% patients had hiccups. hypotonic hyponatremia was seen in 68 patients, 17 patients had isotonic hyponatremia, 15 patients had hypertonic hyponatremia. fig.1: symptoms at presentation pre existing illness: in our study, 14 patients had hypertension, 12 patients had diabetes mellitus, 6 patients had chronic kidney disease. ten patients had history of tuberculosis, 11 patients had retroviral disease. hyponatremia – etiology and clincal presentation in a tertiary care center original research paper dr muralidhara yadiyal associate professor, department of medicine. kasturba medical college, mangalore. manipal academy of higher education, manipal, karnataka 576104. x 21gjra global journal for research analysis medicine keywords : dr taha parweiz post graduate, department of medicine. kasturba medical college, mangalore. manipal academy of higher education, manipal, karnataka 576104. dr christopher pais professor, department of medicine. kasturba medical college, mangalore. manipal academy of higher education, manipal, karnataka576104 dr mayoor prabhu* assistant professor, department of nephrology. kasturba medical college, mangalore. manipal academy of higher education, manipal, karnataka 576104.*corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 22 x gjra global journal for research analysis fig.2: pre-existing illness systems involved at presentation: a total of 23 patients had pulmonary disorder, 14 patients had gasterointestinal disorder, 13 patients had neurological disease, 12 patients had malignancy, 9 patients had renal disorder, 29 patients had other disorders (endocrine, haematological). volume status: largest proportion of patients was euvolemic (61 patients). others were hypovolemic (25 patients), hypervolemic (14 patients). among the 61 patients with euvolemia, 38 patients had siadh. table 1: laboratory parameters of cases that presented with hyponatremia aetiology of hyponatremia: forty four patients fullled the criteria for siadh. twenty ve patients had depletional hyponatremia and twelve patients had dilutional hyponatremia. six patients had pseudo hyponatremia. twelve patients had multiple aetiologies causing hyponatremia, amongst these, 4 patients had siadh plus depletional hyponatremia, other causes being hypopitutarism with hypocortisolism (patient no. 25), hypopitutarism + depletional + siadh (patient no. 61), hypothyroidism + siadh (patient no.2, 73), siadh + drug induce hypocortisol hyponatremia (patient no.84), hypocortisol/drug induced depletional (patient no. 85), depletional with primary hyperaldosteronism (patient no. 91). pseudohyponatremia + polydipsia (patient no. 32). one patient was undiagnosed. fig.3 : aetiology of hyponatremia aetiology of siadh: amongst patients with siadh, 13 cases were due to malignancy, 8 cases had cerebrovascular accident, 6 had hiv associated condition, 4 had pneumonia, 3 had pulmonary tuberculosis. cause could not be determined for rest of the cases. aetiology of depletional hyponatremia (25 cases): in fifty percent patients hyponatremia was drug induced, 25% was due to vomiting and rest, due to pulmonary tuberculosis, lower respiratory tract infection, urosepsis, etc. amongst drug induced depletional hyponatremia (12cases), all the patients were on thiazide diuretics. amongst dilutional hyponatremia: majority (6 cases) were due to decompensated chronic liver disease. aetiology in patients with severe hyponatremia (sodium < 120): siadh (12 patients), depletional (13 patients), dilutional (4 patients) , mult iple et iological factors causing hyponatremia (9 patients). amongst the patients with depletional hyponatremia, thiazide diuretics were the cause in 50% patients. discussion our study was conducted on 100 patients who presented with hyponatremia (serum sodium less than 135 meq/l). out of the 100 patients studied there were 61% males and 39% females with a ratio of 1.56:1.the mean age of presentation in our study was 58.8, which was comparable to study by anderson et al 5where the mean age was 58. incidence of hyponatremia has been shown to have direct 6correlation with age. in our study most of the patients were in the age group of 41-80yrs (83%), while maximum number of patients were in the age group of 61-70 yrs (28%). multiple co morbidities like hypertension and diabetes mellitus are present in this age group where the disease or treatment is likely to predispose a patient to hyponatremia. use of diuretics is also common among the elderly patients, which has been a major cause of hyponatremia in hospitalized patients. hawkins et al noted that increasing age, was independent ly associated wi th hyponatremia at 6 presentation. a study done by chen et al on elderly patients also showed that nutritional status is also a risk factor in 7developing hyponatremia in elderly. in our study 70% of the patients had symptoms attributable to hyponatremia at presentation. the rest of the patients (30%) did not have evident clinical manifestations of hyponatremia, but presented with the symptoms of the system involved. respiratory system was the commonest system involved (23%). other systems involved were gastrointestinal (14%), renal (9%) and neurological (13%). the commonest symptom of presentation was lethargy (40%) followed by vomiting (19%). amongst the other symptoms at presentation were neurological symptoms like disorientation (19%), seizure (5%) and coma (2%). lethargy was also the commonest symptom in patients with severe hyponatremia (sodium <120 meq/l) followed by disorientation (11 patients). in a study by nzerue et al on outcome of hyponatremia in hospitalized patients, 52.9% patients had neurological 8manifestations. these included seizures, reduced consciousness level, confusion, unsteadiness and falls. in the study we conducted, 31% patients had varied neurological manifestations of hyponatremia. the reason for this difference being, the former study was conducted only on patients with severe hyponatremia. in a study by aasina yawar et al in karachi, a quarter of patients presented with 9neurological manifestations, which was similar to our results. major pre-existing illness amongst our patients was hypertension (14%), diabetes mellitus (12%) and retroviral disease (12%). volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra s. no laboratory parameter n range mean standard deviation 1 plasma glucose (mg/dl) 86 73 522 151.12 92.96 2 serum urea (mg/dl) 100 7 162 34.17 25.39 3 serum creatinine (mg/dl) 100 0.3 7.7 1.24 1.16 4 serum sodium (meq/l) 100 100 134 122.23 9.22 5 serum triglyceride (mg/dl) 75 20 276 104.95 55.40 6 serum potassium (meq/l) 98 1.6 6.3 4.14 0.81 7 serum protein (g/dl) 64 4 9.5 6.74 0.97 8 serum uric acid (mg/dl) 92 0.9 10.60 3.70 1.84 9 serum osmolality mosmol/kg serum water) 100 199 350 264.68 25.28 10 serum tsh (miu/l) 92 0.10 14.79 2.10 1.88 11 serum cortisol (mg/dl) 87 1.34 338.7 33.95 38.95 12 spot urine sodium (meq/l) 99 4 215 60.50 40.82 13 urine osmolality (mosmol/kg serum water) 97 66 892 351.84 177.16 hyponatremia can be classied into hypotonic and non hypotonic. non hypotonic hyponatremia has been further c lass ied in to iso tonic hyonatremia, hyper tonic 10,11 hyponatremia and pseudo hyponatremia. in our study 68% of the patients had hypotonic hyponatremia, 17% had isotonic hyponatremia, 15% had hypertonic hyponatremia. all the patients were classied as hypovolemic, euvolemic or hypervolemic depending on the volume status which was determined by clinical evaluation. it was found that 61% of the patients were euvolemic, 25% were hypovolemic and 14% were hypervolemic. this was similar to the other studies, 12 13hochman (50%) and nandini et al (50.74%), which showed maximum percentage of euvolmic patients. according to a study done by berghmans t, siadh was found 14 to be the most frequent cause of hyponatremia. in our study, 44 patients out of 100 fullled the criteria for siadh which was the leading cause of hyponatremia. similarly in another indian study done by my rao et al in elderly, commonest 15cause of hyponatremia was found to be siadh. a common cause of hyponatremia in patients with cancer is syndrome of inappropriate secretion of antidiuretic hormone (siadh) which may result from ectopic production of argentine vasopressin (avp) by tumor tissue. in our study 13 out of 44 patients with siadh had cancer, commonly head and neck. other risk factors which increased the possibility of hyponatremia were chemotherapy, vomiting, pain, narcotic drugs and physical and emotional stress. other causes of siadh being cerebrovascular accident (8 cases) and hiv associated conditions (6 cases). four patients had pneumonia, 4 had pulmonary tuberculosis, while cause could not be determined for rest of the 11 cases. depletional hyponatremia (hypovolemic hyponatremia) was detected in 25% of the cases, this being the second most common cause of hyponatremia. a commonest cause of depletional hyponatremia was found to be drug induced (50%). all of the 12 patients with drug induced hyponatremia were on thiazide diuretics. hyponatremia is a common complication of thaizide diuretics, as seen in studies by byatt 16, 17cm and sunderam sg. vomiting is a strong inducer of adh release.in our study, out of 25 patients of depletional hyponatremia, 5 were due to vomiting. gasteroenteritis was the commonest cause for vomiting (4 patients). dilutional hyponatremia was seen in chronic liver disease (6 patients), copd corpulmonale (2 patients), dialated cardiomyopathy (1 patient), chronic kidney disease (2 patients) and ascites due to ovarian mass (1 patient). pseudohyponatremia is a falsely low serum sodium measurement. it occurs in cases of extreme hyperlipidemia or hyperproteinemia when serum sodium is measured by some 18laboratory methods. in our study 6 patients were diagnosed as pseudohyponatremia, 2 patients had hyperlipidemia, 1 patient had hyperproteinemia and 3 patients had hyperglycemia. twelve percent of the patients in our study had multiple etiologies. previously it has been seen that in varying proportion of patients hyponatremia has been attributed to a 19multiple etiologies. a couple of studies by clayton et al and 8nzerue et al had 75% and 10.9% patients with hyponatremia due to multiple etiologies. it is important to determine all the factors causing hyponatremia as the treatment depends on the etiology and thus correct measures could be taken accordingly. mean value of sodium in our study was 122.23 meq/l (100 meq/l – 134 meq/l). this was a little lower than mean 13obtained by study done by nandini et al. plasma glucose level was calculated in 86 patients with range varying from 73-522 mg/dl. it was this high glucose values w h i c h w a s r e s p o n s i b l e f o r t h e p r e s e n c e o f pseudohyponatremia in our study. similar observation holds true for serum triglycerides (range 20-276 mg/dl). evaluation of serum osmolality was done in all 100 patients and mean value was determined to be 264.68 mosmol/kg water which goes well with our observation that most of the cases studied were true hyponatremias (serum osmolality < 280 mosmol/kg serum water). the mean value of spot urine sodium was 60.50 meq/l. this was because of the fact that the common aetiology of hyponatremia was siadh. in patients with severe hyponatremia (sodium < 120, n = 38), the commonest aetiology was depletional hyponatremia (13 patients). siadh was the next common cause (12 patients). 20this was similar to the study done by wong r et al , in which they had obtained similar results. conclusion based on the ndings of this study, it may be concluded that hyponatremia can present with varied clinical manifestations. the presentation can vary from mild symptoms such as vomiting, lethargy, and malaise to severe forms such as confusion, seizure, and coma. majority of patients report cns symptoms and these patients are likely to have euvolemic hypoosmolar hyponatremia with siadh as the predominant cause. clinicians need to be aware about the common occurrence of hyponatremia, its early identication, and its association with a large variety of diseases. therefore, evaluating for the cause of hyponatremia is equally important, as treating the underlying cause would prevent considerable morbidity and mortality associated with this enigmatic electrolyte disorder. annexures ethics committee approval x 23gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra proforma 1. patient's name: date: 2. age: 3. sex: 4. date of admission: 5. symptoms: a) lethargy / disorientation / muscle cramps / agitation. b) shortness of breath / orthopnea. c) fever / cough / haemoptysis. d) distension of abdomen / hiccups / anorexia / vomiting. e) weight loss. f) focal neurological decit / hoarseness of voice / dysphagia. g) coma / seizures. h) excessive water intake. 6. past history: similar episode / tuberculosis / renal failure / hypothyroidism / adrenal insufciency / steroid intake. 7. personal history: menstrual history. 8. treatment history: thiazides / nicotine/ chlorpropamide / tolbutamide / clobrate / cyclophosphamide / morphine / barbiturate / vincrist ine / carbamezapine / a c e t a m in o p h e n / n s a i d s / a n t ip s y c h o t i c s / antidepressants / heparin. 9. general examination: level of consciousness / built / pallor / icterus / cyanosis / clubbing / lymphnodes / pedal oedema / thyroid. 10. vitals: temp: pulse: blood pressure: respiratory rate: 11. systemic examination: a) cardiovascular system. b) respiratory system. c) gastrointestinal system. d) central nervous system examination. 12. investigations: ÿ serum glucose: ÿ serum urea: ÿ serum creatinine: ÿ serum electrolytes: sodium / potassium. ÿ serum triglyceride: ÿ serum uric acid: ÿ urine osmolality: ÿ spot urine sodium: ÿ serum osmolality: ÿ t.s.h: ÿ serum cortisol: ÿ hiv spot test: ÿ serum protein: 13. radiological examination: ÿ chest x ray (optional) ÿ ultrasound abdomen (optional) references 1. waikar ss, mount db, curhan gc. mortality after hospitalization with mild, moderate, and severe hyponatremia. am j med. 2009;122(9):857-865. 2. douglas i. hyponatremia: why it matters, how it presents, how we can change it. cleve clin j med. 2006;73(suppl 3):s4-s12. 3. upadhyay a, jaber bl, madias ne. incidence and prevalence of hyponatremia. am j med. 2006;119(7 suppl 1):s30-s35. 4. devita mv, gardenswartz mh, konecky a, zabetakis pm. incidence and etiology of hyponatremia in an intensive care unit. clin nephrol. 1990;34(4):163-166. 5. anderson rj, chung hm, kluge r, schrier rw. hyponatremia: a prospective analysis of its epidemiology. ann intern med. 1985 feb;102(2):164-8. 6. hawkins rc. age and gender as risk factors for hyponatremia and hypernatremia. clin chim acta. 2003;337:169 –172. 7. chen lk, lin mh, hwang sj, chen tw. hyponatremia a among the institutionalized elderly in 2 long-term care facilities in taipe. j chin med assoc. 2006 mar;69(3):115-9. 8. nzerue cm, baffoe-bonnie h, you w, falana b, dai s. predictors of outcome in hospitalized patients with severe hyponatremia. j natl med assoc. 2003 may;95(5):335-43. 9. yawar a, jabbar a, haque nu, zuberi lm, islam n, akhtar j. hyponatraemia: etiology, management and outcome. j coll physicians surg pak. 2008 aug;18(8):467-71. 10. davison am, cameron js, grünfeld j-p, kerr dns, ritz e, winearls cg, editors. oxford textbook of clinical nephrology. 2nd ed. vol. 1. oxford, england: oxford university press, 1998. p. 175-200. 11. adrogué hj, wesson de. salt & water. boston: blackwell scientic, 1994:205-84. 12. hochman i, cabili s, peer g. hyponatremia in internal medicine ward patients: causes, treatment and prognosis. isr j med sci. 1989 feb;25(2):73-6. 13. nandini c, nilanjan s, chanchal d, atanu rc, ashis kb, salil kp. a descriptive study of hyponatremia in tertiary care hospital in eastern india. indian j endocrinol metab. 2012 apr;16(2):288-4. 14. berghmans t, paesmans m, body jj. a prospective study on hyponatraemia in medical cancer patients: epidemiology, aetiology and differential diagnosis. support care cancer 2000;8:192-7. 15. rao my, sudhir u, anil kumar t, saravanan s, mahesh e, punith k. hospitalbased descriptive study of symptomatic hyponatremia in elderly patients. j assoc physicians india. 2010 nov;58:667-9. 16. byatt cm, millard ph, levin ge: diuretics and electrolyte disturbances in 1000 consecutive geriatric admissions. j r soc med 83:704-708, 1990. 17. sunderam sg, mankikar gd: hyponatraemia in the elderly. age ageing 12:77-80, 1983. 18. weisberg ls. pseudohyponatremia: a reappraisal [review]. am j med. 1989;86:315-318. 19. clayton j.a., le jeune i.r. and hall i.p. severe hyponatraemia in medical inpatients:aetiology, assessment and outcome. q j med 2006;99:505–511. 20. vu t, wong r, hamblin ps, zajac j, grossmann m. patients presenting with severe hypotonic hyponatremia: etiological factors, assessment, and outcomes. hosp pract (1995). 2009 dec;37(1):128-36. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 24 x gjra global journal for research analysis introduction india's population of over 1.3 billion is slated to overtake china as the world's most populous country. family planning is not only important for population stabilization, but is also [5]central for improvement of maternal and newborn health. india contributes to 20% of maternal deaths worldwide [6]according to a 2012 report of world bank, unfpa, who. family planning can avert more than 30% of maternal deaths and 10% of child mortality if couples spaced their pregnancies [7]more than 2 years apart. there is shift of focus of india's family planning program from mere population control to ensuring healthy timing and spacing of pregnancy to improve health of mother and newborn. government of india offers iucd services free of cost as it is one of the most effective, [5]reversible and safe contraceptive method. despite many advantages of the iucd , it is unpopular in india. use of modern contraceptive methods in the india is limited to about 48 % and that of iucd is as low as 1.5 % [8](nfhs 2015-16) . increased institutional deliveries after introduction of jsy(janani suraksha yojana) in india provides an opportunity to offer family planning services to the women, who have just delivered and want to prevent unintended pregnancies or delay having more children. taking advantage of the immediate postpartum period for counseling on family planning and iucd insertion, overcomes multiple barriers to [5]service provision. methods a prospective questionnaire based study conducted between st st 1 march 2016 to 31 march 2017 in the department of obstetrics & gynecology, netaji subhash chandra bose medical college & hospital, jabalpur (m.p.) who medical eligibility criteria was followed as a guide line. [9]it has four categories. :1. no restriction for the use. 2. advantages of using method outweigh the risks. 3. risks outweigh the advantages of using method. 4. unacceptable health risk if method used. inclusion criteria: all antenatal patients admitted for delivery and post partum patients in our hospital were counselled for ppiucd. consent was obtained from those, who opted for insertion. those who fullled the following criteria were considered for inclusion : ÿ 18–45 years old. ÿ desire to have cut after counselling before insertion. ÿ no local infections. ÿ hb>10gm% exclusion criteria: ÿ fever during labor and delivery. ÿ having active std(sexually transmitted disease) or other lower genital tract infection or high risk for std. ÿ known to have ruptured membranes for more than 18hrs prior to delivery. ÿ known uterine abnormalities e.g., bicornuate/septate, uterine myomas. post partum iud (ppiucd) insertion : it is the insertion of iud within 48 hours after delivery. it is of 3 types on the basis of insertion time. a. post placental insertion : insertion within 10 minutes following delivery of the placenta following a vaginal delivery. b. intra cesarean insertion: insertion that take place during a cesarean delivery, after removal of the placenta and before closure of the uterine incision. c. post partum before discharge: insertion of iud within 48 hours after delivery and before the women leaves the facility where she delivered. steps of iucd insertion : an informed consent taken and woman's records checked to ensure that she is an appropriate client, ruling out conditions which prevent iucd insertion . client explained about the a study of factors affecting acceptance & continuation of ppiucd original research paper dr. prof r. chauhan department of obstetrics & gynecology,n.s.c.b medical college , jabalpur , madhya pradesh , india obstetrics & gynaecology background: [1,2] india is presently the second most populous country in the world , soon to be on the top. the modern intrauterine contraceptive device (iucd) is one of the most cost effective method of [3,4]contraception with fewer side effects still underused in india. aim: to evaluate factors affecting acceptance & continuation of ppiucd in the department of obstetrics and gynecology , n.s.c.b medical college , jabalpur. methods: questionnaire based prospective study (march 2016 -17) on all antenatal and post partum patients who fullled the who medical eligibility criteria for ppiucd. results: acceptance was 53.3%, highest amongst 21-30 yrs age group (85.1%),in primi women(66.1%) & in patients counseled during antenatal period(53.1%).continuation rate was 77.7%.most common reason for discontinuation was bleeding . conclusions: antenatal counseling holds most important role. reassurance & awareness about the safety and efcacy of ppiucd should be emphasized. abstract keywords : ppiucd, awareness, contraception. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. sonal sahni* department of obstetrics & gynecology,n.s.c.b medical college , jabalpur , madhya pradesh , india *corresponding author dr. shaily hanumantaiya department of obstetrics & gynecology,n.s.c.b medical college , jabalpur , madhya pradesh , india 18 x gjra global journal for research analysis procedure and her queries answered . under all aseptic precautions iucd inserted with aid of ppiucd inserting forceps using a 'no-touch technique'. conrmation that the end of ppiucd insertion forceps has reached the fundus is done by the resistance offered and the thrust of the instrument felt at the fundus of the uterus with left hand placed on the abdomen. ppiucd insertion forceps after releasing iucd at fundus is swept to the right along the side wall of the uterus ensuring they are away from the iucd and thus removed from uterine cavity, keeping it slightly open. particular care taken not to dislodge the iucd as ppiucd insertion forceps are removed. cervix examined to ensure there is no bleeding and iucd is properly inserted. woman provided with post insertion instructions. information regarding the ppiucd insertion in the woman's record and in the ppiucd register recorded. at discharge women informed about the side effects, warning signs and follow up schedule and advised to report immediately in case of untoward signs. at follow up examinat ion pat ient 's sat is fact ion assessed and complications like bleeding, pain and infection were treated appropriately. in case of discomfort due to long thread , cutting short of thread was done. the women in whom the procedure was uneventful were requested to follow up at 6 months. results the study was conducted to evaluate ppiucd as a family planning method and the observations were as follows : after counselling of 1800 clients total 961 women accepted for ppiucd as method of contraception (53.3%). volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 1 parity no. of cases ( n= 961) % follow up cases (n=492) continued discontinued total (492) no. of cases % no. of cases % <20 yrs 93 9.7% 32 66.7% 16 33.3% 48 21-30 yrs 818 85.1% 330 78.9% 88 21.1% 418 31-40 yrs 44 4.6% 18 78.3% 5 21.7% 23 >40 yrs 6 0.6% 2 66.7% 1 33.3% 3 table no. 1 shows that maximum acceptance was among 2130 years age group while continuation was high among 21 to 40 years aged patients. table 2 impact of parity on acceptance and continuation rates ppiucd parity no. of cases ( n= 961) % follow up cases (n=492) continued discontinued total (492) no. of cases % no. of cases % primi 635 66.10% 250 77.6% 72 22.4% 322 second 260 27.10% 105 76.6% 32 23.4% 137 multi 66 6.90% 27 81.8% 6 18.2% 33 table no. 2 shows that acceptance was highest among primi para clients while continuation rates were marginally raised among the multipara clients. table 3 impact of socio-demographic characteristics on acceptance of ppiucd as a method of contraception characteristics no. of cases ( n= 961) % follow up cases (n=492) continued (382) discontinued (110) total (492) no. of cases % no. of cases % religion hindu 894 93% 362 77.2% 107 22.8% 469 muslim 53 5.5% 17 85% 3 15% 20 others 14 1.5% 3 100% 0 0.0% 3 locality rural 602 62.6% 282 77.5% 82 22.5% 364 urban 359 37.4% 100 78.1% 28 21.9% 128 type of family nuclear 410 42.7% 212 77.7% 61 22.3% 273 joint 551 57.3% 170 77.6% 49 22.4% 219 socio-economic status lower 479 49.8% 186 79.8% 47 20.2% 233 middle 437 45.5% 172 74.5% 59 25.5% 231 upper 45 4.7% 24 85.7% 4 14.3% 28 education of client no formal education 186 19.4% 87 82.1% 19 17.9% 106 primary 254 26.4% 102 85% 18 15% 120 high school 476 49.5% 175 72% 68 28% 243 graduate 45 4.7% 18 78.3% 5 21.7% 23 education of partner no formal education 74 7.7% 35 85.4% 6 14.6% 41 primary 204 21.2% 89 79.5% 23 20.5% 112 high school 532 55.4% 194 76.7% 65 23.3% 259 graduate 151 15.7% 64 80% 16 20% 80 occupation of client home maker 751 78.1% 294 76.7% 92 23.8% 386 farmer 14 1.5% 6 85.7% 1 14.3% 7 labourer 133 13.8% 58 86.6% 9 13.4% 67 govt servant 17 1.8% 7 77.7% 2 22.3% 9 business 46 4.8% 17 73.9% 6 26.1% 23 occupation of partner unemployed 15 1.6% 3 37.5% 5 62.5% 8 farmer 53 5.5% 25 80.6% 6 19.4% 31 labourer 593 61.7% 234 78% 66 22% 300 govt servant 82 8.5% 39 86.7% 6 13.3% 45 business 218 22.7% 81 75% 27 25% 108 x 19gjra global journal for research analysis table no. 3 shows that ppiucd acceptance was highest in hindu women , those belonging to joint families and women from rural areas . acceptance was good in lower and middle socioeconomic classes. it rose with the level of education of the patients & their partners. majority of the women accepted were homemakers and their partners were laborers mostly . it was also observed that the rates of continuation of ppiucd did not vary much wi th the di f ferent socio -demographic characteristics , as nearly all had comparable rates of continuation . volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 4 impact of timing of counselling on acceptance continuation rates time of counselling no. of cases ( n= 961) % follow up cases (n=492) continued discontinued total no. of cases % no. of cases % anc period 510 53.1% 253 78.1% 71 21.9% 324 early labor or preparation for lscs 349 36.3% 104 76.5% 32 23.5% 136 after delivery 94 9.8% 22 88% 3 12% 25 postpartum stay 8 0.8% 3 42.9% 4 57.1% 7 table no.4 reveals that acceptance was highest in clients who were counselled during antenatal period. and at follow up , continuation rates were poor amongst the cases who were counselled during postpartum period. table 5 follow up study for complaints at follow up and their correlation with desire for iucd removal symptoms follow up cases (n=492) % desire for removal yes % no % pain 82 16.7% 39 47.60% 43 52.40% hanging tail 28 5.7% 5 17.90% 23 82.10% bleeding irregularities 12 2.4% 10 83.30% 2 16.70% foul smelling discharge 6 1.2% 0 0% 6 100.00% no symptoms 364 74% 8 2.20% 356 97.80% table no.5 shows that most common complaint of cases at follow up was that of pain i.e. 16.7% , followed by discomfort due to hanging tail , heavy bleeding and foul smelling discharge respectively . amongst the clients who desired for removal bleeding irregularities was most important complaint. discussion in the our study out of 1800 cases counseled for ppiucd insertion , 961 cases (53.3% ) accepted it by choice and with informed consent .acceptance in study conducted by runjun [10 ] [11 ]doley et al (36.6%) , and by mishra s et al ( 17.17%) was [12 ]lower while gunjan goswamy et al found higher (66.6%) acceptance. in our study, majority (85.1%) of the ppiucd acceptors belonged to younger population( age group of 2130 yrs) which is comparable with other studies done by runjun doley [13 ]et al and katheki g et al whereas in a study by maluchuru s [14]et al from guntur, the highest rate of acceptance was among age group of 30-39 years. in the present study continuation was high and comparable among 21-30 yrs and 31-40 yrs age groups and results are comparable in study [15]conducted by vilvapriya et al . [ 11, 16]most of the studies observed higher acceptance rate in primi para which is in line with our study. study done by sudha [17 ]c.p et al shows comparable acceptance between primi(36.7%) and multi para (38.3%) women. gunjan [18]goswamy et al. and sonali deshpande et al found highest acceptance among second para and multipara patients respectively . this suggests that the mothers with a recent rst experience of delivery were receptive to this spacing method as a semi-permanent method of contraception. in this study although acceptance rate is highest (66%) among primi para yet the continuation rate was comparable among primi para and second para patients. also acceptance rate is low in multi para patients due to preference for permanent sterilization methods but continuation rate is high showing it can serve as a good alternative to permanent sterilization methods. in the study done by vilvapriya et al ,continuation rate was high among primipara clients. in our study 93% of the acceptors were hindu ,49.8% of the acceptors belonged to lower socioeconomic group and 62.6% from rural localities. 49.5% clients and 55.4% of the partners were educated upto high school .78.1 % were homemaker and 61.7% of the partners were labourer .similar ndings were observed by maluchuru s et al and mrs. suchitra a. rati et al [19] .with context to the type of family, 83.7% of women were from joint family. majority (89.9%) of women were housewife, 57.3% of husbands were semiskilled workers. most of the families (62%) had income less than rs. 3000 per month. similar ndings were reported by sonali deshpande et al while in a [20]similar study done in telangana by sangeetha jairaj et al majority were from urban area (79.75%). acceptance was more in those who completed their secondary school level education (23.3%) in the current study acceptance and continuation rates were high in the cases who were counseled for ppiucd insertion during their antenatal period which is similar to studies by [ 21] [22] [23]zeroi et al , soliman et al & duong et al which emphasize the need of counseling in antenatal period. the antenatal ,intranatal & immediate postnatal periods are the most suitable time to counsel the patients about the benets of ppiucds . it is relevant to emphasize over here , that when the patients are going through various physical & mental stress during antenatal span as well as extreme agony of labor pains/post operative pain,their receptivity and understanding of the usefulness of contraception overall is at its peak.later on in the late postnatal phase and interval period ,the inuence of family & friends ; social myths ;religious beliefs ; over engagement in domestic routine activities hamper the acceptance & continuation of contraceptive advice. in our study we found out of 961 cases 492( 51.2%) cases had follow up visit after discharge. 77.7% was the continuation rate after rst follow up (6 weeks) which is comparable with the [24]study conducted by kittur s et al & less than vilvapriya s et al. satyavathi et al found reasons for removal were bleeding (27.27%), menstrual disturbances (18.18%), pressure from family (27.27%) other problems (18.18%) and pain (9%) . majority of the studies including our study observed pain and bleeding as the main problems for removal of iucd. although pain was the commonest complaint at follow up but 20 x gjra global journal for research analysis bleeding was the leading cause where clients sought removal of iucd (83.3%). runjundoley et al found the continuation rate to be 90.84%. summary to summarize the evaluation of ppiucd , we observed that acceptability rate was 53.3%. higher in the lower socioeconomic status directly proportional to the literacy levels and in primiparas. antenatal counseling was most benecial. 77.7% of the clients continued using iucd as the method of contraception. bleeding irregularities was most important cause for desire to discontinue. conclusion to conclude , we found average acceptance rate , good continuation rate and no major complication with ppiucd.the initial counseling include information on the changes likely to occur in bleeding pattern, in particular the adaptation period lasting 3-6 months. inserting iucd with in 10 minutes after placental delivery and during cesarean section is one time , long term , coitus independent , reversible , demonstrably safe and effective method of contraception having low expulsion rate and has no effect on breast feeding. the government needs to develop strategies to increase public awareness for ppiucd along with continuous training and enhancement of the knowledge and skills of the health care providers . acknowledgements declarations funding: conict of interest: ethical approval references 1. demographic and health survey ,india. orc macro. 2001 2. world population data sheet , 2003. population reference bureau. www.prb.org 3. world population policies, 2003. united nations, population division, department of economic and social affairs 4. huezo, c.m., malhotra, u., slogett, a. and cleland, j.: acceptability and continuation of use of contraceptive methods: a multicentre study. in: e.s. teoh, s.s. ratman and sir m. macnaughton (eds.) proceedings of the xiiith world congress of gynaecology and obstetrics, vol. 1, 11-35, 1993. 5. reference manual for mos and nursing personnel . retrieved fromhttp://www.nrhmtn.gov.in/modules/iucd_reference_manual_for_mos_ and_nursing_personne_-final-sept_2013.pdf 6. trends in maternal mortality: 1990 to 2015 estimates by who, unicef, unfpa, world bank group and the united nations population division . retrieved from http://www.afro.who.int/sites/default/les/2017-05/trends-inmaternal-mortality-1990-to-2015.pdf 7. cleland j et al. 2006. family planning: the unnished agenda. the lancet. 368(9549): 1810–1827 8. international institute for population sciences (iips) and icf. 2017. national family health survey (nfhs-4), 2015-16: 112 . india. mumbai: iips. 9. medical eligibility criteria for contraceptive use, fifth edition 2015. available a t h t t p : / / a p p s . w h o . i n t / i r i s / b i t s t r e a m / 1 0 6 6 5 / 1 8 1 4 6 8 / 1 / 9 7 89241549158_eng.pdf 10. doley r, pegu b. a retrospective study on acceptability and complications of ppiucd insertion. j evolution med. dent. sci. 2016;5(31):1631-4. 11. mishra s. et al. evaluation of safety, efcacy, and expulsion of post-placental and intra-cesarean insertion of intrauterine contraceptive devices (ppiucd) j obstetgynaecol india. 2014;64(5):337–43.[pmc free article] [pubmed] 12. gunjangoswami, et al. a prospective study to evaluate safety, efcacy and expulsion rate of post placental insertion of intra uterine device. journal of evolution of medical and dental sciences. 2015;4(56):9770–74. 13. katheit g, agarwal j. evaluation of post placental intrauterine contraceptive device (ppiucd) in terms of awareness, acceptance and expulsion in a tertiary care centre. international journal of reproduction, contraception obstetrics and gynaecology 2013;2(4):539-43. 14. maluchuru s, aruna v, prabhavathi n. post partum intrauterine device insertion-2 years experience at tertiary care center in guntur medical college/govt general hospital, guntur. journal of dental and medical sciences 2015;14(3):56-61 15. vilvapriya s, veeraragavan k. long term clinical outcome of intra caesarean intrauterine contraceptive device insertion. int j reprod contracept obstet gynecol 2017;6:1894-9. 16. rajnigautam, k. n. arya, s. kharakwal, sudhir singh, monika trivedi. overview of immediate ppiucd application in bundelkhand region. journal of evolution of medical and dental sciences 2014; vol. 3, issue 36, august 18; page: 9518-9526,doi: 10.14260/jemds/2014/3230. 17. sudha cp, priyanka hk, nagaiah d. a study to evaluate safety and efcacy of i m m e d i a t e p o s t p a r t u m p o s t p l a c e n t a l i u c d i n s e r t i o n . i n t j reprodcontraceptobstetgynecol 2017;6:2284-8. 18. deshpande s, gadappa s, yelikar k, wanjare n, andurkar s. awareness, acceptability and clinical outcome of post-placental insertion of intrauterine contraceptive device in marathwada region, india: indian j obstetrgynecol res. 2017;4(1):77-82. 19. mrs.suchitra a. rati a study to assess the factors affecting acceptance of intrauterine device (iud) among rural women of hirebagewadi, belgaum.” e-issn: 2320–1959.pissn: 2320–1940 volume 3, issue 2 ver. v (mar-apr. 2014), pp 37-52 www.iosrjournals.org 20. jairaj, sangeetha, and sridhar dayyala. “a cross sectional study on acceptability and safety of iucd among postpartum mothers at tertiary care hospital, telangana.” journal of clinical and diagnostic research� : jcdr 10.1 (2016): lc01–lc04. pmc. 21. zeroi et al the relationship between prenatal care and subsequent modern contraceptive use bolivia , egypt and thailand . (afr j reprod health 2001; 5[2]: 68-82) 22. saliman, m. h. (1999) impact of antenatal counselling on couple knowledge and proctice of contraception in mansoura, egypt, east mediteranean health journal, 5(5),10021013. 23. duong, d. v., lec, a.h., and binns, c.w. (2005) contraception within six month postpartum in rural vietnam; implication on family planning and maternity services. european journal of contraception and reproductive health care, 10(2), 111-118. 24. eroglu, k. akkuzu, g. vural, g. dilbaz, b., akin, a. complications of iud insertion in immediate postplacental/ early postpartum period with interval period: 1 year follow up contraception, 2006 nov;74(5):376-81. epub 2006 sep 15. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 21gjra global journal for research analysis background human tuberculosis, a known historical disease, as per genetic and archaeological data mycobacterium tuberculosis complex (mtbc) may have co-existed with humans for 15,000 [1]years. it's etiology was discovered by sir robert koch in th [2]march 24 1882. globally, estimated 10.0 million people (range, 9.0–11.1 million) developed tb disease in 2017: 5.8 [3]million men, 3.2 million women and 1.0 million children. although witha running programmeto control tuberculosis for almost more than 50 years tb continues to be india's one of the leading health hazard. almost 480,000 persons die per year and more than 1,400 every day due to tuberculosis in india. many cases are lost to follow up or inadequately treated in [4]private sector. side effects and toxicity of the rst line anti-tubercular drugs (rifampicin, isoniazid, pyrazinamide, ethambutol and streptomycin) are a hurdle to the physician and the patients [5]for continuation of treatment. the most severe side-effects leading to interruption of treatment were hepatotoxicity (11%), [5]skin rash (6%), and joint pain (2%). drug induced injury to liver with rst line drugs is a serious challenge during the treatment as well as signicant hazard while re-introduction [6]of the same regimen. incidence of hepatotoxicity in indian population is around 11.5%, compared with 4.3% in western population, with mortality of 6-12% when continued even after the onset of symptoms. some responsible factors for hepatotoxicity are older age, female population, poor nutritional status, high alcohol intake, existing liver disease, hepatitis b carriage, increased prevalence of viral hepatitis in developing countries, hypoalbuminemia and advanced [7,8]tuberculosis, and inappropriate use of drugs. asymp tom [9,10]atic elevation of transaminases is common, around 20%. clinical presentation of anti-tuberculosis drug induced hepatitis usually resembles acute viral hepatitis and resolves spontaneously following withdrawal of the anti-tuberculosis [9,10]drugs. many mechanisms were suggested for druginduced liver damage such asidiosyncratic damage, dosedependent toxicity, induction of hepatic enzymes, drug[9,10]induced acute hepatitis and allergic reactions. it takes around 16 weeks (range 6 weeks-6 months) from treatment [10]initiation to development of clinical symptoms. though there are controversies regarding hepatotoxicity with alternate day regimen and daily regimen. some studies are of opinion that there is no difference in hepatotoxicity incidences [11]among daily and alternate day regimen. therefore, monitoring should be done after starting of anti-tuberculosis drugs every 2 weeks interval to get a chance to avoid undue disruption in treatment, fatal complications and better patient [12]counselling. various studies have shown that anti-tb drugs are common [13,14,15]cause of hepatotoxicity worldwide. the incidence of antitb drug induced hepatotoxicity varies with the characteristics of the populations, drug regimens involved, upper limit used to dene hepatotoxicity, monitoring and reporting pattern. overall, hepatotoxicity due to anti-tb drugs has been reported [14]in 5%–28% of people treated with anti-tb drugs. many of these may not t into a more recent international case denition of drug-induced liver injury (dili). majority of the reports have used an elevated alanine (alt) or aspartate transaminase (ast) of 3 times upper limit of normal range (uln) with symptoms (abdominal pain, nausea, vomiting, unexplained fatigue or jaundice) attributable to liver injury or 5 times uln of alt or ast without symptoms to dene [16]hepatotoxicity. combination therapy develop transient asymptomatic elevation in liver enzymes, which comes to [17,18]normal level with continuation of the drug. the median interval from treatment initiation of drug to development of [19,20]clinical symptoms is 16 weeks. poor nutritional status has been considered to be one of the factors contributing to a higher incidence of dih induced by short-course chemotherapy for tb in the developing countries. drug metabolism pathways including acetylation pathways have been shown to be deranged in states of protein energy [29]malnutrition. a study to detect association of body mass index and hyperbilirubinemia as well as body mass index and liver enzymes among patients on first line anti-tubercular drugs from rntcp during the course of anti-tb treatment original research paper dr. rupam kumar ta associate professor. department of pulmonary medicine. burdwan medical college, burdwan pulmonary medicine background: globally, estimated 10.0 million people developed tuberculosis in 2017. side effects and toxicity of the rst line anti-tubercular drugs were hepatotoxicity, skin rash, and joint pain. poor nutritional status has been considered to be one of the factors contributing to a higher incidence of dih induced by short-course chemotherapy for tb in the developing countries. hence this study was conducted to nd out the association between body mass index and hyperbilirubinemia as well as body mass index and liver enzymes among patients on rst line anti-tubercular drugs from rntcp during the course of anti-tb treatment. methods: 116 patients who were diagnosed to have pulmonary (ptb)/ extrapulmonary (eptb) tuberculosis at outpatient & in-patients of department of chest medicine, burdwan medical college & hospital for eleven months after fullling the inclusion and exclusion criteria. treatment was given as per guidelines by revised national tb control program. results: signicant association was observed between bmi<18.5 kg/m2 and hyperbilirubinemia and bmi>=18.5 and elevation in sgpt level at 2nd week of treatment. conclusion: hyperbilirubinemia is a common occurrence during the course of anti-tb treatment in patients with low bmi. most patients show tolerance to anti-tb drugs and get adjusted after transient rise in liver enzymes. clinicians should be vigilant for occurrence of hyperbilirubinemia in this high-risk group. abstract keywords : hyperbilirubinemia, sgpt, bmi, tuberculosis. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. saugata bhaumik* rd3 year junior resident, department of pulmonary medicine. burdwan medical college, burdwan *corresponding author dr. pronoy sen st1 year junior resident, department of pulmonary medicine. burdwan medical college, burdwan 8 x gjra global journal for research analysis therefore, in a country like india where malnutrition is very common it is very important to consider the nutritional status of patients on anti-tb drugs and provide nutritional care. due to paucity of studies in this respect, this study was conducted to nd out the association between body mass index and hyperbilirubinemia as well as bmi and liver enzymes among patients on rst line anti-tubercular drugs from rntcp during the course of anti-tb treatment. methods aprospective observational study after taking proper written consent from the patients wasconducted in outpatient department (opd) & in-patients of department (ipd) of burdwan medical college, department of pulmonary medicine after they were diagnosed with tuberculosis either clinically or microbiologically as pulmonary or extrapulmonary during the period of 11months. base line data were collected such as history, detailed clinical examination, body mass index, residence, occupation, smoking and alcoholic status, sputum microscopy and cbnaat, pleural uid analysis ( in cases of pleural effusion), lymph node ne needle aspiration for cytology and cbnaat ( in lymphadenopathy), chest x-ray, and routine blood along with base line liver function test. all the patients were put on xed dose combination (fdc) daily regimen with isoniazid, rifampicin, pyrazinamide and ethambutol as per rntcp guidelines and according to body weight. blood samples were drawn for assessment of bilirubin, sgpt, sgot and alkaline phosphatase (alp) on follow-up at 2 weeks interval during the intensive phase (ip) and 1-month interval during continuation phase (cp). during each follow up visit detailed history and clinical check-ups were done and duly put down on preformed data sheet. patients were educated about the signs and symptoms of hepatitis and hepatotoxicity such as nausea, vomiting, abdominal pain and yellowish discoloration of skin and eyes. if any of the mentioned features observed then they were tested for hepatitis (viral) prole, prothrombin time, bilirubin, sgpt, sgot and alkaline phosphatase test. also, patients were tested for other organ involvement such, urea and creatinine. normal range taken as for liver function tests were as follow bilirubin <1.2mg/dl, sgpt<40 iu/l, sgot<40 iu/l, alp 40120 iu/l, ggt <60 iu/l, albumin >3mg/dl. hepatotoxicity was considered as per american thoracic society guidelines as 1) rise in serum alt above 5 times from baseline, 2) serum alt above 3 times with symptoms like nausea, vomiting, pain abdomen and jaundice. in cases with hepatitis patients were admitted in our indoor department and symptomatic treatment given. atd were stopped for 2 weeks or until sgpt and sgot comes down to less than 2 times the upper normal limit in cases with hepatitis. re-introduction with atd were done with same regimen in full doses after 2 weeks. and patients were closely observed for any further hepatitis. if symptomatic hepatitis develops or liver enzymes start raise alarmingly then patient were planned for shift the current regimen to hepato-safe regimen. serial increase or decrease in liver function were recorded and patients were counselled not to take any hepatotoxic drugs or alcohol during the treatment period. every patient's sputum samples were tested as per rntcp guidelines. those who were not responding to atd regimens were further investigated for drug resistance.if any of the patients found to be a case of drtb (drug resistance tuberculosis) then he/she was excluded from the study. statistical analysis was done by spss version 20. categorical variables are expressed as number of patients and percentage of patients and compared across the groups using pearson's chi square test for independence of attributes/ fisher's exact test as appropriate. continuous variables are expressed as mean, median and standard deviation and compared over time using wilcoxon signed ranks test. association between continuous variables are captured using spearman's rank correlation coefcient. results out of 114 treated cases 5 patients developed hepatitis and we re subjected to interruption in treatment, whereas rest of the patients continued treatment without any symptoms. among the 5 patients 4 male and 1 female. 4 ptb and 1 eptb. 2 patients developed hepatitis 4 weeks after treatment, 1 developed after 2 weeks, and other 2 patients developed after 4 months of treatment. 2 patients had bmi < 18.5 kg/m2 and other were >18.5 kg/m2. 3 patients were age below 40 years and 2 of the patients were above 40 years. all of them were newly diagnosed cases. among the 5 cases 3 had sgpt and sgot levels above 3 times but below 5 times and had symptoms like nausea vomiting and abdominal pain and jaundice. on the other hand, 2 cases had sgpt and sgot above 5 times and they also presented with symptoms like volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 1. demographic chart of tb patients included in the study characteristics no(n) percentage (%) age (years) 11-20 yrs. 27 23.7 21-30 yrs. 39 34.2 31-40 yrs. 21 18.4 41-50 yrs. 4 3.5 51-60 yrs. 17 14.9 61-70 yrs. 6 5.3 gender male 59 51.8 female 55 48.2 patient registered at ipd 56 49.1 opd 58 50.9 address rural 73 64 urban 41 36 marital status married 94 82.5 unmarried 20 17.5 smoking status smoker 43 37.7 non-smoker 71 62.3 alcohol intake yes 42 36.8 no 72 63.2 sputum smear positive 41 36 negative 73 74 diagnosis microbiologically 77 67.5 clinically 37 32.5 cbnaat mtb detected 77 67.5 mtb not detected 37 32.4 family/contact h/o ptb present 64 56.1 absent 50 43.9 chest x-ray normal 57 50 abnormal 57 50 case type newly diagnosed 94 82.5 previously treated 20 17.5 x 9gjra global journal for research analysis jaundice, nausea and vomiting. serum hepatitis virology markers were negative for all the 5 cases and their serum urea and creatinine levels were within normal limit. prothrombin time and inr was within normal range in all the hepatitis cases. all the case had raised serum bilirubin at the time of hepatitis and were between 3mg/dl and 5 mg/dl. att was on hold for an average 2 (10 to 15 days) weeks for all the patients and same regimen of att continued. no second episode of symptomatic hepatitis developed later, although 2 patients had sgpt and sgot above normal range but were below 2 times of upper normal limit. no other symptoms were noted in ththese cases of dili. at the end of 6 month all patients with att induced hepatitis had normal serum bilirubin, sgpt and sgot level. among the 114 patient's bilirubin levels were nd thabnormal in 13.2% after 2 week, 7.9% after 4 week, 6.1% th th rdafter 6 week, 5.3% after 8 week, 3.5% after 3 month, 6.1% th thafter 4 month, 6.1% after 5 month, but all patient had normal thbilirubin after 6 month. mean, median and standard deviation in bilirubin levels during the treatment period were shown in table 2. statistically signicant changes seen ndcompared to bilirubin level at the start of treatment and 2 th thweek [p-value <0.001], 4 week [p-value 0.020], 4 month [pthvalue 0.026] and 5 month [p-value 0.016] [table 2]. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 2. statistical signicance of changes in bilirubin levels p value signicance bilirubin (mg/dl) 2nd week bilirubin (mg/dl) day 0 <0.001 signicant bilirubin (mg/dl) 4th week bilirubin (mg/dl) day 0 0.020 signicant bilirubin (mg/dl) 6th week bilirubin (mg/dl) day 0 0.181 not signicant bilirubin (mg/dl) 8th week bilirubin (mg/dl) day 0 0.426 not signicant bilirubin (mg/dl) 3rd month bilirubin (mg/dl) day 0 0.822 not signicant table 3. elevation of liver enzymes in follow up characteristic no (n) percentage (%) serum sgpt elevated 95 83.3 not elevated 19 16.7 serum sgot elevated 81 71.1 not elevated 33 28.9 serum sgpt&sgot both elevated 76 66.7 not elevated 38 33.3 serum sgpt&sgot elevated >5 times 2 1.75 >3 times but <5 times 3 2.63 serum sgpt&sgot elevated > 3 times symptomatic 5 4.38 asymptomatic 0 0 sgpt elevated in no follow-up 19 16.7 1 follow-up 45 39.5 2 follow-ups 28 24.6 3 follow-ups 12 10.5 4 follow-ups 8 7 6 follow-ups 2 1.8 sgot elevated in no follow-up 33 28.9 1 follow-up 38 33.3 2 follow-ups 29 25.4 3 follow-ups 10 8.8 4 follow-ups 1 0.9 5 follow-ups 1 0.9 6 follow-ups 2 1.8 bilirubin (mg/dl) 4th month bilirubin (mg/dl) day 0 0.026 signicant bilirubin (mg/dl) 5th month bilirubin (mg/dl) day 0 0.016 signicant bilirubin (mg/dl) 6th month bilirubin (mg/dl) day 0 0.065 not signicant wilcoxon signed ranks test table 5: association of bmi with sgpt bmi kg/m2 total <18.5 >=18.5 p value signicance sgpt (iu/l) 2nd week normal 32(68.09) 31(46.27) 63(55.26) 0.021 signicant abnormal 15(31.91) 36(53.73) 51(44.74) total 47(100) 67(100) 114(100) table 6: association of bmi with serum bilirubin values in 2nd week bmi kg/m2 total <18.5 >=18.5 p value signicance bilirubin (mg/dl) 2nd week normal 18(40.91) 44(63.89) 62(54.38) 0.033 signicant abnormal 26(59.09) 26(36.11) 52(45.62) total 44(100) 70(100) 114(100) signicant association was observed between bmi>=18.5 kg/m2 and elevation in sgpt level at 2nd week of treatment compared to bmi < 18.5kg/m2 statistically signicant number of patients having bmi <18.5have high bilirubin levels. in contrary to that liver adaptive response is higher among the patients with bmi >=18.5 which is also statistically signicant. discussion in the present study, transient hepatic function derangement was seen in patients initially more in the second week of treatment and the effect seems to fade of later subsequent follow up. all patients were closely monitored during treatment, counselling done to prevent use of any kind of hepatotoxic agents or alcohol. those who developed hepatitis were also observed not report any kind of hepatic symptoms even after completion of treatment. and all patients completed their treatment successfully without further adverse reactions. so, from our study we can say that att can be reintroduced, even after hepatitis develop during treatment, safely after a gap and waiting for the patient to become asymptomatic with [21,22]normalization of enzymes. in a study by gulati et al. it was observed that most cases of hepatic enzyme elevations occur in intensive phase of att, in our study we have seen that most number patients have abnormal liver enzymes in second and fourth week after [23]treatment. as most anti-tb drugs are metabolized by the liver, therefore, it is the central to detoxication of inh, rif, and pza. so poor compliance in the initial phase of treatment is more likely. in the study by vijayalakshmi et al drug induced hepatitis cases were reintroduced with hepatosafe regimen of att to [24]complete the treatment, but in our case, we stay with the same regimen and started with the full dose in all the 5 cases of hepatitis and didn't observed any further hepatitis in all the cases. a study with full dose re-introduction of all antitu 10 x gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra bercular drugs also had successful completion of att course [25]comparable to other safer regimen. therefore, it can be said that though drug induced hepatitis can occur with the standard four drug regimen initially but on rechallenge same event may not happen. incidence of drug induced hepatitis was 4.38% in our study which supporting the existing literature. as per the study by surendra k sharma et al att induced hepatitis was about 5% of all anti-tb treatment for [7]indian population and only 2% for western populations. asymptomatic elevation liver enzymes are noted in various [26,27,28]studies to be around 20%. but our study observes that this gure is much higher in our study population. near about 76% patients in our study showing abnormal level of liver enzymes (both sgpt and sgot). only 16.7% had no elevation in sgpt and 28.9% had no elevation in sgot. so adaptive response to anti-tb medications are much more common in our study population than previous study suggests. [29]in the study by singla et al poor nutritional status has been considered to beone of the factors contributing to a higher incidenceof drug induced hepatotoxicity induced by shortcourse chemotherapy for tbin the developing countries. similarly, in our study we have found statistically signicant association between low bmi and serum hyperbilirubinemia ndin the 2 week of receiving att. conclusion drug induced liver function abnormality is a common occurrence during the course of anti-tb treatment. most patients show tolerance to anti-tb drugs and get adjusted after transient rise in liver enzymes. some patients may develop serious hepatitis and need treatment interruption, but we should always try to stay with the present regimen and see whether reintroduction leads to any further derangement or hepatitis. asymptomatic rise may be upto 3 times from the baseline value, but that does not need any intervention unless patients develop symptoms. serum bilirubin values show statistically signicant rise in patients with low bmi on att compared to those patients having higher bmi. hence serum bilirubin values along with liver enzymes have to be measured in low bmi group of patients.abdominal symptoms like pain, nausea, vomiting and jaundice should always be taken seriously and needs intervention by holding the att. risk factors like, age, gender, smoking habits, alcohol intake, tuberculosis disease severity, along with bmi must be studied further to have better understanding in relation to liver function changes. concomitant use of hepatotoxic agents in low bmi groups should be avoided as far as possible. references 1. hershkovitz i, donoghue hd, minnikin de, may h, lee oy-c, feldman m, galili e, spigelman m, rothschild bm, bar-gal gk, tuberculosis origin: the neolithic scenario, tuberculosis (2015) jun;95 suppl 1:s122-6. doi: 10.1016/j.tube.2015.02.021. epub 2015 feb 13. 2. alex sakula, robert koch: centenary of the discovery of the tubercle bacillus, 1882-thorax 1982;37:246-251(246). 3. global tuberculosis report 2018-who-executive summary/page-xvii. 4. revised national tuberculosis control programme, national strategic plan for tuberculosis elimination -2017–2025/p-5. 5. t. schaberg, k. rebhan, h. lode-risk factors for side-effects of isoniazid, rifampin and pyrazinamide in patients hospitalized for pulmonary tuberculosis-european respiratory journal issn 0903 – 1936, 1996, 9, 2026–2030. 6. kishore pv, palaian s, paudel r, mishra p, prabhu m, shankar pr-drug induced hepatitis with anti-tubercular chemotherapy: challenges and difculties in treatment-kathmandu university medical journal (2007), vol. 5, no. 2, issue 18, 256-260(256). 7. surendra k. sharma, arumugam balamurugan, pradip kumar saha, ravindra m. pandey, and narinder k. mehraevaluation of clinical and immunogenetic risk factors for the development of hepatotoxicity during antituberculosis treatment-american journal of respiratory and critical care2002 oct 1;166(7):916-9. 8. samson e. isa, augustine o. ebonyi, nathan y. shehu, patrick idoko, joseph a. anejo-okopi, gomerepsimji, rachael u. odesanya, isaac o. abah, hafsat o. jimoh-antituberculosis drugs and hepatotoxicity among hospitalized patients in jos, nigeria-international journal of mycobacteriology 5(2016) 2126. 9. sk sharma, alladi mohanantituberculosis treatment-induced hepato toxicity: from bench to bedsidemedicine update 2005, chapter 96/p479484(482). 10. vidyasagar ramappa, guruprasad p. aithalhepatotoxicity related to antituberculosis drugs: mechanisms and managementjournal of clinical and experimental hepatology/ 2013 mar; 3(1): 37–49. 11. k.c. chang, c.c. leung, w.w. yew and c.m. tamstandard anti-tuberculosis treatment and hepatotoxicity: do dosing schedules matter? – european respiratory journal 2007; 29: 347–351(349). 12. wing wai yew and chi chiu leung-antituberculosis drugs and hepatotoxicity-respirology (2006) 11, 699–707(701&702). 13. harshad devarbhavi, md, dm, ross dierkhising, ms, walter k. kremers, phd 3, m.s. sandeep, md, dm 1, dheeraj karanth, md and c.k. adarsh, mdsinglecenter experience with drug-induced liver injury from india: causes, outcome, prognosis, and predictors of mortality-american journal gastroenterology 2010; 105:2396–2404; doi: 10.1038/ajg.2010.287; published online 20 july 2010. 14. ostapowicz g, fontana rj, schiodt fv, et al. results of a prospective study of acute liver failure at 17 tertiary care centers in the united states. ann intern med. 2002; 137:947–954. 15. kumar r, bhatia v, khanal s, et al. antituberculosis therapy induced acute liver failure: magnitude, prole, prognosis, and predictors of outcome. hepatology. 2010; 51:1665–1674. 16. tostmann a, boeree mj, aarnoutse re, et al. antituberculosis drug-induced hepatotoxicity: concise up-to-date review. j gastroenterol hepatol. 2008;23:192–202. 17. mitchell jr, zimmerman hj, ishak kg, et al. isoniazid liver injury: clinical spectrum, pathology, and probable pathogenesis. ann intern med. 1976;84:181–192. 18. scharer l, smith jp. serum transaminase elevations and other hepatic abnormalities in patients receiving isoniazid. ann intern med. 1969;71:1113–1120. 19. kopanoff de, snider jr de, caras gj. isoniazid-related hepatitis: a u.s. public health service cooperative surveillance study. am rev respir dis. 1978;117:991–1001. 20. international union against tuberculosis committee on prophylaxis. efcacy of various durations of isoniazid preventive therapy for tuberculosis: ve years of follow-up in the iuat trial. bull world health organ. 1982;60:555–564. 21. lacroix c, tranvouez jl, phan hoang t, et al. pharmacokinetics of pyrazinamide and its metabolites in patients with hepatic cirrhotic insufciency. arzneimittelforschung. 1990;40:76–79. 22. singh j, garg pk, tandon rk. hepatotoxicity due to antituberculosis therapy. clinical prole and reintroduction of therapy. j clin gastroenterol 1996;22(3):211-4. 23. dossing m, wilcke jt, askgaard ds, nybo b. liver injury during antituberculosis treatment: an 11-year study. tuber lung dis 1996;77(4):33540. 24. gulati k, ray a, vijayan vk. assessment of protective role of polyherbal preparation livina against anti-tubercular drug induced liver dysfunction. inian j exp biol 2010;48(3):318-22. 25. vijayalakshmi a, thanmayi g, jayakumari s-a prospective study on abnormal liver function test patterns in patients receiving anti-tuberculosis therapy-asian j pharm clin res, vol 9, issue 5, 2016, 136-139. 26. sharma sk, singla r, sarda p, et al. safety of 3 different reintroduction regimens of antituberculosis drugs after development of antituberculosis treatment-induced hepatotoxicity. clin infect dis. 2010;50:833–839. 27. girling dj. the hepatic toxicity of antituberculosis regimens containing isoniazid, rifampicin and pyrazinamide. tubercle 1978;59: 13–32. 28. ormerod lp, horseld n. frequency and type of reactions to antituberculosis drugs: observations in routine treatment. tuber.lung dis. 1996; 77: 37–42. 29. rohit singla, surendra k. sharma, alladi mohan, govind makharia†, v. sreenivas et al. evaluation of risk factors for antituberculosis treatment inducedhepatotoxicity x 11gjra global journal for research analysis introduction: nocturnal enuresis despite being discussed over decades now requires a much more comprehensive approach to dealing with primary nocturnal enuresis behavioural 1interventions, and need for parent education is a top priority . yet there seems to be limited understanding of its current 2 prevalence, parental knowledge attitude and practice. a newspaper report of 2017 of a school child being ostracised and withdrawn from school once again focused on the urgent need for identifying the magnitude of the problem and factors associated and parenting factors with regard to nocturnal 3,4enuresis among children. material and methods: a study was conducted to assess the knowledge attitude and practice of mothers regarding nocturnal enuresis. community based door-to-door survey of the houses of children aged between 5-12 years in all villages in the two randomly selected phcs were included. structured interview schedules were used. tools for knowledge, attitude and practice were validated and tested reliability r = 0.70, r = 0.739 and r = 0.794 respectively. results: totally 89 children with nocturnal enuresis were identied. after the screening found only 81 children had primary nocturnal enuresis and among them 68 mothers consented and participated in the study. the nding of the initial survey has been presented in the tables and gures. table 1 knowledge, attitude and practice scores of mothers regarding nocturnal enuresis n=68 the table shows that mothers had poor knowledge (11.85 ± 2.67) of basic facts regarding causes treatment and management of nocturnal enuresis. their attitudes were moderately positive (43.06 ±6.42) towards nocturnal enuresis in their children. the practice was poor (31.75 ±3.72) in the management of nocturnal enuresis. practices were focused towards 'pre-bed pee' and restriction of post-dinner uid and punishment. association of demographic variables with nocturnal enuresis table 2 association of demographic variables of children with frequency of nocturnal enuresis * ** signicant at p <0.05 signicant at p <0.01 nocturnal enuresis frequency was associated signicantly for type of birth, difculty to wake up, snoring, nightmares at p <0.05. fear of darkness and duration of breast feeding at p <0.01. all other factors did not show any signicant association. association of demographic variables of chil dren with frequency of nocturnal enuresis of children analysis using chi square test reveals that only mother's parenting task at [p <0.01] and father's parenting task [p <0.05] is associated with nocturnal enuresis frequency of children. none of the variables seem to have association with nocturnal enuresis of children. discussion: in the study, mothers had poor knowledge which is supported by ndings in maharashtra where 58% of the mothers had 5information on bedwetting . with regard to parental attitude, readiness to punish was observed by other studies and news . 3,4,5reports the ndings reveal parenting practices specic to nocturnal enuresis were poor and negative. in studies of parenting practices, it was found parents did practice lifestyle modication in terms of uid and sleep hygiene, while in terms rd 5,6,7 of punishing wetting behaviour were only 1/3 of the parents there was statistically signicant relations between mothers' level of knowledge about enuresis, attitude and practice 7(p<0.001) . conclusion: in this study, most of the background factors were not associated with nocturnal enuresis frequency of the children. mothers had poor knowledge regarding nocturnal enuresis. certain practices were engaged without their sound understanding on its bearing on wetting behaviour of the child, thus making a strong case for community and homebased intervention for the management of nocturnal enuresis. references 1. gontard av, jong, badawi jk, o’connell ka, hanna-michell at. nieuwholfleppink & cardozo l. psychological and physical environmental factors in knowledge, attitude and practice regarding nocturnal enuresis among mothers of children with primary nocturnal enuresis original research paper sequeira s j phd scholar, national consortium for phd in nursing, rguhs karnataka, faculty of community health nursing. nursing mothers had poor knowledge (11.85 ± 2.67) of basic facts regarding nocturnal enuresis. their attitudes were moderately positive (43.06 ±6.42) towards nocturnal enuresis in their children. the practice was poor (31.75 ±3.72) in the management of nocturnal enuresis. among variables, child's fear of darkness and duration of breast feeding (p <0.01), mothers parenting task (p <0.01) and fathers parenting task (p <0.05) were associated with nocturnal enuresis frequency of children. abstract keywords : enuresis, nocturnal enuresis, knowledge, attitude, practice volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra mean std. std. error mean knowledge 11.85 2.67 .324 attitude 43.06 6.42 .778 practice 31.75 3.72 .451 gender 8.692 .27 birth type 16.039 .02* birth term 15.093 .37 duration of breast feeding 52.231 .004** education 71.034 .09 difculty to wake up 26.489 .02* snores at sleep 24.224 .04* nightmares 24.751 .04* fear of darkness 27.044 .01** mile stones 11.742 .11 demographic variable chi square value signicance p value age 12.669 .92 14 x gjra global journal for research analysis the development of incontinence in adults and children. j wound ostomy continence nursing. 2017;44(2):181-187 2. mathew jl evidence-based management of nocturnal enuresis: an overview of systematic reviews indian paediatrics 2017:9 (47) 777-79 3. times of india bedwetting dr anuradha2017 october 10th 4. india pages rst enuresis clinic in pune 2016 may 5. duraphe, 2015a study to assess knowledge and practices of mothers about management of children with enuresis residing in kamgarnagar, pimprichinchwad municipal corporation, pune-18 ijnh vol 1 (3), 179-185, 6. magda alyessawy. caregivers' management for their children with nocturnal enuresis iosr journal of nursing and health science (iosr-jnhs) , vol. 7, no.5 , 2018, pp. 12-23. 7. rasha a. mohamed, ohoud youssef el-sheikh, and ahmed noaman, “applying health education learning package for mothers regarding nocturnal enuresis.” american journal of nursing research, vol. 7, no. 4 (2019): 561-573. doi: 10.12691/ajnr-7-4-18. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 15gjra global journal for research analysis introduction neurobroma in isolation is a rare entity that involves the peripheral extremities most commonly. it usually occurs in patients with neurobromatosis. neurobromatosis is an autosomal dominant inherited disorder with an incidence of approximately 1 in 3000 live births. it is characterized by hyper-pigmented lesions (café-au-lait spots), neurobromas, iris hamartomas, macrocephaly, central nervous system tumors, defects of skull and facial bones and vascular lesions. these neurobromas in the female gentital tract involve most commonly the vulva, clitoris and labia. they are rarely seen to involve the vagina, cervix, endometrium, myometrium and the (1)urinary tract. neurobromas are categorized as cutaneous, intraneural, massive soft tissue type and sporadic neurobromas or those (2, 3).in association with neurobromatosis type1 they are commonly asymptomatic. vulva is a common site for epithelial and mesenchymal tumors. vulval neurobroma makes up to (4)5% of all benign vulvar lesions. majority of these are associated with neurobromatosis type 1 (nf 1) or von recklinghausen's disease. vulval involvement is (5)seen in 18 % of these cases. a few of these are seen after surgical trauma. they are thought to occur spontaneously in morphologically abnormal tissues that are subjected to trauma, exact etiology is however, unclear. signicant complications from neurobroma of vulva are generally not .(6)noted because it is benign tumor . although benign, some of the following are worrisome observations with them. ÿ stress of a neoplasm ÿ cosmetic concerns ÿ dyspareunia and bleeding ÿ injury to vital structures while excision and surgical site infectionslater ÿ recurrence ÿ neurobromatosis type 1 related morbidity management strategies are as follows – ÿ surgical excision ÿ vulvectomy ÿ myolysis –procedure includes inserting a needle wherein the neoplasm is subjected to electric current or cryoablation. ÿ tumor embolization by interventional radiology ÿ radiofrequency ablation –herein the tumor cells are subjected to radio waves case report a 52-year-old nulligravida hypertensive female presented with a history of an insidious onset progressively increasing mass involving the vulva. the mass was not associated with pain. there was no history of trauma preceding the onset. there was no associated vaginal discharge, urinary symptoms or any such similar swellings in other areas. there was history of left sided hemiparesis and bell's palsy 7 years ago. she also had bronchial asthma. there was also history of cervical lymphadenopathy 35 years ago for which akt was given. she achieved menopause 3 years ago. on examination, there was a pedunculated, soft, non-tender, mobile mass on right labia majora about 4 x 3 cm. it was seen to involve labia minora and lower third of vagina. the left side was normal. her routine blood workup was unremarkable. ultrasound of abdomen and pelvis showed no abnormality. xray pelvis did not show any bony involvement. mri pelvis revealed a large well dened lobulated soft tissue mass in right labial region arising from circumferentially thickened mucosa of lower one third of vagina. focal loss of fat planes with adjacent anterior wall of anal canal and adjacent right perineal muscles was observed. few insignicant lymph nodes in bilateral internal iliac region were also noted. the mass biopsy was taken and sent for histopathological examination. on histopathological examination the mass was benign. it was spindle shaped with cellular arrangement as fascicles and bundles. individual tumor cells had spindle shaped plump nuclei showing waviness at certain places. cytoplasm was eosinophilic with indistinct cellular margins. this was diagnostic of a neurobroma. the mass was completely excised under spinal anesthesia and patient made an uneventful recovery. she is on routine follow-up in the outpatient clinic and is doing well with no signs of recurrence at one month follow up. vulval mass 6x4 cm in right labial fold and lower one third of vagina vulval mass excision under spinal anaesthesia isolated neurofibroma of vulva and vagina: a rare case report original research paper dr priya bulchandani resident at dept of obstetrics and gynecology at grant govt. medical college & jj group of hospitals, mumbai x 39gjra global journal for research analysis gynaecology neurobroma is a disease of peripheral nervous system that involves most commonly the extremities. amongst female genital tract, neurobroma involves most commonly the vulva, clitoris and labia but rarely may be seen in vagina, cervix, endometrium and myometrium as well as urinary tract. isolated neurobroma of vagina is a rare association which is usually a part of von recklinghausen's disease. we present here a rare clinical entity of vulval neurobroma in a 52-year-old female with no other features of von recklinghausen's disease. the mass was excised surgically and sent for histopathological examination which conrmed the diagnosis. abstract keywords : dr tushar palve* asstt.proff. at dept of obstetrics and gynecology at grant govt. medical college & jj group of hospitals, mumbai *corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 40 x gjra global journal for research analysis discussion vulval involvement is seen in approximately 18% of women with nf1 . neurobromas in the female genital tract commonly involve the vulva, clitoris and the labia. rarely they involve vagina, cervix, endometrium, myometrium and ovaries. they .may also be seen in the urinary tract vulval neurobromas may result as a sequelae of surgical trauma like episiotomy or other vulval injuries. history of trauma and symptoms related to urinary tract should be sought. genitourinary system examination including cystoscopy should also be considered while managing. the cases with nf1 may transform into malignant sarcomas. however, solitary lesions are usually benign with no reported cases of malignant transformation. reported cases have been usually small in size (<3 cm in diameter) and slow growing. rarely, they may be giant lesions with orid growth pattern. (3)they are usually asymptomatic but venter et al. and gordon .(7)et al have reported giant lesions with intractable chronic pelvic pain and dyspareunia. surgical excision seems to be the sole treatment modality, however, the risk of recurrence entails a close follow-up involving both history and clinical examination. in this case, the vulvar location of the isolated lesion and its large size in absence of other cutaneous or visceral lesions or positive family history is striking. solitary, genital neurobromas have been described by (3) (7)venter et al. and gordon et al. presenting with intractable chronic pelvic pain and dyspareunia respectively. but the rate of growth of the tumor in our case was not very large compared (3)to two cases reported by venter et al (8)kane et al. in their study have reported a case of isolated vulval neurobroma in an 18-month-old female child. in our report patient was 52 years with both vulval and vaginal (10)involvement sa'adatu et al. have reported case of neurobroma of labium majus in young female as globular pedunculated cutaneous tissue. (9)amita et al. and negi et al. have reported a case of giant (11) vulval neurobroma of 17x8x6 cm presenting as soft tissue (12)mass hussein l kidanto et al. have reported a large neurobroma of labia majora presenting as globular (13)pedunculated mass of 20x20 cm nibhoria s et al reported an isolated vaginal neurobroma presenting as vaginal wall cyst as a rare case report with review of literature . our patient presented with mass in vulva and vagina. (14) (15)mourali et al and yayli et al reported a 71 year old patient with vaginal neurobroma with von recklinghausen disease. our patient was at 52 years old and hasn't had von recklinghausen disease. (16)baulies et al reported a 20-year-old woman with a history of type-1 neurobromatos is wi th a vaginal nodule neurobroma. but our patient did not have history of type-1 neurobromatosis. ( 1 7 )sharma et al reported huge localized vaginal neurobromatosis as an unusual cause of postmenopausal bleeding . in our report, the bleeding was not a manifestation. (18)eusebi and schönauer reported pigmented vaginal neurobroma. in our report there were no pigmentations . (19)gold published about neurobromatosis of the bladder and vagina. in our report the vagina and vulva was involved. (20)drescher and herzog published about neurobromatosis of the vulva and vagina. in our report patient did not have any features of von recklinghausen disease. (21)marmey and lacroix published about recklinghausen disease and pregnancy. but our patient was not pregnant at presentation and the neurobroma was solitary. (22)belvederi et al reported anatomo-clinical ndings on a case of neurobroma of the vagina. during follow up, the patients should be advised to report in case of development of cutaneous lesion or any symptoms of the genitourinary tract. conclusion to conclude isolated neurobromas of female genital tract is not a common entity. the evaluation should consist of history and examination for presence of nf1 features and exclude genitourinary involvement. the rare incidence of these being in isolation with risk of recurrence and rare likelihood of malignant transformation emphasizes formulation of plan for close follow up of these patients post-surgical excision. although rare, they should be considered as a differential of benign solid tumors of vagina. references (1). gersell dj, fulling kh. localized neurobromatosis of the female genitourinary tract. amjsurgpatho1989;13:873-8. (2). haley jc, mirowski gw, hood af. benign vulval tumours. semincutan med surg1998;17:196-204. (3). venter pf, röhm gf, slabber cf. giant neurobromas of the labia. obstetgynecol1981;57:128-30. (4). gersell dj, fulling kh. localized neurobromatosis of the female genitourinary surgpathol1989;13:873-8 (5). haley jc, mirowski gw, hood af. benign vulvaltumours. semincutan med surg1998;17:196-204. (6). who classication of tumors of female reproductive organs ; edited by robert j kurman , maria lusia carcangui simon herrington ,robert h young ; 4th edition ,, iarc press ,lyon ,2014 (7). gordonmd, weilertm, irelandk. plexiformneurobromatosisinvolving the uterinecervix, endometrium, myometrium andovary. obstetgyneco l1996;88:699-701. (8). kanea,bassetséguinn,bessisd,dereureo,guilhoujj. isolatedvulv alneurobroma.europeanjournalofdermatology1997;7:123-4. (9). amitam, darshid, rekhaw, hemantt. giantneurobroma of the valva. austnzjobstetgynaecol200 5;45:84-5 (10) sa'adatu ts, shehu s, umar hs. neurobroma of the labium majus: a case report 2006;8:99-100. (11). negil, wahal sp, gulati a, kaushal v. giant vulvalneurobroma: a rare entity with review of literature. j can res ther 2015;11:1045 (12). hussein l. kidanto1, 2,3*, joshua garrison1 and peter wangwe. large neurobroma of the labia majora: a case report tanzania journal of health research doi: volume 15, number 1, january 2013. (13). nibhoria s, kaur tiwana k, kaur m, phutela r.isolated vaginal neurobroma presenting as vaginal wall cyst: a rare case report with review of literature j family reprod health. 2016 mar;10(1):49-51. (14). mouralim , hammedi n, fekih c, essoussi-chikhaoui j, binous n, ben zineb s, et al. vaginal neurobroma.tunis med. 2009;87:411. [pubmed] [google scholar] (15). yayli s, bahadir s, cim sit g, bozkaya h, imamo˘glu hi, kul s. coexistence of mayer-rokitansky-kuster-hauser syndrome and neurobromatosis type. am j clindermatol. 2008;9:57–60. [pubmed] [google scholar] (16). baulies s, cusidó mt, grases pj, ubeda b, pascual ma, fábregas r. neurobroma of the vaginal wall. clinexpobstet gynecol. 2008;35:140–3. [pubmed] [google scholar] (17). sharma jb, wadhwa l, malhotra m, arora r, garg a, singh s. huge localized vaginal neurobromatosis: an unusual cause of postmenopausal bleeding. j obstetgynaecol res. 2004;30:96–9. [pubmed] [google scholar] (18). eusebi v, schönauer s. pigmented vaginal neurobroma. minerva ginecol. 1974;24:265–70. [pubmed][google scholar] (19). gold bm. neurobromatosis of the bladder and vagina. am j obstet gynecol. 1972;113:1055–6. [pubmed][google scholar] (20). drescher h, herzog w. on neurobromatosis of the vulva and vagina. zentralblgynakol. 1961;83:743–50.[pubmed] [google scholar] (21). marmey j, lacroix a. [recklinghausen disease and pregnancy; cesarean section in vaginal neurobromatosis]bull fed socgynecolobstet lang fr. 1951;3:645–6. [pubmed] [google scholar] (22). belvederi gd, pelusig , tosi p. anatomo-clinical ndings on a case of neurobroma of the vagina. riv ital ginecol. 1974;55:403–11. [pubmed] [google scholar] volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction distal radius fracture constituting around 17% of the total skeletal trauma, involving both the elderly and young patients 1in emergency room .distal end radius fractures, which can be extra or intra-articular. intra-articular fracture has tendency to loss of reduction , malunion & deformity with conservative 2treatment .an intra-articular step of more than 2 mm inevitably 3leads to osteoarthritis and a functional decit .recently, it was clinically proved that intra-articular step-off and radial shortening corrected by surgery had improved patient 4outcome. in the past, these fractures were managed with external xation or a combination of limited open reduction, kirschner wire (k-wire) augmentation, and bone grafting. fixed angle volar plates for the xation of distal radius 5fractures were introduced by orbay and fernandez . open reduction and internal xation (orif) using volar fixed-angle plates has also shown to be a valid treatment option for unstable, intra-articular displaced distal radial 6fractures, more so in osteoporotic bones . volar xed angle locking plates are pre-contoured to the anatomical shape of volar side of the distal radius. the direction of the distal locking screws is xed by the plate design ensures more consistent correction of displacement and maintenance of reduction. this study evaluates the functional & radiological outcome of open reduction and internal xation using xed angle volar locking plate in the management of intra-articular fracture distal end radius. method twenty ve patients with intra-articular distal radial fractures treated with xed angle locked volar plating at the institute from july 2018 until september 2019 were included for the study with six months follow up. closed fracture in skeletally mature patients with modied ao type b2, b3, c with less than three weeks old trauma were included in the study. patients with open fracture , pathological fracture , fracture associated with neurovascular injury,skeletally immature & medically unt were excluded .permission of ethical committee was obtained. surgical procedure (volar approach)-surgery was performed under appropriate anesthesia i.e. either general anesthesia or axillary or supra clavicular block under tourniquet control. open reduction and internal xation was done using modied henry approach between the exor carpi radialis and radial artery. evaluation of outcome the patients were followed up for minimum of 6 months. functional (gartland & werley scale) and radiological (lindstorm criteria) reviews were performed. results there were 25 patients treated with xed angle volar locking plate system in this study. 22 male and 3 female patients with the average age of 38 year (range 20-60) and right side predilection. the patients were followed up for a period of six months. all fractures were closed and classied according to the ao/ota classication. the ao classication of the study cases indicated that type c2 (meta physeal multifragmentary) was maximum in 13 cases (52%), 5 cases c1 (20%), 4 cases c3 (16%), 2 case b3, 1 case b2. the mean time to union was nine weeks. at the time of nal follow-up (six months) the clinical scoring chart was done according to gartland and werley scale. intra articular distal radius fractures and fixed angle volar locking plate fixation: a prospective study original research paper dr. hemeshwar harshwardhan professor, department of orthopaedics, jln medical college & hospital , ajmer , rajasthan . orthopaedics background: intra-articular distal radius fractures still a therapeutic challenge to orthopedic surgeons. with the advent of locking plates, the xation of these fractures has been made better, specically by fixed angle volar locking plate. this study investigates the efcacy of these plates using volar approach, functional & radiological outcome evaluated. methods: this study was conducted at orthopedic department jln medical college & associated hospital ajmer (rajasthan). twenty ve patients with closed intra-articular distal radius fractures, with ao type b2, b3, and c fracture pattern, operated with fixed angle locking plate xation using volar approach, were included in the study during the period of july 2018 to september 2019, with a minimum follow up of six months, radiological outcome was analysed (sarmientos modication of lindstorm criteria) and functional outcome recorded (gartland and werley's demerit scoring system). results: with a mean age of 38.4 years and follow up of three months, the range of movement of the wrist was very satisfactory, and the mean grip strength was 85% of the opposite wrist. functional parameters by gartland and werley showed a signicant improvement in most of the patients during the follow-up period(68% excellent,16% good,16% fair) and radiological parameters were well maintained (lindstorm criteria 60% excellent,29% good,7% fair,4% poor) and the complication rate was less and insignicant. conclusions: primary xed angle volar plate xation of intra-articular distal radius fracture provides a stable xation that effective in anatomic realignment, allows early joint motion, owing to its xation strength, thereby better functional & radiological outcomes and minimal complication. abstract keywords : fixed angle volar locking plate, distal radius, gartand and werley, lindstorm criteria, wrist dr. ashwani jangir* post graduate trainee,department of orthopaedics,jln medical college & hospital ,ajmer *corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 144 x gjra global journal for research analysis table1: functional outcome based on gartland & werley scale gartl and and werley scores in the study, with 68% of patients having good to excellent results. table2: anatomical and radiological evaluation using sarmientos modication of lindstorm criteria radiographs and clinical anatomy was analysed as per sarmientos modication of lindstorm criteria. at nal follow-up, the mean volar tilt was 10.8°, radial inclination averaged 19.8° and radial length averaged 11 mm with 60 % excellent result. there were two cases of supercial wound infection that settled well with oral antibiotics. residual pain, stiffness and deformity were there are about twenty percent of the patients. no case of intra-articular screw placement ,tendon rupture median nerve neuropathy & crps was noted. case figure 1-pre op xray figure2immediate post op xray figure 3-follow up xray at 6 month figure 4range of motion at 6 months follow up discussion in treating intra articular distal radial fractures, the main aim is to achieve and maintain anatomic reduction and get satisfactory motion and rehabilitation. the biomechanical results show that locking volar plates provides signicantly greater resistance to fracture gap motion compared with standard volar plates in a comminuted distal radius fractures7. fixed-angle volar plates prove stronger under cyclical loading tests and locking screws help in attaining implant stability and in addition, spares the vascularity and 8periosteum. rozental et al reported patients treated with volar xedangle plating for unstable distal radius fractures, with average 9follow-up period of 17 months. the radiological parameters in this study with volar tilt of 6.7 degrees and radial inclination 20 degrees was about in the same range as rozental et and and also by lueng et al. in most cases effective restoration of anatomic alignment was acquired and maintained, along 10 with functional restoration and rehabilitation. in study by chauvan 91% patients treated with volar locking plate had good to excellent outcomes while in our study 81% had well to 12excellent outcome. the overall complication rate in our study was 20%, which is comparable to that reported by jagodzinski et al in a bicentric 11study on distal radius volar locking plates. they reported a complication rate of 19.6%. in our study, there was no case of screw misplacement because extra care was taken to prevent this complication since it could have resulted in longer uoroscopy time. no complications related to extensor tendons was observed in this study. similar conclusion was 13,14reached in separate studies by hakim et al and othman. this study was a single centric study with limited number of cases and no control group or other modes of xation for comparison. further analysis and work will help to delineate the strategy in distal radius plating to avoid complications and adverse outcomes. conclusion present study documents 84% functional and 89% radiological excellent to good results, suggests that stabilizing the fracture fragments with xed angle volar locking plate in the management of the intra articular fractures of distal radius, is an effective method to maintain the reduction till union and prevent collapse of the fracture fragments, even when the fracture is grossly comminuted /intra-articular/unstable and limited complication. so in our opinion, xed angle volar locking plate for treatment of intra articular fracture distal end radius is good method with excellent outcomes. references:1. court-brown, charles m.; heckman, james d.; mcqueen, margaret m.; ricci, william m.; (iii), paul tornetta; mckee, michael d. (2015). rockwood and green's fractures in adults. court-brown, charles m.,, heckman, james d.,, mcqueen, margaret m.,, ricci, william m.,, tornetta, paul, iii,, mckee, volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra outcome no. of patient % of case excellent 17 (mean:1.52, sd: 0.84) 68% good 4(mean:5.75, sd: 1.08) 16% fair 4(mean:10.75,sd: 1.47) 16% poor 0 0% outcome loss of palmer inclination radial shortening loss of radial deviation residual deformity mean excellent 5 (20%) 18(72%) 17(68%) 20(80%) 60 % good 17(68%) 5(20%) 4(16%) 3(12%) 29% fair 3(12%) 2(8%) 2(8%) 0 7% poor 0 2(8%) 2(8%) 4% x 145gjra global journal for research analysis michael d. (8th ed.). philadelphia. isbn 9781451175318. oclc 893628028. 2. cherubino p, bini a, marcolli d. management of distal radius fractures: treatment protocol and functional results. injury 2010; 4: 1120-6. 3. frykmann g. fractures of the distal radius including sequelae shoulderhand-nger syndrome, disturbance in the distal radioulnar joint and impairment of nerve function. a clinical and experimental study. acta orthop scand j 1967; 108: 1-124. melone cp jr. open treatment for displaced articular fractures of the distal radius. clin orthop 1986; 202: 103-11. fernandez dl. malunion of the distal radius: current approach to management. instr course lect 1993; 42: 99-113. 4. solgaard s. function after distal radius fracture. acta orthop scand 1988;59(1):3942. 5. orbay j, fernandez dl: volar xation for dorsally displaced fractures of the distal radius: a preliminary report. j hand surg 2002;27a:205–215 6. orbay j, fernandez dl: volar xed-angle plate xation for unstable distal radius fractures in the elderly patient. j hand surg 2004;29a:96–102. 7. willis aa, kutsumi k, zobitz me, cooney wp. internal xation of dorsally displaced fractures of the distal part of the radius: a biomechanical analysis of volar plate fracture stability. jbjs am. 2006;88(11):2411-7. 8. nana ad, joshi a, lichtman dm. plating of the distal radius. j am acad orthop surg. 2005;13(3):159-71. 9. rozental td, blazar pe. functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius. j hand surg am. 2006;31:359-65. 10. leung f, zhu l, ho h, luww, chow sp. palmar plate xation of ao type c2 fracture of distal radius using a locking compression plate--a biomechanical study in a cadavericmodel. j hand surg br. 2003;28:263-6. 11. jagodzinski na, singh t, norris r, jones j, power d. early results of a variableangle volar locking plate for distal radius fractures: a bi-centre study. orthopaedic proceedings; 2012. 12. chavhan an et al functional and radiological outcome in distal radius fractures treated with locking compression plate. int j res med sci 2017; 5:574-82. 13. hakimi m, jungbluth p, windolf j, wild m. functional results and complications following locking palmar plating on the distal radius: a retrospective study. journal hand surg. 2010;35(4):283–8. 14. othman ay. fixation of dorsally displaced distal radius fractures with volar plate. j trauma 2009;66:1416-20. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 146 x gjra global journal for research analysis introduction: the unfolded protein response (upr) is a cellular stress response related to the endoplasmic reticulum (er) stress. the upr is activated in response to an accumulation of unfolded or misfolded proteins in the lumen of the endoplasmic reticulum. in this scenario, the upr has three aims: initially to restore normal function of the cell by halting protein translation, degrading misfolded proteins, and activating the signalling pathways that lead to increasing the production of molecular chaperones involved in protein folding. molecular mechanism: the molecular chaperone bip/grp78maintains specic transmembrane receptor proteins involved in initiating of the downstream signalling of the upr in an inactive state by binding to their luminal domains. an overwhelming load of misfolded proteins or simply the over-expression of proteins [1] requires more of the available bip/grp78 to bind to the exposed hydrophobic regions of these proteins, and consequently bip/grp78 dissociates from these receptor sites to meet this requirement. dissociation from the intracellular receptor domains allows them to become active. perk dimerizes with bip in resting cells and oligomerizes in erstressed cells. an alternative model has been proposed, whereby unfolded proteins interact directly with the erlumenal domain of ire1, causing oligomerization and transautophosphorylation.[2] the initial phases of upr activation have two key roles: translation attenuation and cell cycle arrest by the perk receptor this occurs within minutes to hours of upr activation to prevent further translational loading of the er. perk (protein kinase rna-like endoplasmic reticulum kinase) activates itself by oligomerization and autophosphorylation of the free luminal domain. the activated cytosolic domain causes translational attenuation by directly phosphorylating the α subunit of the regulating initiator of the mrna translation machinery, eif2. this also produces translational attenuation of the protein machinery involved in running the cell cycle, producing cell cycle arrest in the g1 phase[3]. perk deciency may have a signicant impact on physiological states associated with er stress. increased production of proteins involved in the functions of the upr upr activation also results in upregulation of proteins involved in chaperoning malfolding proteins, protein folding and erad, including further production of grp78. ultimately this increases the cell's molecular mechanisms by which it can deal with the misfolded protein load. these receptor proteins have been identied as: inositol-requiring kinase 1[4], whose free luminal domain activates itself by homodimerisation and transautopho sphorylation[5]. the activated domain is able to activate the transcription factor xbp1(xbox binding protein) mrna (the mammalian equivalent of the yeast hac1 mrna) by cleavage and removal of a 26bp intron. the activated transcription factor upregulates upr 'stress genes' by directly binding to stress element promoters in the nucleus[6]. atf6 (activating transcription factor 6) is a basic leucine zipper transcription factor[7].upon grp78 dissociation, the entire 90kda protein translocates to the golgi, where it is cleaved by proteases to form an active 50kda transcription factor[8] that translocates to the nucleus. it binds to stress element promoters upstream of genes that are upregulated in the upr [9]. unfolded protein response in cardiovascular disease 2+abnormal intracellular calcium (ca ) handling can trigger endoplasmic reticulum (er) stress, leading to activation of the unfolded protein response (upr) in an attempt to prevent cell death. mechanical unloading with a left ventricular assist device (lvad) relieves pressure-volume overload and promotes reverse remodeling of the failing myocardium. estibaliz castillero et al hypothesized that mechanical unloading would alter the upr in patients with advanced role of unfolded protein response in cardiac diseases. original research paper smita sharma* md,dtcd,clinical biochemist,regional lab.,nejran.[ksa] *corresponding author biochemistry cardiovascular disease is the leading cause of death worldwide. multiple forms of the cardiovascular disease involve acute or chronic disturbance in cardiac myocytes, which may lead to potent activation of the unfolded protein response (upr), a cellular adaptive reaction to accommodate protein-folding stress. ample evidence has rmly established that the upr is strongly induced in heart disease. recently, the mechanism of action and multiple pharmacological means to favorably modulate the upr are emerging to curb the initiation and progression of cardiovascular disease.in this review we tried to focus the unfolded protein response in cardiovascular disease. modulating the upr may be clinically benecial. for example, in heart failure, upr activation contributes to arrhythmic risk and inhibiting the upr may decrease that risk. targeting the upr seems to be a potentially fruitful approach in novel therapeutics for cardiac disease. abstract keywords : cardiovascular disease ,unfolded protein response,arrythmias. rami abdullah ali al dagrer master in biotechnology,director blood banks and laboratories,nejran zone.[ksa] ramesh maheshwari md.(medicine),general physician, punjab civil medical services, bhatinda [india] sk mathur dm(endo), md(paediatrics), consultant endocrinologist, max.hospital, chandigarh.[india] simmi kharab md(biochemistry), sr.prof.&head, pgims, rohtak.[india] volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 18 x gjra global journal for research analysis heart failure (hf). upr was analyzed in paired myocardial tissue from 10 patients with dilated cardiomyopathy obtained during lvad implantation and explantation. samples from healthy hearts served as controls. markers of upr [binding immunoglobulin protein (bip), phosphorylated (p-) eukaryotic initiation factor (eif2�), and x-box binding protein (xbp1) were signicantly increased in hf, whereas lvad support signicantly decreased bip, p-eif2�, and xbp1s levels. apoptosis as reected by c/ebp homologous protein and dna damage were also signicantly reduced after lvad support. improvement in left ventricular dimensions positively correlated with p-eif2�/eif2� and apoptosis level recovery[10]. sen et al. [11]have previously suggested an attenuation of the upr by mechanical unloading in hf patients. these authors reported a decrease in the er chaperones grp72, grp94, and bip in hf patients after lvad support. lvad-induced reverse remodeling is accompanied by improvement in �-adrenergic signal transduction, lower natriuretic peptide levels, increased cell viability, and reduced inammation . it is likely that these effects are partially 2+mediated not only by an improvement in ca cycling but also improvement in upr. the er is recognized as a vitally important organelle that determines cell survival or death. upr plays critical roles in the pathophysiology of ischemic heart disease. the three signaling branches may elicit distinct but overlapping effects in cardiac response to ischemia. cardiac injury results in upr activation, which induces ion channel downregulations. these downregulations can explain some of the arrhythmic risk. downregulation of multiple cardiac ion channels corresponds to the apd prolongation and dv/dtmax reduction [١٢]. inhibition of either the perk or ire1 arm led to a shortened apd and recovered dv/dtmax. this suggests that perkand ire1-mediated channel downregulations are specic for a certain set of channels, and that some cross talk exists between the perk and ire1 arms of upr. with 4µ8c [١٢], suggesting that the upr results in changes in post-translational modications of nav1.5 or possibly changes in associated channel subunits. it is noteworthy that inhibition of ire1 under physiological condition downregulates cav1.2, herg and kvlqt1 and prolongs the apd, indicating that certain ire1 activity may be necessary to maintain these channels under physiological conditions. inhibition of either perk or ire1 shows partial reversal of electrical remodeling, suggesting that the atf6α arm may play a role in electrical remodeling or that there are overlapping effects of the upr arms. blocking upr activation can raise ion channel levels and may represent a new and potentially fruitful antiarrhythmic paradigm. conclusion: unfolded protein response plays a vital role in cardiovascular disease. it can be used as therapeutic target in future to treat life threatning conditions especially arrhythmias. conflict of interest: there is no conict of interest. references: 1. hammond, c; braakman, i; helenius, a ."role of n-linked oligosaccharide recognition, glucose trimming, and calnexin in glycoprotein folding and quality control". proceedings of the national academy of sciences of the united states of america.1994; 91 (3): 913–7. 2. ron, d.; harding, h. p.; zhang, y."protein translation and folding are coupled by an endoplasmic-reticulum-resident kinase". nature.1995. 397 (6716): 271–4. 3. .lee, a. h.; iwakoshi, n. n.; anderson, k. c.; glimcher, l. h. "proteasome inhibitors disrupt the unfolded protein response in myeloma cells". proceedings of the national academy of sciences.2003; 100 (17): 9946–51. 4. lee, as trends biochem sci .1987;12: 20-23. 5. .machamer, ce., doms, rw., bole, dg,. helenius, a., rose, jk. j biol chem 1995;265 (12) 6879-6883 6. mccullough, k., martindale, j., klotz, l., aw, t., holbrook. mol cell biol 2001;21 : 1249-1259. 7. molinari, m., galli, c., piccaluga, v., pieren, m., paganetti, p.) j cell biol.2002; 158 (2) 247-257. 8. mori, k., ogawa, o., kawahara, t., yanagi, h., yura, t. (2000) proc natl acad sci usa 97 4660-4665. 9. urano, f; wang, x; bertolotti, a; zhang, y; chung, p; harding, h. p.; ron, d . "coupling of stress in the er to activation of jnk protein kinases by transmembrane protein kinase ire1". science.2000; 287 (5453): 664–6. 10. estibaliz castillero, hirokazu akashi, klara pendrak, halit yerebakan, marc najjar, catherine wang. attenuation of the unfolded protein response and endoplasmic reticulum stress after mechanical unloading in dilated cardiomyopathy am j physiol heart circ physiol.2015; 309: h459–h470, 2015. 11. sen s, kundu bk, wu hc, hashmi ss, guthrie p, locke lw, roy rj, matherne gp, berr ss, terwelp m, scott b, carranza s, frazier oh, glover dk, dillmann wh, gambello mj, entman ml, taegtmeyer h. glucose regulation of loadinduced mtor signaling and er stress in mammalian heart. j am heart assoc 2013;2: e004796. 12. liu m, shi g, zhou a, et al. activation of the unfolded protein response downregulates cardiac ion channels in human induced pluripotent stem cellderived cardiomyocytes. j mol cell cardiol. 2018;117:62–71. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 19gjra global journal for research analysis introduction induction of labour is one of the most common procedures in obstetrics. generally, labour induction is indicated when the benets of delivery to the mother or fetus outweigh the [1-2]potential risks of continuing the pregnancy . the most appropriate timing for labour induction is the point at which the maternal or perinatal benets are greater if the pregnancy is interrupted, than if the pregnancy is continued. ideally, most pregnancies should be allowed to reach term, with the onset of spontaneous labour being the signal for physiologic [3]termination of pregnancy . occasionally, however, a woman must deliver before the spontaneous onset of labour. aims and objectives aims: to compare the effect of low dose oral misoprostol with vaginal misoprostol administration for induction of labour at term. objectives: ÿ to compare induction delivery intervals by oral and vaginal routes of misoprostol administration. ÿ to evaluate maternal outcomes after oral and vaginal routes of administration ÿ to compare neonatal outcome in terms of apgar score, meconium stained liquor and admission to nicu. materials and methods: this study was conducted in the department of obstetrics and gynaecology of maharani laxmi bai medical college, jhansi, uttar pradesh (india) from september 2017 to july 2019. the study was approved by the college ethical. on an average 90 antenatal patient come to our department including opd and emergency department. after applying inclusion and exclusion criteria ~1-2 patient i get daily. it take approximately 36-40 month for me to get 400 patients for my study. as it is a randomized clinical trial so in order to avail raising from both observer and participant. a simple method of randomisation is applied. i have devided patients into two groups – ÿ group a – vaginal misoprostol ÿ group b – oral misoprostol for randomization after selecting patients i use to see opd ticket number and patients with odd ticket number were given vaginal misoprostol and those having even opd ticket number are given oral misoprostol. by applying this method nally in group a 220 patients and group b – 180 patients were selected for the study. inclusion criteria: 1. primigravida 2. gestation age between 37-42weeks 3. age between 18-35 years 4. singleton fetus 5. cephalic presentation 6. intact or early rupture of membranes (<6 hrs) a comparative study of low dose oral misoprostol versus vaginal misoprostol for induction of labour original research paper dr. rajni gautam* associate professor, department of obstetrics and gynaecology of m.l.b. medical college, jhansi * corresponding author dr. sanjaya sharma professor and head department of obstetrics and gynaecology of m.l.b. medical college, jhansi obstetrics & gynecology introduction: misoprostol is a new promising agent for cervical ripening and induction of labour. the ideal dose, route and frequency of administration of misoprostol are still under investigation. although, vaginal application of misoprostol has been validated as a reasonable mean of induction, there is a patient resistance to digital examination and there is a risk of ascending infection. for this reason, oral administration of misoprostol for cervical ripening and labour induction has been tried. aims: to compare the effect of low dose oral misoprostol with vaginal misoprostol administration for induction of labour at term. materials and methods: this study was conducted in the department of obstetrics and gynaecology of maharani laxmi bai medical college, jhansi, uttar pradesh (india) from september 2017 to july 2019. the study was approved by the college ethical. results: there were 220 women in the oral and 180 women in the vaginal misoprostol groups. the mean induction to delivery interval in this study was found to be in group i mean was 13.83 hours with in group ii mean was 11.9 hours. conclusion: oral and vaginal route of administration of misoprostol for induction of labour are equally effective for induction of labour, number of doses of misoprostol used in vaginal route of administration, was signicantly lesser compared to oral route, there was no difference in induction to delivery interval between the two routes of administration of misoprostol, there was no difference in fetal and maternal complications in both groups., there was no difference in outcome of labour in both groups. abstract keywords : induction of labor, prostaglandins, uterine contractions volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. sushila kharakwal professor, department of obstetrics and gynaecology of m.l.b. medical college, jhansi dr. gouher fatima junior resident department of obstetrics and gynaecology of m.l.b. medical college, jhansi 52 x gjra global journal for research analysis 7. bishop's score <6 8. normal admission cardiotocography exclusion criteria: 1. age <18 and >35 years 2. malpresentations 3. fetal distress 4. previous uterine scar 5. placenta previa, vasa previa, active genital herpes methodology: oral misoprostol regimen: 1. initially 25 mcg is given orally 2. after 4 hrs if uterine contractions are adequate further dose will be withheld 3. if uterine contractions are inadequate and if cervical bishop score is unfavourable, 20mcg will be given and repeated every 4hrs till adequate contractions 4 contractions lasting for 40 seconds in 10 minute period or bishop score improves(>6), evaluated once in 4 hours. 4. labour augmentation may be done with amniotomy and oxytocin, once cervix is 5cm and more dilated. vaginal misoprostol regimen: 1. initially 25mcg will be kept in posterior vaginal fornix after moistening with two drops of saline. 2. after 4hrs if uterine contractions are adequate no further action is taken 3. if uterine contractions are inadequate or bishop score is unfavourable, 25mcg will be given and repeated every 4hrs till adequate contractions 4 contractions lasting for more than 40 seconds in 10 minutes period or bishop score improves(>6), evaluated once in 4 hours. 4. labour augmentation may be done by amniotomy and oxytocin, once cervix is 5cm or more dilated. management of tachysystole: in case patient has tachysystole, i.e. more than 6 contractions in 10 minutes period ,patient will be managed as per the following protocol 1. stop oxytocin drip { if on augmentation of labour} 2. inj terbutaline 250mcg subcutaneously stat 3. close monitoring of fetal heart rate and hasten delivery in case of fetal distress. study design: a randomized clinical trial to compare the effects of titrated low dose oral misoprostol regimen with vaginal misoprostol administration for induction of labour at term. method of data analysis: the data was collected and entered in microsoft excel sheet and later on excel sheet is transported to the spss 15.0 and appropriate statistical test student t-test are applied. results: discussion: 400 women were enrolled for study who were belonging to selection criteria. they were divided into 2 groups: ÿ group i: 200 women for oral misoprostol administration of 25mcg every 4 hourly ÿ group ii: 180 women for oral misoprostol administration of 25mcg every 4 hourly doses of drug required for delivery: mean number of doses required in group i was 3.85 to group ii which was 7.0. mean number of doses difference statistically more in group ii compared to group i requirement of augmentation with oxytocin: in my study, it was found that 39.3% in group i and 57.4% in group ii required augmentation with oxytocin. the difference was statistically signicant. means more augmentation [4-5]needed with oxytocin needed in oral route . induction to delivery interval: the mean induction to delivery interval in this study was found to be in group i mean was 13.83 hours with in group ii mean [5]was 11.9 hours . failed induction: in this study number of cases who did not progress to active labour after 24 hours of induction was considered as failed induction. grop a 79.6% failed induction while group b have [4-5]28.33 mean more failed induction in oral route . mode of delivery after induction:'' number of patients who had normal delivery was, 80.6% in volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra parameters group a [vaginal misoprostol] (n=220) group b [oral misoprostol] (n=180) number percentage number percentage age groups (in years) ÿ 16-25 ÿ 26-32 168 52 76.6% 23.6% 112 68 62.2 37.7 gestational age (in weeks) ÿ 37-39 ÿ 40-42 188 32 85.5 14.5 146 34 81.1 18.8 indication of induction ÿ post pregnancy ÿ gestational hypertension ÿ prom ÿ preeclampsia ÿ other 84 37 35 27 37 36.2% 16.8% 15.91% 12.27% 16.87% 61 27 14 31 47 33.89% 15.0% 7.75 17.22% 26.11% number of dose ÿ 1 ÿ 2 ÿ 3 ÿ 4 ÿ 5 ÿ 6 22 39 44 75 28 12 10.0% 17.7% 20.0% 34.1% 72.7% 6.6% 9 27 30 29 53 32 5.0% 15.0% 13.8% 18.8% 29.4% 17.8% side effects ÿ nausea/ vomiting ÿ diarhoea ÿ headache ÿ fever ÿ uterine hyperstimulation 18 25 17 12 22 8.2% 11.4% 7.7% 5.45% 10.0% 22 17 14 4 24 12.2% 9.4% 7.78% 0.22% 18.89% mode of delivery ÿ vaginal ÿ lscs 187 33 88.0% 12.0% 139 41 77.22% 22.78% delay time (in hours) ÿ <5 hours ÿ 6-10 hours ÿ 11-15 hours ÿ 16-20 hours ÿ >20 hours 20 47 74 45 34 9.17% 21.4% 37% 20.5% 15.5% 16 22 27 55 61 8.33% 12.22% 15.0% 30.55% 33.9% apgar score at 1 minute ÿ <7 ÿ >7 at 5 minute ÿ <7 ÿ >7 59 161 31 189 26.82% 73.18% 14.1% 85.9% 63 117 41 139 35% 65% 21.58% 78.42% x 53gjra global journal for research analysis group a, compared to 71.6% in group b. 19.5% from group a and 28.33% from group b underwent emergency caesarean section. indications for caesarean section in group a was two cases in view of fetal distress, one case in view of failed indu ction and one case in view of arrest of descent. indications for three cases in group b was fetal distress, one case in view of failed induction and one case in view of deep transverse arrest. the mode of delivery in terms of normal vaginal, instrumental (forceps/vacuum) and lscs was similar in both [4-5]groups with p=0.430 . characteristics of liquor: in the present study, 75% cases from group a and 67.22% from groip b had clear liquor and 26% cases from group a and 32% cases from group b had meconium coloured liquor. cases of meconium stained liquor from oral group one was thick meconium stained, and underwent lscs in view of nonreassuring ctg and the other case had thin meconium stained liquor in view of arrest of labour underwent lscs. both the neonates did not require nicu admission and none developed respiratory distress syndrome. cases of meconium stained liquor from vaginal group had thick meconium stained liquor and both cases underwent lscs in view of non reassuring ctg. both neonates did not require nicu admi [4,6]ssion and none developed respiratory distress syndrome . maternal complications: in the present study, only one case from group b complication in 45% cases, this difference was not statistically signicant. other common adverse effects of misoprostol like, nausea, vomiting, watery diarrhea, fever were not encountered in pres [4,7]ent study . one case which developed hyperstimulation, was given injection terbutaline 250mcg subcutaneously. bishop score: in both groups bishop score is between 2-5 and is comparable in both groups. apgar score at 1 and 5 minutes: in both the groups, 1 minute apgar <7 was seen in 26.82% neonates. in group a both babies were admitted to nicu in [4,7]view of respiratory distress syndrome . in group b 36% neonates had apgar score <7 at 1 minute and did not require nicu admission. neonates in both the groups had apgar score < 7 at 5 minutes are 31% and 21% respectively in group a and group b. neonatal outcome in terms of nicu admission: in the present study, 13.3% cases in group a and 23.3% cases in grop b required nicu admission in view of respiratory [4-5]distress syndrome and none from group b . conclusions 1. oral and vaginal route of administration of misoprostol for induction of labour are equally effective for induction of labour. 2. number of doses of misoprostol used in vaginal route of administration, was signicantly lesser compared to oral route. 3. there was no difference in induction to delivery interval between the two routes of administration of misoprostol. there was no difference in fetal and maternal complications in both groups. 5) there was no difference in outcome of labour in both groups. references: 1. sogc clinical practice guidelines, 2001. 2. tenore jl. methods for cervical ripening and induction of labor. american family physician. 2003;67(10):2123–2128. 3. with the onset,david james, philip steer.0 induction of labor and termination of the previable pregnancy.online publication date: october 2017.publisher: cambridge university press pp 1709-1749. 4. ashalatha shetty, peter danielian, allan templeton. a comparison of oral and vaginal misoprostol tablets in induction of labour at term. british journal of obstetrics and gynaecology march 2001, vol. 108, pp. 238±243 5. shi-yann cheng, md, ho ming, md, and jui-chi lee, md. titrated oral compared with vaginal misoprostol for labor induction. obstet gynecol 2008;111:119–25. 6. rozina rasheed, azra ahsan alam, shehnaz younus, farahnaz raza. oral versus vaginal misoprostol for labour induction. j pak med assoc; vol 57;issue 8;404-7pp. 7. janice s. kwon, gregory a.l. davies*, v. paul mackenzie. a comparison of oral and vaginal misoprostol for induction of labour at term: a randomised trial. british journal of obstetrics and gynaecology january 2001, vol. 108, pp. 23±26 volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 54 x gjra global journal for research analysis introduction the nutritional status of children encompasses normal nutrition as well as malnutrition. malnutrition comprises of two diametrically opposite entitiesundernutrition and overnutrition. both of these entities occurring during school age are detrimental to the development of children, they negatively impact health, work capacity and quality of life 1across the lifespan. apart from many other factors, there are some peculiar personal dietary habits which have a bearing on the nutritional status of school aged children. the objective of this study was to explore and identify a couple of them. material and methods study setting: the present study was conducted in an urban slum area among 1867 families which were registered at urban health training centre of llrm medical college, meerut. study subjects: 5-14 years (school aged) children of the registered families. study period : february 2011 to june 2011. study design: cross-sectional study. sample size: sample size was calculated using the formula: 2 2n=z pq/d1-�/2 by taking prevalence of malnutrition in school aged children , p=50% d=10% of p α=5%, z =11.961-α/2 n=384 assuming a non response rate of 5%, the total sample size is estimated as 400. sampling technique: simple random sampling techn ique data collection: by house to house visit. informed consent was taken from the parents of the children. a predesigned & pretested questionnaire was used to collect all the relevant data supplemented by physical examination.the us center for disease control and prevention (cdc) 2000 growth charts which provide gender specic bmi for age for school aged children were used to assess the nutritional status of the children. in order to calculate bmi, weight and height of the children were measured.the weight was recorded with the help of weighing machine to the nearest 100 grams. the height was measured from head to heels by an ordinary measuring tape to the nearest centimeter. data analysis: data was analyzed using spss software version 16. qualitative variables were expressed in percentages. chi square test was used to test the association between two attributes. pvalue less than 0.05 was considered signicant. results we managed to collect data from 400 children in the age group of 5-14 years who fully cooperated with us for the study. table -1 : nutritional status of children in relation to daily intake of breakfast 2*for calculation of χ overweight and obese have been clubbed together. the difference in prevalence of underweight (p < 0.05) but not overweight and obesity (p> 0.5) in relation to habit of eating breakfast daily was found to be statistically signicant. table2 : nutritional status of children in relation to daily intake of milk personal dietary habits and its influence on the nutritional status of school aged children dwelling in an urban slum in india. original research paper dr. ranu rawat* associate professor,deptt. of community medicine, adesh medical college and hospital, shahabad, kurukshetra, haryana. *corresponding author community medicine background: malnutrition comprising of both undernutrition and overnutrition is a public health issue in school aged children in developing countries. objectives: to study the inuence of personal dietary habits on the nutritional status of school aged children. methods : a cross sectional study comprising of 400 school aged children was carried out in an urban slum in meerut results: a statistically signicant difference was found between the prevalence of underweight in children and the habit of not having daily breakfast and milk (p < 0.05 and p< 0.001 respectively) and vegetarian food intake (p< 0.0001) and also between the prevalence of overweight and obesity in children and the habit of daily intake of milk ( p<0.01 ) and non-vegetarian food (p <0.05). conclusion: personal dietary habits of children affect the nutritional status in school aged children. abstract keywords : nutritional status, school aged children, personal dietary habits volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra nutritional status daily intake of breakfast population underweight healthy weight overweight obese no. % no. % no. % no. % no. % no 58 14.5 39 67.2 12 20.7 6 10.4 1 1.7 yes 342 85.5 153 44.7 142 41.5 33 9.7 14 4.1 total 400 100.0 192 48.0 154 38.5 39 9.8 15 3.7 2χ = 10.06; df=1; p< 0.05 2*χ = 0.12; df=1; p>0.5 nutritional status daily intake of milk population underweight healthy weight overweight obese no. % no. % no. % no. % no. % no 108 27.0 80 74.1 22 20.3 3 2.8 3 2.8 one glass 212 53.0 107 50.5 74 34.9 24 11.3 7 3.3 two 1glasses 75 18.8 5 6.7 56 74.7 10 13.3 4 5.3 three 2glasses 5 1.2 0 0.0 2 40.0 2 40.0 1 20. 0 total 400 100.0 192 48.0 154 38.5 39 9.8 15 3.7 2χ =86.02; df=2; p<0.001 2*χ =10.21; df=2; p< 0.01 36 x gjra global journal for research analysis 2*for calculation of χ 1 and 2 have been merged together and overweight and obese have been clubbed together. the difference in prevalence of underweight (p<0.001) as well as overweight and obesity (p< 0.01) in relation to habit of daily milk intake was found to be statistically signicant. table3 : nutritional status of children in relation to vegeta rian/ non vegetarian food intake 2*for calculation of χ overweight and obese have been clubbed together. the difference in prevalence of underweight (p < 0.001) as well as overweight and obesity (p< 0.05) in relation to veg./ non veg. food intake was found to be statistically signicant. discussion in the present study statistically signicant difference was seen in the prevalence of underweight in children not consuming breakfast daily and in those doing so which was 67.2% and 44.7% respectively (p< 0.05). this is similar to the 2ndings of gajre et al (2008) who reported that 62.3% students (11-13 year old) regularly consumed breakfast and were better nourished than those children who skipped 3breakfast and ahmad et al (2009) who reported that 79.51% adolescents took breakfast regularly all days of the week while only 20% of the adolescents skipped breakfast due to one reason or the other and the majority who took breakfast regularly all the days of week were found to be normally nourished. in the present study no statistically signicant difference was seen in the prevalence of overweight and obesity in children not consuming breakfast daily and in those doing so which was 12.1% and 13.8% respectively(p> 0.5). 4this is in contrast to the ndings of boutelle et al (2002) who reported that adolescents who are breakfast eaters are less 5likely to be overweight and snoek et al (2007) who reported that there is an inverse association with overweight and habit of having breakfast. in the present study statistically signicant difference was found in the prevalence of underweight in children not taking milk daily and in those taking 1,2 and 3 glasses of milk daily which was 74.1%, 50.5% ,6.7% and 0% respectively (p< 0.001). this is in accordance with the ndings of ahmad et al 3(2009) who reported that 60.6% adolescents consumed milk at least once a week whereas 27.1% did not take milk at all and adolescents consuming milk regularly enjoyed better nutritional status.in the present study statistically signicant difference was seen in the prevalence of overweight and obesity in children not taking milk daily and in those taking 1,2 and 3 glasses of milk daily which was 5.6%, 14.6%, 18.6% and 60% respectively (p< 0.01). this is in contrast to the ndings of 6 a report on human nutrition in health and disease (2008-09) which revealed that low consumption of milk was associated with higher prevalence of overweight in adolescents. in the present study statistically signicant difference was seen in the prevalence of underweight in vegetarian and non vegetarian children which was 57.3% and 36% respectively (p< 0.001).this is in contrast to the ndings of goyal et al 7(2010) who reported that vegetarian and non vegetarian diet did not have any effect on prevalence of underweight in adolescent school going children. in the present study statistically signicant difference was seen in the prevalence of overweight and obesity in vegetarian and non vegetarian children which was 9.3% and 18.9% respectively ( p< 0.05). 7this is in contrast to the ndings of goyal et al (2010) who reported that vegetarian or non vegetarian diet did not have any effect on prevalence of overweight and obesity in adolescent school going children. conclusion: personal dietary factors have a bearing on the nutritional status in school aged children. references: 1. the nutritional status of school-aged children: why should we care? best cora , neunger nicole, geel laura van, briel tina van den and osendarp saskia. food and nutrition bulletin, 2010. vol.31,no.3; 400-417. 2. gajre n.s., fernandez s., balakrishna n. and vazir s. breakfast eating habit and its inuence on attention-concentration,immediate memory and school achievement.indian paediatrics 2008; 45: 824-828. 3. ahmad hajra,liaqat parveen,paracha p.i.,qayyum abdul,uppal m.arshad.assessment of nutritional status of adolescents versus eating practices in islamabad city. pak.j.nutr., 2009,8(8):1304-1308. 4. boutelle k, neumark-sztainer d, story m, resnick m.weight control behaviors among obese,overweight and nonoverweight adolescents.j pediatr psychol 2002; 27(6):531-40 5. snoek hm,van strien t, janssens jm,engels rc.emotional,external restrained eating and overweight in dutch adolescents.scand j psychol.2007;48:23-32. 6. human nutrition in health and disease, annual report. 2008-09. 7. goyal ramesh k, shah vitthaldas n, saboo banshi d, phatak sanjiv r,shah navneet n, gohel mukesh c, raval prashad b, patel snehal s. prevalence of overweight and obesity in indian adolescent school going children: its relationship with socioeconomic status and associated lifestyle factors., japi.org,2010.vol.58. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra nutritional status veg./non veg. food intake population underweight healthy weight overweight obese no. % no. % no. % no. % no. % non-veg. 175 43.7 63 36.0 79 45.1 25 14.3 8 4.6 veg. 225 56.3 129 57.3 75 33.3 14 6.2 7 3.1 total 400 100.0 192 48.0 154 38.5 39 9.8 15 3.7 2χ = 17.95; df=1; p< 0.001 2*χ = 7.65; df=1; p< 0.05 x 37gjra global journal for research analysis 12.dr. rakesh faujdar.cdr introduction hypospadias is one of the commonest congenital anomalies of the male genital system. the reported incidence in the usa in 2001 was 1 per 200–300 live male births,1 while the rate in the netherlands in 2002 was 3 per 1000 live male births.2 in addition to the abnormal position of the urethral meatus on the ventral penile surface, it may also be associated with ventral curvature of the penis (chordee). hypospadias causes not only functional problems but also psychological problems for patients and their parents. many techniques have been described for repairing hypospadias, but none was considered the standard method. in 1994, snodgrass described tubularized incised plate (tip) urethroplasty for distal penile hypospadias repair. it was subsequently also applied to proximal hypospadias, with encouraging results.3,4 the longitudinal split of the urethral plate described by snodgrass represents signicant progress in urethral plate-preserving surgery, permitting tensionfree tubularization of the urethral plate to form a neourethra of adequate size. the technique is now widely accepted.5 the principal steps are a deep longitudinal incision of the urethral plate to allow tubularization, and addition of a layer between the neourethra and the overlying skin to avoid urethro cut aneous stula.6,7 the surgical goals of hypospadias repair are full straightening of the penis, formation of a hairless urethra of uniform caliber and adequate size, positioning of the meatus at the tip of the glans and normal penile appearance with minimum complications. nevertheless, complications such as stula, meatal stenosis, urethral ap necrosis and dehiscence are still encountered. surgeons use small variations in the technique to limit the complications. the distal limit of the deep longitudinal incision may be either the mid-glans or the tip of the glans. the covering ap of the neourethra is usually raised from the preputial skin; however, this may result in penile torsion and devascularization of the preputial skin that is often used in reconstruction of the penile skin.8 a ventral dartos ap has been used to cover the neourethra in order to avoid these complications. despite such modications, complications of hypospadias repair, such as stulae, urethral stricture, meatal stenosis, penile torsion, persistent chordee, infections and wound dehiscence, are still reported.9 in this paper, we describe our experience with two variations in performing snodgrass tip urethroplasty with respect to postoperative complications and outcomes, with emphasis on meatal stenosis, stulae formation, residual chordee and penile torsion. aims and objectives ÿ to study the types and varieties of hypospadias and their occurrence in our patient population. ÿ to study the result and complications encountered in the snodgrass urethroplasty for hypospadias repair using spongioplasty as additional cover. materials and methods this study was done to follow and evaluate the outcome of hypospadias in whom snodgrass urethroplasty along with spongioplasty was done. all cases were studied after proper to study the outcome and complications of snodgrass urethroplasty in hypospadias repair using spongioplasty as an additional cover original research paper dr. rakesh faujdar senior resident, department of surgery, m.l.b. medical college, jhansi x 31gjra global journal for research analysis general surgery aim: to study the result and complications encountered in the snodgrass urethroplasty for hypospadias repair using spongioplasty as additional cover. materials and methods: this study was done to follow and evaluate the outcome of hypospadias in whom snodgrass urethroplasty along with spongioplasty was done. all cases were studied after proper sampling (n=30) between november 2016 to april 2018. the patients were called for follow-up every week for two weeks, at three months and after one year. the minimum period of follow-up in this series was of three months. the clinical details of the patients were recorded according to the proforma. results: out of 30 patients who had snodgrass repair with spongioplasty, 01 were with signicant chordee which was corrected after degloving and 29 were without chordee. out of total 30 patients who had snodgrass urethroplasty, 24 patients urethral plate was well formed and grooved, whereas 6 patients had wide and at urethral plate. among 30 patients, 24 patients were operated within 1 hrs and 6 patients were operated in more than 1 hrs to 1.25 hrs. in our study of 30 patients hospital stay was of up to 10 days in 18 patients and 11 days in 12 patients. meatal stenosis was noted as a common complication. the incidence noted was 10% (3 out of 30 cases). waterproong with well vascularized spongioplasty prevent from meatal stenosis. meatal stenosis itself increases resistance in urinary ow and predispose to stula formation which is a dreaded complication of hypospadias surgery. in 1 case it was associated with urethra cutaneous stula. in rest 2 cases it was improved by dilatation with feeding tube 8 fr. in our study of 30 cases, 3 patients developed urethro-cutaneous stula out of which all 3 healed conservatively. 3 patients developed stula in patients with distal penile hypospadias, in all three a small coronal stula was noticed on rst follow-up. at the time of discharge they did not have a stula. meatal stenosis was observed with one of them,when the stula was noticed. with regular dilatation of the meatus for a period of 3 months the stula closed spontaneusly. 2 cases had urethrocutaneous stula corresponding to incidence of double stream. in our study of 30 cases we achieved satisfactory cosmetic appearance post surgery in 27 cases (90%). poor cosmetic results were achieved in 3 cases (10%) in the form of torsion, necrosis and residual edema each in different patients. conclusion: spongioplasty is a simple method to provide additional covering to the constructed neourethra, which achieves the goal of non-crossing suture lines and maximum vascularity. abstract keywords : snodgrass urethroplasty, hypospadias, spongioplasty. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. sudhir kumar* professor plastic surgery, m.l.b. medical college, jhansi *corresponding author dr. manish jain professor surgery, m.l.b. medical college, jhansi 32 x gjra global journal for research analysis sampling (n=30) between november 2016 to april 2018. the patients were called for follow-up every week for two weeks, at three months and after one year. the minimum period of follow-up in this series was of three months. the clinical details of the patients were recorded according to the proforma. inclusion criteria: 1. urethral plate of adequate width (>8mm) 2. coronal and distal penile hypospadias. exclusion criteria: 1. urethral plate of inadequate width, 2. severe hypospadias requiring more complex repair 3. lntersex cases 4. inadequate penile length surgical technique: all the patients were primary cases and operated under general anesthesia with supplementation of caudal block. firlet collar incision was given; chordee was completely released by degloving of the penis. glanular wings were raised. the plate was then incised in the midline from meatus to the glans. incision was not extended to the tip of the glans, to prevent subsequent meatal stenosis. deep incision was taken to divide all transverse webs and expose the corporal bodies. mobility of the epithelial strips created by longitudinal incision of the plate was conrmed. the urethral plate was tubularized over infant feeding tube no. 7 with vicryl 6-0 continuous subcuticular vicryl sutures. splayed out corpus spongiosum on either side of the urethral plate was mobilized and sutured over the tubularized urethra. spongioplasty done in this way gave additional cover to the neourethra. a vertical midline incision was given in the dorsal prepucial skin extending up to the corona. length of the skin required to cover the ventral skin defect was assessed. the excess skin which otherwise would have been discarded was deepithelialized using blade no. 15. incision was given over the inner aspect of prepuce and subcutaneous tissue was separated from the skin using sharp dissection. the deepithelialized ap derived from the dorsal prepucial skin was sutured over the neourethra with vicryl 6-0. glans wings were approximated with interrupted vicryl 5-0 suture. rotated skin aps were sutured in the midline. this helped in avoiding crossing over of suture lines. the neourethral suture line was in the midline, while the de-epithelialized ap suture line was laterally. excess skin was trimmed and then approximated in midline using vicryl 5-0 interrupted sutures. transurethral feeding tube was kept per urethrally to drain urine. sponge dressing was applied over the penis. dressing was changed on fth postoperative day. per-urethral catheter was removed on the tenth postoperative day. results table 1: age distribution table 2: position of meatus satiasfactory cosmetic results were observed in all cases. the resultant neomeatus was vertically oriented, slit like and glans was looking normal which was cosmetically well accepted. the penile raphe was in the midline. table 3: chordee preoperatively the meatal site was sub coronal in 15 patients (50%), distal penile in 15 patients (50%) out of 30 patients who had snodgrass repair with spongi o plasty, 01 were with signicant chordee which was corrected after degloving and 29 were without chordee. table 4: urethral plate out of total 30 patients who had snodgrass urethroplasty, 24 patients urethral plate was well formed and grooved, whereas 6 patients had wide and at urethral plate table 5: operative time among 30 patients, 24 patients were operated within 1 hrs and 6 patients were operated in more than 1 hrs to 1.25 hrs. table 6: hospitalization volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra age (years) no. of patients % 1-4 11 36.67% 5-6 8 26.67% 7-8 7 23.33% 9-20 4 13.33% position of meatus no. of patients % subcoronal 15 50 distal penile 15 50 chordee no of patients % absent 29 96.67 present (corrected after degloving) 01 3.33 urethral plate no. of patients % well formed, grooved 24 80 wide and at 6 20 operative time no. of patient % up to 1 hrs 24 80 >1 to 1.25 hrs 6 20 hospitalization no. of patients % 10 days 18 60 11days 12 40 in our study of 30 patients hospital stay was of up to 10 days in 18 patients and 11 days in 12 patients. table 7: meatal stenosis meatal stenosis was noted as a common complication. the incidence noted was 10% (3 out of 30 cases). waterproong with well vascularized spongioplasty prevent from meatal stenosis. meatal stenosis itself increases resistance in urinary ow and predispose to stula formation which is a dreaded complication of hypospadias surgery. in 1 case it was associated with urethra cutaneous stula. in rest 2 cases it was improved by dilatation with feeding tube 8 fr. narrow stream of urinary ow was noted in 3 cases corres ponding to meatal stenosis. table 8: urethro cuteneous stula in our study of 30 cases, 3 patients developed urethrocutaneous stula out of which all 3 healed conservatively. 3 patients developed stula in patients with distal penile hypospadias, in all three a small coronal stula was noticed on rst follow-up. at the time of discharge they did not have a stula. meatal stenosis was observed with one of them,when the stula was noticed. with regular dilatation of the meatus for a period of 3 months the stula closed spontaneusly. 2 cases had urethrocutaneous stula corresponding to incidence of double stream. table 9: cosmetic appearance in our study of 30 cases we achieved satisfactory cosmetic appearance post surgery in 27 cases (90%). poor cosmetic results were achieved in 3 cases (10%) in the form of torsion, necrosis and residual edema each in different patients. discussion surgical techniques for the repair of hypospadias are being developed continuously, implying that no single technique is considered as perfect for hypospadias. although numerous techniques have become available for the correction of hypospadias to improve further cosmetic appearance and yield perfection, new methods are still described. in european cohort study of 1072 danish boys most common age of presentation to hospital was less than 5 yrs of age(55%).in joint international study of 8122 boys most common age of presentation to hospital was was between hypospadias was between 0-3 yrs. in our study most common age group was 1-4 yrs. hypospadias arises by a failure of urethral folds to fuse and thus surgical techniques based on tubularization of the urethral plate with no skin grafts have been described. duckett (1996) reported incidence of site of meatus as; anterior 50%, middle30% and posterior 20%. tuskewinsky (2014) reported 70% anterior, 16% middle and 14% posterior meatus while standolireported 80% anterior, 14% middle and 6% posterior hypospadias. we had 100% anterior (glanular hypospadias excluded). however this is a very small series of selected cases to comment on the percentage of the meatal location. on meatal calibration with feeding tube no .8 it could not be passed in 20 patients, which was suggestive of meatal stenosis, whereas in rest of the cases meatus could be calibrated with feeding tube no.10. dividing urethral plate in the midline was helpful in increasing the caliber of the meatus, which then could admit no.10 feeding tube easily. the more distal locations, in particular, are often associated with stenotic meatus. sweet et al (2017) reported 35% incidence of chordee, while in our series it was 3%. khuri et al (2005) have reported incidence of undescended testis as high as 10%. we had one patient of right undescended testis in our series of 30 cases (approximately 3%), reason for this low incidence may be the exclusion of posterior hypospadias cases in our study. snodgrass (1994) technique of tubularized incised plate urethroplasty makes a narrow urethral plate wide enough for easy tubularization and provides vertically oriented and a cosmetically normal neomeatus. the tubularized incised plate urethroplasty extend the concept of hinging the urethral plate described previously by rich et al (1989) as a cosmetic modication of meatal-based onlay island ap repairs. the key step in the procedure is the deep sagittal incision of the urethral plate, dividing all transverse webs and exposing the underlying corporal bodies. this allows for its subsequent tubularization. this method in essence recapitulates the normal closure of the urethral folds, creating a neourethra of appropriate diameter and a vertically oriented normal appearing meatus. the deep incision of urethral plate does not compromise its viability, and the dorsal surface of the plate re-epithelized during the brief period of urinary diversion. in this technique the urethral plate is divided into two epithelial strips that are approximated in the midline ventrally to form the roof of the neourethra, while the oor and the sidewalls are formed by the incised raw area that will be eventually covered by epithelium regenerating from the edges of the plate. in dennis browne (1953) repair, the urethral plate forms the oor of the neourethra and the roof is formed by epithelial growth from the edges of the plate to cover the raw area underneath the skin cover around the stent. a. erol and baskin (2000) did anatomical study of the urethral plate and stated its importance in hypospadias repair. they concluded that the urethral plate is well vascularised and it has a rich nerve supply and an extensive muscular and connective tissue backing and gland formation. this may explain the reported long-term success of this procedure and the excessive bleeding that can occur with the incision. dorsal incision of the urethral plate, which is integral part of snodgrass repair, doesn't compromise the blood supply and re-epithelisation occurs rapidly without scarring. also as it does not use skin aps, previous circumcision or hypospadias repair is not a limitation. x 33gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra meatal stenosis number % present 3 10 absent 27 90 urethro cuteneous stula snodgrass % present 3 10% absent 27 90% cosmetic appearance number satisfactory 27 poor torsion 01 necrosis 01 residual edema. 01 in our series one patient was circumcised but had good urethral plate. in this case neourethra could be well constructed from the urethral plate with good result. various techniques have been described for correction of the distal hypospadias. the technique to be used depends on the meatal and glanular conguration. meatal advancement and glanuloplasty (magpi, 1981) is a commonly used technique but it depends on the mobility of the urethra. if the urethra is not sufciently mobile it may result in distortion of the glans and an elliptical meatus. in excessively thin or rigid ventral parameatal skin or a meatus too wide or proximal, magpi is not recommended. the parameatal based ap (mathieu's procedure, 2001) is a successful method for correcting more proximal hypospadias cases in the absence of chordee but it often results in a transversely oriented and rounded meatus which is cosmetically less acceptable than a normal vertical slit like meatus. in addition the two suture lines necessary for the ap increases the risk of developing a coronal urethro-cutaneous stula. there is also an increased risk of meatal stenosis as the blood ow in the distal part of the ap is reduced. in the constructed neourethra skin is used to form half the circumference of urethra. snodgrass (1994) described additional coverage to neoure thra by vascularised subcutaneous tissue dissected from dorsal prepucial and shaft skin. this dissection requires skill and there are chances that vascularity of the skin cover may get compromised resulting in subsequent dermal necrosis. as compared to this according to us, creation of de-epithelialized ap is a simpler alternative. one of the causes of urethral meatal stenosis after hypo spadias repair is known to be devascularization of the distal urethra. a reduction in the incidence of this complication in all series suggests that the de-epithelialized ap may also serve to prevent this problem by increasing vascularity of the neomeatus. the de-epithelialized ap might be compared to the omentum used in the abdomen in reconstructive and ablative surgery amilal bhatt (2017) in a study of 113 patients performed tiup in 113 patients without any waterproong except spong io plasty, reporting a stula rate of 12 % and meatal stenosis of 2%. in 1994, snodgrass reported tubularized incised plate urethr oplasty for distal hypospadias. no stula was reported. later on he reported multicentric experience in tubularized incised urethroplasty (148 patients) in 1996. complication was reported in 10 patients (7%). five boys had stula in the distal penile shaft or subcoronal region. there was no stula involving the glans. meatal stenosis was reported in three other boys including two who also had stula. in 1998, snodgrass reported results of tubularized incised urethroplasty in proximal hypospadias. complication occurred in 3 of 27 patients (11%), who underwent only tubularized incised plate repair. a stula and meatal stenosis resulting in diverticulum formation developed in one patient each. he did not report any neourethral stula. a. elbakry (2005) reported a series of 27 patients of distal hypospadias repair, done using snodgrass technique with good functional and cosmetic results. four patients had small stula associated with meatal stenosis, which resolved spontaneously by regular dilatation. j.oswald et al (2000) reported 30 patient's comparative series of who underwent mathieu's (parameatal based ap) repair had complication (two stula and one meatal stenosis), compared with only one complication in snodgrass group yerkes (2000) reported no stulae in any of patients for whom spongioplasty was implemented in number of urethral repair techniques, where as beaudoin (2000) described the anatomical characteristics of the spongiosal layer in the hypospadic penis and implemented spongioplasty in patients who underwent tubularization. in 2003, dodat et al showed no stula formation in any of the 51 patients who underwent tipu and spongioplasty. elsherbiny et al (2004) reported that covering the neourethra with a ap or spongioplasty minimized the risk of stula formation. in a series of 500 cases, sarhan et al (2009) used a dartos ap, spongioplasty, or a combination of these techniques in addition to tip.they observed a statistically signicant decrease in stula formation in cases in which spongioplasty was implemented compared with cases in which it was not kamyar tavakkoli tabassi et al (2012) in their prospective study of 33 patients with penile hypospadias treated using a tubularized incised plate urethroplasty (snodgrass method) and vascularized tunica vaginalis ap as a second layer, achieved good cosmetic results in 93.93% cases. they had stula in 3 (10.34%), wound infections in 4 (13.79%), and meatal stenosis in 3 (10.34%) pattern. our results are comparable to j. oswald (2000). we had one patient in whom circumcision was already done. we saw additional advantage of this procedure that it can be done in circumcised patients, as construction of neourethra doesn't require any skin ap. at this point we would like to emphasize that this is a repair in which the urethra is entirely formed by urethral plate. uday s. chatterjee et al (2004) in their comparative study of 49 patients (mean age 4.6 years, range 1–22) with hypospadias of different types (varying from coronal to penoscrotal) using the tip technique, with dartos fascia wrap used in 20 and tvpw(tunica vaginalis pedicle wrap) in 29. in the dartos fascia group three patients developed stulae, but there were none in the tvpw group. aman essam, et al (2011) in their study of 40 patients reported stula formation in 1 patient. their study comprised of 32 patients of distal and 8 of mid penile hypospadias. they used snodgrass tip urethroplasty in all cases with dorsal dartos vascularised ap in all cases. so the stula rate in our study is less than these studies sho wing depithelialised ap to be a better alternative as waterproong. one of our patients developed meatal stenosis with stula. it was observed on rst follow up when the stula was also noticed. with regular dilatation of the meatus for a period of 3 months the stula closed spontaneously. the occurrence of meatal stenosis after snodgrass repair is due to adherence of both raw sides of incised plates during healing. jordon and schlossberg explained in detail, the healing process of urethral wounds, if the epithelia are apposed wound healing occurs by primary intention resulting in stenosis. when epithelial apposition is prevented by separating both sides of the wound, healing occurs by secondary intention and the epithelium progress slowly from the edges of the wound to cover the raw area. m. dayane in 2000 reported a series of 20 distal and 5 mid penile hypospadias cases. in distal, meatal stenosis occurred 34 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra in 1 patient and urethral stula in another. the overall complication rate was 10% among midpenile cases, meatal stenosis was observed in one patient. in this series of 30 patients we had 3 patients with midpenile hypospadias who developed stula. this patient had spontaneous closure of the stula with regular dilatations. the most reliable method to counteract the process of urethral wound contraction is long term and regular dilatation of the urethra. neourethral dilatation is easy, painless and can be done by parents at home. w. snodgrass reported that the neourethra in 10 of his patients was routinely calibrated at regular intervals for a period of 3 months we believe that if the plate is incised deep enough then it will not heal by apposition and epithelium will grow to make the caliber of the urethra adequate. to prevent apposition of the incised ap we recommend keeping the stent for a longer duration i.e. 10 days. in our study operative time was 1-1.25 hrs (100%) in all cases which is comparable to most other studies. hospital stay was 10 to 11 days in all cases (100%). long hospital stay was adopted because most of our patients were from rural areas and there was risk of accidental catheter removal and uncertainty of strict follow up. shanberg et al in year 2000 stated that snodgrass repair could be used successfully in re-operative hypospadias repair with relatively fewer complications. we recommend snodgrass urethroplasty with spongioplasty repair in all distal and subcoronal hypospadias. it can also be done in circumcised patients. conclusions 1. snodgrass urethroplasty is a simple and versatile tech nique which is applicable to all varieties of hypospadias 2. the neourethra is formed entirely by urethral plate. 3. it gives an excellent cosmetic appearance to the glans with a vertically oriented slit like neomeatus. 4. spongioplasty is a simple method to provide additional covering to the constructed neourethra, which achieves the goal of non-crossing suture lines and maximum vascularity. 5. this technique is a good alternative to meatal based and onlay island procedure. references: 1. king l r hypospadias a one stage repair without skin graft based on a new principle chordee is sometimes produced by skin alone. j urol 973; 103:6603. 2. sadlowski r w, king l r further experience with one stage repair. j urol 1974; 12; 664-7. 3. rich m a et al hinging the urethral plate in hypospadias meatoplasty. j urol 1989; 2; 1551. 4. durham smith a de-epithilialized overlap ap technique in the repair of hypospadias. br j plast surg 1973,26:106-114. 5. w.snodgrasstubularized incised plate urethroplasty in distal hypospadias. j urol 1994; vol 151; 464-465. 6. j w duckett hypospadias-history of surgical procedures. campbell’s urology; 7th ed.; vol 2; pg. 2097. 7. byars l t technique of consistently satisfactory repair of hypospadias. surg gynecol obstet 1955;100;184-190. 8. gittes r f, mc.laughin a p injection technique to induce penile erection. urology 1974; 4; 473-475. 9. smith e d hypospadias aschcraft k ; ed. paediatric urology. philadelphia; w.b. saunders; 1990. 10. zaontz m r the gap for glanular hypospadias repair. j urol 1989;141 359-3. 11. w. snodgrass tubularized incised plate hypospadias repair; resuts of a multicentic experience. j urol aug 1996; vol.156; 839-841. 12. w.snodgrass tubularized incised plate hypospadias repair for proximal hypospadias. j urol 1998; vol. 159; 2139-2141. 13. belman the de-epithelialized ap and its inuence on hypospadias repair. j urol 1994; vol 152 ; 2334-2334. 14. belman a b de-epithialized skin ap cover in hypospadias repair. urol nov1988; vol. 140; 1273-127 15. duckett j w hypospadias walsh pc, retik ab, eds campbell’s urology, 7th ed., vol.2, pg 2093. 16. a. erol & ls baskin anatomical studies of the urethral plate: why preservation of the urethral plate is important in hypospadias repair. br j urol int 2000; 85; 728-734. 17. duckett j w magpi repair after 1000 cases: avoidance of meatal stenosis. j urol 1992; 147; 665-669. 18. mathieu p treatment en un temps de i hypospadias balanique et juxta balanique j chir 1932; 39 ; 481-4. 19. a.elbakry tipu: is regular dilatation necessary for success. br j urol int 1999; 84; 683-688. 20. j. oswald comparison of mathieu’s and snodgrass repair in primary distal hypospadias. br j urol int 2000; 85; 725-727. 21. murat dayane tipu for distal and mid penile hypospadias. european urol ; 37 ; 102-105. 22. shanberg a m re-operative hypospadias repair using snodgrass technique. br j urol int 2000; 85; supp 4; 72-74. x 35gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction the system of trade over and done with barter is as old as the social civilization. barter system is a system in which people sell goods and chattels and services in order to obtain other goods and services through direct exchange. the functioning of a barter economy was however cumbersome and inopportune due to double happenstance of wants. complications of barter system lead to the primer and progress of financial activities. this deserves to be ranked among the outstanding innovations of the entire history. the birth of nancial activities came as a multifold blessing to mankind. it had been dened in various ways. somebody says these are used in the place of barter. in other words anything that performs the functions of nancial activity is money. economics makes it clear that money plays an important role in the nancial structure. in india, the ancient hindu scriptures refer to the moneylending activities in the vedic period. during the era of ramayana and mahabharata, the banking had become a full-edged activity. during the smrity period which followed the vedic period, the business of banking was largely carried on by the members of vaish community. as the civilization grew with the development of economic systems the development in the banking was also inevitable. the banker in this period performed many of the functions which a modern banker performs these days viz. accepting deposits, granting of advances, acting as banker to state and issuing and managing currency of the country. in olden days the happenings of nancial activities are conned with accepting deposits and lending loans. this gives the chance for the growth of paper money, bills of exchange, cheques and other accompanying transactional areas. in accumulation to receipt of deposits and lending activities, the modern institutions render many services. it becomes necessary to fascinate to businesses by providing a wide choice of innovative facilities to customers. adam smith rightly observed, “the earliest banks of italy where the name began were nance companies to make loans to and oat loans for the government of the cities in which they were formed … after these banks had been long established, they began to do what we call as banking business, but at rst they never thought of it”. the growing demand for banking activities and technological advancements gave chances for the birth of cyber centric financial transactions. cyber centric financial activities finland was the rst country in the world to have taken a lead in cyber centric financial transactions – a notied new age facility. in india, it was icici bank which initiated cyber centric financial transactions as early as 1997 under the brand name innity. cyber centric financial transactions is a genetic term encompassing internet banking, telephone banking, and mobile banking etc., in other words, it is a process of delivery of banking services and products through electronic channels such as telephone, internet, and cell phone. cyber centric financial transactions are an umbrella term for the process by which a customer may perform banking transactions electronically without visiting a brickand-mortar institution. the quality, range and price of these electronic services decide a bank's competitive position in the industry. so cyber centric financial transaction is dened as “the automated delivery of new and traditional nancial products and services directly to customers through electronic, interactive communication channels.” cyber centric financial transaction is a convenient way to access customer account 24 hours a day, 7 days a week, through the internet. a cyber centric nancial activity includes the following services. they are 1. net banking – operating and accessing the bank account through internet facilities. 2. plastic money the plastic money generally a credit or debit card with a magnetic strip, many people carry in their wallets or purses. holders of a valid card have the authorization to purchase goods and services up to a predetermined amount, called a credit limit for credit cards and availability of balances for debit cards . 3. mobile banking – availing facilities through phones. normally this facility is available in smart phones. but now central government has introduced these facilities through ordinary cell phone through some notied application such as bhim, *99# etc., 4. payment wallets – these are electronic applications. the customer can make payments for their purchases through these applications such as pay tm, mobivik, freecharge etc., problems in cyber centric financial transactions: all the banking companies, both public sector and privatesector institutions and foreign institutions are providing these new phases of modern facilities. but the question is up to what extent these facilities are affordable to the customers in rural side. cyber centric financial transactions – a study original research paper p. manivannan head, department of corporate secretaryship x 47gjra global journal for research analysis management financial activities in india have faced radical alterations due to the implementation of new economic policies. before liberalization, in 1969 and 1980 banking establishments were nationalized based on the thrust aim of supplementary banking i.e., rapid spreading out of banking activities. whereas now the industry is operated on the concept of customer centric and cyber centric banking i.e. changed towards “better nancial activities from more nancial activities” in order to face the market challenges. after the adoption of technological development it allows the banking businesses and other stakeholders to interact and transact with the institutions seamlessly through a variety of conduits. they are internet, wireless devices, atm's, mobile payment wallets and various digital applications. these facilities are widely provided by almost all the institutions. based on this background an attempt has been made to draw the responses about the level of usage and customer satisfaction towards cyber centric financial activities. abstract keywords : financial activities, customer satisfaction. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra variable 18-30 31-45 years 46 years and above total agree 45 45 26 116 disagree 17 34 5 56 no opinion 47 62 11 120 total 109 141 42 292 variable 1830years 31-45 years 46years and above total almost daily 15 9 2 26 6-10 times in month 30 36 10 76 3-5 times in month 36 69 22 127 1-2 time in month 21 21 4 46 once in a month 2 3 3 8 occasionally used 5 3 1 9 total 109 141 42 292 48 x gjra global journal for research analysis objectives of the study: the following are the important objectives of the study. 1. to test the awareness and satisfaction level of the respondents. 2. to nd out the socio-economic proles of the customers. 3. to explore the various areas of usage through modern payment systems. importance of the study: the ever growing demand for money and banking activities, the present study focuses on the opinion about cyber centric activities and how far the need of the individual is satised. survey period: the period of survey was made in the month of january 2019. limitations of the study: the main limitations of the study are as follows: ÿ the study is based on the opinion of the individuals in the study area i.e. chennai. ÿ the respondent’s bias noticed during the survey may slightly inuence the ndings of the study. analysis and interpretation: distribution of respondents according to frequency of usage and age group this table shows more than 50 percent of the respondents are in the age group of 31-45 years, of which 69 respondents are using modern banking services 3-5 time in month. the least group are in the age level of more than 46 years. so it is evident that middle age group customers are availing more banking facilities. distribution of respondents according to monthly spending and age group this table shows the amount spend through new age payment system and age group. it is observed that, more no of respondents are in the age group of 31-45 years are spending the amount in the category of rs.5001 to rs.15000. only 7 respondents are spending more than rs. 30000 through cyber centric financial transactions facilities. hence it is clear that majority are spending only reasonable amount and they are in middle age group. distribution of respondents according to misuse of facilities and gender this table shows the how many respondents are saying that their banking facilities i.e. cards, net banking, phone banking facilities are misused. out of the total respondents' 16 male respondents and 3 female respondents have opinioned that, their accounts are misused. in general not even 10 percent of the respondent's account is misused. so this may be on the reason that, new age facilities are not widely used in the study area. distribution of respondents according to age and legal system this table shows the level of respondents agreeing that the legal system is confusing and cumbersome. out of the respondents in the survey 116 respondents have opinioned that the legal system is confusing and cumbersome. only 56 respondents have disagreed this statement. but at the same time 120 respondents have not expressed any opinion. this is so evident because the customers are not fully aware about the legality cyber centric financial transactions. distribution of respondents according to factors inuencing the choice of cyber centric financial transactions this table shows the ranking of various variables considered for the study. out of the variables considered convenience of using cyber centric financial transactions is ranked 1 based on weighted average mean (wam) of 11.01. this was followed by acceptability of the bank which secures second rank. among the variables considered less ranked variable includes transaction fees (12), bank staff recommendation (11) and annual fees (10).the anova result indicates that status symbol and transaction fees were statistically signicant. distribution of respondents according to spending pattern through plastic money volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra variable male female total yes 16 3 19 no 210 63 273 total 226 66 292 variable 18-30years 31-45 years 4 6 y e a r s and above total < 5000 40 27 9 76 rs.5001 to rs.15000 53 77 20 150 rs.15001 to rs.30000 14 33 12 59 more that rs.30000 2 4 1 7 total 109 141 42 291 s.no variable rank wam e value sig 1 convenience 1 11.01 4.37 .014 2 status symbol 7 6.48 11.94 0 3 brand of the bank 5 7.17 3.08 .048 4 acceptability 2 9.04 0.81 .0448 5 charges for various facilities 3 8.20 2.11 .0124 6 distribution network 4 7.76 3.51 .032 7 bank staff recommendation 11 4.23 3.73 .026 8 peer feed back 9 4.33 4.49 .012 9 free credit period 6 6.59 0.68 .51 10 credit limit 8 4.77 4.96 .008 11 annual fees 10 4.3 4.55 .012 12 transaction fees 12 4.14 7.11 .001 s.no variable rank wam f value sig 1 groceries 1 5.45 3.46 .033 2 restaurant bill payment 2 5.4 .51 .6 3 consumer durables 5 4.555 .56 .57 4 electronic 6 4.315 .30 .738 5 cash withdrawn through atm 3 4.965 3.68 .027 6 hotel accommodation 8 2.94 0.48 .619 7 airlines/railway tickets 7 3.595 1.07 .344 8 clothing and jewelry 4 4.78 .20 .816 this table shows the ranking of variables based on the spending pattern of the respondents in the study area. even though the shops where possibilities for digital payments are very limited, in spite of that also respondents are willing to avail the facilities of digital payments. among the variables considered groceries is considered as 1st rank. the least ranked responses are hotel accommodation (8), travel ticket booking (7). and the important notable point is usage of cards for cash withdrawals through atms secured 3rd rank. but only three atms are working with cash. all other atms are having cash out position on most of the days during the survey period. major findings of the study: ÿ the acceptability of new age payment wallets is not good in the study area. but many of the merchant point’s start accepting. ÿ the study shows more of male respondents agreed that the new phase of facilities are essential than female respondents. ÿ the age-wise analysis indicates that, out of the total respondents who are using new phase financial activity facilities, which comes to 50% (approx.) majority are in middle age i.e. 31-45 years. this shows that middle and young aged customers are ready to accept the technological advancements. ÿ the survey further reveals that 127 respondents have opinioned that they are using the facilities ve times in a month. on this 69 respondents who are in this category are in the age group of 31-45 years. conclusion: cyber centric financial activities which was well thought-out to be a luxury has turned into required. the modern technological advancements were considered to be used by higher income group. among the various nancial services rendered by commercial banks and other nancial institutions extending their facility to customers through cyber centric financial activities i.e., net banking, plastic money, mobile banking etc. are important modern day function. these facilities are extended not only to customers in urban areas or cities, but also to customers residing in rural area. but today, with the development of banking and trading activity, the xed income group or salaried classes have also start using these facilities. but still there may be the criticisms that, it induces more purchases or make the people for spend thrift economy. this may be so in the primary stage, but when once a customer gets used to avail these modern banking facilities they will know how to use the same in a discretionary manner. on the whole, the paper concludes that, availability of new and modern age facilities in the nancial sector are really considered as opportunity in general. but, the same is also considered as a threat in rural areas. because they are partaking glitches with respect to cyber centric financial transactions i.e. functioning of atm, distribution of network, acceptability of new age payment systems, safety of online transactions etc. references: 1. adam smith, “an enquiry in to the nature and causes of the wealth of nations”, 769, vol iv, pp. 420-423. 2. press notication of reserve bank of india, 2004/663, dated 24th december, 2004. 3. gautam gosh, “spending is priority today”, the hindu, 31st october 1999. 4. investment world, 25th june 2000, business line. 5. banking on technology by priya nair. 6. a.subramani, “attention credit cards”, the hindu, 16th november 2006. 7. jyoti pal, “cards in india”, they money times, 31st december 2006. 8. plastic money: roadway towards cash less society, bansi patel and urvi amin, paripex -indian journal of research, volume 1, issue 11, november 2012. 9. plastic money a way for cash less payment systems, p.manivannan, global research analysis, volume 2, issue 1, january 2013, pp11-12 10. mobile payments in india, deloitte, april 2011. 11. levesque, and mc dougall, “determinants of customer satisfaction in banking”, international of journal of bank marketing, 14(7), pp12-20, 1996. 12. anand, g.m., murugauag, w.j., 2003 “comments on ‘bank selection decision and market segmentation”, journal of marketing, october, pp. 89-91. 13. s.n. maheswari and s.k.maheswari, “banking theory, law & practice, kalyani publishers, edition 2005, pp. i-4. 14. edward and others, “commercial banking”, englewood cliffs, new jersey, pp. 10-15. 15. www.google.com 16. www.nowstuffworks.com x 49gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction the greatest millstones of medicine must be conquering pain which has impact on every human life since 1846, mankind's greatest fears, the pain of surgery, was eliminated with 1anaesthesia. regional anaesthesia techniques provide important advantages over general anaesthesia, including excellent pain control, reduced side effects (trauma to lips, teeth, pharynx, vocal cords; nausea, vomiting; bronchospasm, aspiration; prolonged somnolence, prolonged paralysis; mal ignant hyper thermia; r isk o f anaphylac t ic or anaphylactoid reactions), and shortened stay in the post2-6anaesthesia care unit. peripheral nerve blocks has become technique of choice for anaesthesia and postoperative analgesia in orthopaedic, plastic, and peripheral vascular surgery and for the treatment 7of chronic pain syndrome. brachial plexus blockade is one of the approaches to sensorimotor regional neural blockade by which surgical anaesthesia of the upper limb may be achieved. it is preferred 8,9in upper limb surgeries because it has certain advantages. supraclavicular approach gives the most effective block for 10all portions of upper extremity. over decades various local anaesthetic agents have been used for utility of supraclavicular brachial plexus block. levobupivacaine, an excellent local anaesthetic drug with lesser side effects is also used for utility of the supraclavicular brachial plexus block. ropivacaine, a long-acting local anaesthetic that is being used for supraclavicular brachial plexus block in upper limb surgery. the aim of prolonging the duration of peripheral nerve blocks to treat postoperative pain is a key issue in regional anaesthesia. adjuvants with local anaesthetics in brachial plexus block are 11 used to achieve a quick, dense, and prolonged block. various 1 2 1 3 1 3adjuvants like tramadol ,sufentanyl clonidine and 14 fentanyl have been employed in the search for near ideal agent. currently, dexmedetomidine, an α -receptor agonist, a 2 congener of cloniodine, has also been reported to improve the 15,16quality of intrathecal and epidural anaesthesia. in this study we will assess and compare the effects of levobupivacaine and ropivacaine along with dexmede tomidine as an adjuvant to both local anaesthetic agents. materials and methods the present prospective randomized double blinded comparative study was done in 60 in-patients admitted in the orthopaedics ward in nscb medical college and hospital, jabalpur (m.p) after obtaining institutional ethical approval and written informed consent from patients. all patients underwent through a pre-anaesthetic check-up (detailed history, thorough physical examination, routine investigation and any especial investigation if required were done) and patients of either sex between 25 – 55 years of age, of asa class-i and ii and of weight >50kg who were posted for elective surgeries on arm, forearm, hand or wrist were included in study. patients who have refused to be the part of study, who has allergy to local anaesthetics, infection at needle insertion site, on anticoagulant therapy or with bleeding disorders, has cardiopulmonary contraindications, pregnant woman, neuropathy or diabetes mellitus, liver or renal dysfunctions were excluded from the study. patients were randomly allocated into two study groups (30 patients each) by using the computer generated table of random numbers: ÿ group ld: all patients received 30 ml of 0.5% injection levobupivacaine and injection dexmedetomidine 1µg/kg. ÿ group rd: all patients received 30 ml of 0.5% injection ropivacaine and injection dexmedetomidine 1µg/kg. after taking thorough history and informed consent, the patients were placed on the operation table in supine position. before starting the procedure all the standard monitors (nibp cuff, pulse oximetery probe, ecg) were connected to all the prospective randomized double blinded comparative study of supraclavicular brachial plexus block using levobupivacaine versus ropivacaine. original research paper dr. ashish gupta assistant professor, department of anesthesiology, nscb medical college, jabalpur x 47gjra global journal for research analysis anaesthesiology background: over decades various local anaesthetic agents have been used for utility of supraclavicular brachial plexus block. levobupivacaine, an excellent local anaesthetic as well as ropivacaine, a long-acting local anaesthetic. methodology: patients were randomly allocated into two study groups (30 patients each) of all patients received 30 ml of 0.5% injection levobupivacaine and injection dexmedetomidine 1µg/kg (ld) while in other group all patients received 30 ml of 0.5% injection ropivacaine and injection dexmedetomidine 1µg/kg (rd). results: time to onset and duration of both sensory and motor block was comparable in two groups (p>0.05). though mean duration of analgesia was signicantly (p<0.005) more for group-ld when compared to group-rd. the difference in mean score of vas in both groups was signicantly better for ld-group at 12, 14 and 16 hour post-operative period (p<0.05) though initially it was comparable.the consumption of diclofenac as rescue analgesia was signicantly higher in group-rd as compared to group-ld. conclusion: addition of dexmedetomidine along with levobupivacaine for supraclavicular brachialplexus block enhances the duration of postoperative analgesia as well diminished requirement for rescue analgesia in postoperative period compaired to along with ropivacaine. abstract keywords : levobupivacaine versus ropivacaine, dexmedetomidine, analgesia. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. gopal singh maravi* associate professor, department of anesthesiology, nscb medical college, jabalpur *corresponding author 48 x gjra global journal for research analysis patients and intravenous access was secured by using an iv cannula of 18g. all patients were pre-medicated with i/v injection midazolam1mg. under all aseptic precautions, after painting and draping the supraclavicular brachial plexus block was performed by using 5cm 22g. in group ld all patients in this group received 30ml of 0.5% inj. levobupivacaine and inj. dexmedetomidine 1µg/kg. in group rd all patients in this group received 30ml of 0.5% inj. ropivacaine and inj. dexmedetomidine1µg/kg. if there was failure of the block in the area of nerve distribution, patients were provided general anaesthesia and these patients were excluded from our study. the onset and duration of sensory block was studied using hollmen sensory score scale. the loss of sensation to pin prick in the midline (with 22g blunt hypodermic needle) was checked every 30 seconds after injection of the drug till the onset of loss of sensation and then every half hourly till the sensations were regained. the motor blockade was assessed by using modied bromage scale score every 1 minute till the loss of movements and then every half hourly till the movements are regained. the cutoff score for sensory block was taken as hollmen sensory scale score of 2. post operative pain was assessed by visual analog scale (vas) at 2h, 4h, 6h, 8h, 10h,12h, 14h,16, 20h, and 24h after surgery. vas score of zero -denote no pain, 1-3 -mild pain, 4–7 moderate pain, 8–10 -severe pain. when vas score became >3, rescue analgesia was provided with the i.m. injection diclofenac sodium75mg. sedation score was assessed according to the ramsay sedation scale (rss) from 16 where higher score suggest higher sedation. after completion of the study, the results were statistically analyzed using chi-square test for nonparametric data and student unpaired t-test for parametric data for inter-group comparison. statistical analysis was done using spss iii statistics for windows, version 20.0. the value of p<0.05 was considered signicant. results patients of two study groups had a comparable (p=0.8076) mean age of the patients was 36.83±10.51years in group-ld and 37.53±11.62 years in group-rd. there were 19 (63.33%) males while 11 (36.66%) were females patients in group-ld, and males were 22 (73.33%) and females were 8 (26.66%) in group-rd (p>0.05). pre-operative vitals like mean blood pressure, and mean pulse rate were also comparable in both groups (p>0.05). time to onset and duration of both sensory and motor block was comparable in two groups (p>0.05). though mean duration of analgesia was signicantly (p<0.005) more for group-ld when compared to group-rd. the difference in mean score of vas in both groups was signicantly better for ld-group at 12, 14 and 16 hour postoperative period (p<0.05) though initially it was comparable. a mean 80±19.02 mg of diclofenac was administered to the patient of group-ld as rescue analgesia, while patients of group-rd consumed 100±35.95 mg of diclofenac. the consumption of diclofenac as rescue analgesia was signicantly higher in group-rd as compared to group-ld. the mean sedation score on ramsay sedation scales core was 2.3±0.83 for group-ld while 2.4±0.77 for group-rd with no difference in sedation scores (p>0.05). table 01: comparison of sensory and motor parameters between two study groups. table 2: post-operative vas score the incidence of any adverse events was almost comparable in both groups. no life threatening complications were noted in the patients of either group. discussion inadequate management of surgical pain can delay surgical recovery, decrease patient satisfaction and increase the length of hospitalization, readmission rates and overall healthcare costs. currently pain relief by regional anaesthesia is the most effective method to manage acute pain and is more effective in comparison with intravenous 17patient controlled analgesia. brachial plexus block is commonly used as a sole anaesthetic technique or may be supplemented with general anaesthesia for surgeries of the upper limb. meanwhile both groups were comparable demographically. in present study the mean onset and recovery time of both sensory block and motor block was comparable in both groups. the duration of post operative analgesia was signicant higher in ld-group then rd-group in our study. connolly et al (2001) observed similar ndings where ropivacaine 225mg was equipotent to levobupivacaine150mg which was used for 18sciatic femoral block. in patient controlled continuous 19 interscalene analgesia, borghi betalin 2006 reported that 0.25% levobupivacaine provided similar quality of anaesthesia as provided by 0.4% ropivacaine and better anaesthesia was achieved with 0.25% levobupivacaine when compared with 0.25% ropivacaine in similar clinical setting. these results were similar to our ndings. duration of block is also inuenced by protein binding level of local anaesthetic agent so higher the binding drug could achieve longer duration of effect. the levobupivacaine (95%) has not signicantly but slightly higher protein bounding in 0,21 comparison to that in ropivacaine (94%).2 levobupivacaine volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra parameters ld mean±sd rd mean±sd p-value sensory block onset (min.) 9.34±1.45 9.99±1.49 0.0912 duration (min.) 769.16±76.23 739.16±44.89 0.0683 motor block onset (min.) 13.87±1.22 14.37±1.41 0.1471 duration (min.) 667.13±57.96 643.5±39.28 0.0696 duration of analgesia (min.) 942.7±80.63 885.76±43.92 0.0012 inj. diclofenac consumption (mg) 80±19.02 100±35.95 0.0093 sedation score (rss) 2.3±0.83 2.4±0.77 0.6319 vas score ld group mean±sd rd group mean±sd p-value 2 hr 0±0 0±0 1.0 4 hr 0±0 0±0 1.0 6 hr 0±0 0±0 1.0 8 hr 0±0 0±0 1.0 10 hr 0±0 0.067±0.36 0.3215 12 hr 0.4±0.77 1.6±0.93 <0.01 14 hr 2.36±1.49 3.46±0.77 <0.01 16 hr 2.53±1.88 1.46±1.96 0.036 20 hr 0.3±1.02 0±0 0.1134 24 hr 1.3±1.48 1.93±1.7 0.1303 reported to have a longer duration of analgesia in comparison to ropivacaine when used in neuraxial block techniques as observed by many authors which may be due to more 22-25lipophilic nature of levobupivacaine. 26patki et al (2013) showed a mean duration of postoperative analgesia was 738.83 minutes and signicantly less need for rescue analgesia in rst 24 hours using 30ml of 0.5% ropivacine along with 50µg of dexmedetomidine injected for supraclavicular block. another recent study by rashmi et al 27(2017) reported a mean duration of postoperative analgesia was 872 minutes ( vs. 885.76 minutes in current study) by using 30ml ropivacaine with 50µg of dexmedetomidine in interscalene brachial plexus block. while kaygusuz et al 28 (2012) used 39ml of 0.5% of levobupivacaine with 1µg/kg of dexmedetomidine in axillary brachial plexus block showed that the mean time for rst analgesic requirement was1279.54 minutes. this observed difference in durations of postoperative analgesia may be attributed due to difference in concentration of local agent. 29in another study by nallam et al (2016) , they found that levobupivacaine combined with varying doses of dexmedetomidine showed prolongation in duration of postoperative analgesia where group using 100 µg of dexmedetomidine analgesia was for 1033.6 minutes while it w a s 7 7 6 . 4 m i n u t e s i n t h e g r o u p u s i n g 5 0 µ g o f dexmedetomidine. in context of our present study mean duration of analgesia in group using 0.5% levobupivacaine combined with 1µg/kg dexmedetomidine is 942.7 minutes. it is s o m e h o w r e l a t e d t o t h e v a r i a t i o n i n d o s e s o f dexmedetomidine in our study. 30 sudani et al (2016) noticed the mean duration of sensory block of 811.66 minutes and less requirement of rescue analges ia wi th 0 .75% ropivacaine wi th 25µg o f dexmedetomidine in supraclavicular brachial plexus block. in a prospective double blinded study, it was found that 31dexmedetomidine gives greater post operative analgesia. the effect of dexmedetomidine on brachial plexus block with ropiovacaine showed that dexmedetomidine not only enhance the efcacy of block, but also reduces the ischaemia 32reperfusion injury caused by tourniquet in upper limb surgery. similar to present study, 30ml of 0.5% ropivacaine along with 1µg/kg dexmedetomidine was injected for supraclavicular brachial plexus block produced a mean 807.5 minutes (vs. 885.76 minutes in present study) post-operative analgesia. by adding dexmedetomidine for supraclavicular blockade, longer duration of post-operative analgesia could be 33achieved without signicant clinical side effects. when comparing two different local anaesthetic agents their molality also must be accountable because of different molecular weights. levobupivacaine possess around 7%-8% 34more active molecules than ropivacaine. pertaining to this study it was proven the duration of sensory and motor block signicantly longer in patients of levobupivacaine group. this observed difference in different parameters of block is not merely due to different molecular weight, but somehow also related to variable protein binding of levobupivacaine which is 95% and 92% of ropivacaine. however type of block as well as site of administration inuence the difference in parameters between two local anaesthetic agents. results of above study cannot be concluded to a generalized clinical practice because of contention in literature about controversial results, with different results according to site of 35,36deposition of local agents. potency of drug is also 37,38inuenced by the type of block administered. 39 in another study by singh ap et al in which 30ml of 0.5% of levobupivacaine with 100µg of dexmedetomidine was administered for supraclavicular brachial plexus block. they found the mean duration of post operative analgesia was 1273.79 minutes. the prolonged duration of post operative analgesia (1273.79 minutes) in previous study may be attributed to increased dose of dexmedetomidine (100µg). above mentioned studies are also in agreement with present one but observed variability in parameters is due to variations in concentration of adjuvant dexmedetomidine. to be concluded the addition of dexmedetomidine along with levobupivacaine for supraclavicular brachialplexus block enhances the duration of postoperative analgesia as well diminished requirement for rescue analgesia in postoperative period. references 1. robinson dh1, toledo ah. historical development of modern anesthesia. j invest surg. 2012 jun;25(3):141-9. 2. liu ss. a comparison of regional versus general anaesthesia for ambulatory anaesthesia: a metaanalysis of randomized controlled trials. anaesth analg 2005;10:1634-42. 3. liu ss. the effect of analgesic technique on post-operative patient reported outcomes including analgesia; a systematic review. anaesth analg 2007; 105:789-808. 4. mccartney cj, brull r, chan vw et al. early but no long term benet of regional compared with general anaesthesia for ambulatory hand surgery. anaesthesiology 2004;10:461-7. 5. hoffmann j, westendroff c, reiner s. evaluation of dental injury following endotracheal intubation using the perioral technique. dent trauma tol. 2005 oct;21(5):263-8 6. aitkenhead ar. injuries associated with anaesthesia. a global perspective. british journal of anaesthesia 2005:95(1):95-109. 7. jacques e. chelly . peripheral nerve blocks: a color atlas.2nd edition. 2004 lippincot williams &wilkins,chapter 1. 8. neal jm, geranchu jc, hebl jr, ilfeld bm, mccartney cj, franco cd et al. upper extremity regional anaesthesia. reg anaesth pain med 2009 mar apr:34(2);134-170. 9. livingston em, werthein h. brachial plexus block: its clinical application. anaesth analog j 1927 jun;6(3) :149-156. 10. fischer hbj. brachial plexus anaesthesia in. principles and practice of regional anaesthesia; wildsmith jaw, armitagfe en, mcclure jh, editors, 3rd edition. london: churchill livingstone, 2003;193-204. 11. abdallah fw, brull r. facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: a systematic review and meta analysis. br. j anaesth. 2013; 110; 915-25. 12. robaux s, blunt c et al. tramadol added to 1.5% mepivacaine for axillary brachial plexus block improves post operative analgesic dose dependency. anaesth analg. 2004;98:1172-7. 13. antonucci s. adjuvants in the axillary brachial plexus blockade. comparision b/w clonidine, sufentanyl & tramadol. minerva anaesthesiol. 2001;67:23-7. 14. geze s, ulusoy h, erturk e, ckeiz b, arduc c. comparision of local anaesthetic mixture with tramadol or fentanyl for axillary plexus block in orthopaedic upper extremity surgery. eur j. gen med. 2012;9:118-23. 15. kanazi ge, aouad mt, jabbour k et al. effect of low dose dexmedetomidine or clonidine as characteristics of bupivacaine spinal block. acta anaesth scand; 2006; 50: 222-7. 16. congedo e, sgreccia m, de cosmo g. new drugs for epidural analgesia. curr drug target. 2009;10:696-706. 17. becchi c, malyanm, coppini r, campolo m, magherini m et al. opioid free analgesia by continuous psoas compartment block after total hip arthroplasty. a randomized study: eur j anaesth.2008;25(5):418-23. 18. connolly c , coventry d m , wild smith j a, double blind comparison of ropivacaine 7.5mg/ml with bupivacaine 5 mg/ml for sciatic nerve block. br j anaesth 2001;86:674-7. 19. borghi b, facchini f, agnoletti v et al. pain relief and motor function during continuous interscalene analgesia after open shoulder surgery: a prospective randomized, double blind comparison between levobupivacaine 0.25% and ropivacaine 0.25% or 0.4%. eur j anaesthesiol 2006;23:1005-9. 20. leone s, di cianni s, casati a, fanelli g. pharmacology, toxicology, and clinical use of new long acting local anaesthetics, ropivacaine and levobupivacaine. acta biomed 2008;79:92 105. 21. buckenmaier cc 3rd, bleckner ll. anaesthetic agent for advanced regional anaesthesia : a north american prospective drugs. 2005;65(6):745-59. 22. sia at, goy rw, lim y et al. a comparison of median effective doses of intrathecal levobupivacaine and ropivacaine for labor analgesia. anaesthesiology 2005;102:651-6. 23. kopacz dj, allen hw, thompson ge. a comparison of epidural levobupivacaine 0.75% with recemic bupivacaine for lower abdominal surgery. anaesth analg 2000;90:642-8. 24. egashira t, fukasaki m, araki h et al. comparative efcacy of levobupivacaine and ropiovacaine for epidural block in out patients with degenerative spinal disease. pain physician 2014;17:525-9. 25. perroti l, cusato m, ingelme p et al. a comparison of differences between the systemic pharmacokinetics of levobupivacaine and ropivacaine during continues epidural infusion: a prospective randomised multicenter double blind controlled trial. anaesth analg 2015;121:348-56. 26. patki ys, bengali r, patil t. efcacy of dexmedetomidine as an adjuvant to 0.5% ropivacaine in supraclavicular brachial plexus block for postoperative analgesia. international journal of science and research (ijsr) 2015;4(1):2345-51. x 49gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 27. rashmi hd, komla hk. effect of dexmedetomidine as an adjuvant to 0.75% ropivacaine in interscalene brachial plexus block using a nerve stimulator: a prospective randomised double blind study. anaesth essay and res .2017 jan-mar;11(1):134-139. 28. kaygusuz k, ozdemir i, duger c, gursoy s, ozturk h; kayacan u et al. effects of adding dexmedetomidine to levobupivacaine in axillary brachial plexus block. curr ther res. 2012;73:103-11. 29. nallam sr, chiruvella s, karanam s. supraclavicular brachial plexus block: comparison of varying doses of dexmedetomidine combined with levobupivacaine: a double-blind randomised trial. indian j anaesth. 2017;61:256–61. 30. sudani c, rao sm, munta k. a comparative study of ropivacaine alone versus ropivacaine with dexmedetomidine in supraclavicular brachial plexus block. anesthesiol open j 2016;1:28-34. 31. gandhi r, shah a, patel i. use of dexmedetomidine along with bupivacaine for brachial plexus block. njmr.2012;2(1):67-69. 32. jun z, han w, wen l et al. effect of dexmedetomidine on brachial plexus block with ropivacaine and upper extremity ischemia-reperfusion (i/r) injury in patient undergoing upper extremity surgery. zhonghua ma zui xue za zhi. 2011;1:84-7. 33. chinappa j, shivanna s, pujari v s, anandaswamy tc. efcacy of dexmedetomidine with ropivacaine in supraclavicular brachial plexus block for upper limb surgeries. j anaesthesiol. clin pharmacol. 2017 janmar;33(1):81-85. 34. mcleod ga, columb mo. moles,weights and potencies: freedom of expression percentage. br j anaesth.2005;95:110-1. 35. casati a, borghi b, fanelli g, cerchierini e, santorsola r, sassoli v et al. a double blinded, randomised comparison of either 0.5% levobupivacaine or 0.5% ropivacaine for sciatic nerve block. anaesth analg.2002;94:987-90. 36. casati a, vinceguerra f, santorsola r, aldegheri g, putzu m, fanelli g. sciatic nerve block with 0.5% levobupivacaine, 0.75% levobupivacaine or 0.75% ropivacaine. a double blind randomised comparison. eur j anaesthesiol.2005;2:452-6. 37. fournier r, faust a, chassot o, gamulin z. levobupivacaine 0.5% provides longer analgesia after sciatic nerve block using labat approach than the same dose of ropivacaine in foot and ankle surgery. anaesth analg.2010;110:1486-9. 38. casati a, santorsola r, aldegheri g, ravasi f, fanelli g, berti m et al. intraoperative epidural anaesthesia and postoperative analgesia with levobupivacaine for major orthopedic surgery: a double blinded randomised comparison comparison of recemic bupivacaine and ropivacaine. j clin anaesth. 2003;15:126-31. 39. singh ap, mahindra m, gupta r, bajwa sjs. dexmedetomidine as an adjuvant to levobupivacaine in supraclavicular brachial plexus block: a novel anaesthetic approach. anaesth essays and researchers. 2016;10(3): 414-419. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 50 x gjra global journal for research analysis 1 introduction for multi-objective optimization problems (mops), it is necessary to optimize many conicting problems concurrently so as to achieve the best overall effect. owing to the contradiction of objectives, there is usually to single optimal solution but a set of solutions，called the pareto set. in the real world, it is not uncommon to face multiple objectives simultaneously, such as water resource engineering [1], industrial scheduling problem [2], control system design [3] and so on [4]. evolutionary algorithms (eas) are considered to be very suitable for mops because of their population-based characteristics and the approximation of pareto sets can be obtained in a single run. in the past decades, many multiobjective evolutionary algorithms (moeas) have been proposed. multi-objective evolutionary optimization algorithms can be roughly divided into three categories. many multi-objective optimization algorithms based on pareto dominance, e.g., strength pareto evolutionary algorithm [5, 6] and nondominated sorting genetic algorithm [7, 8]. these algorithms use the dominant relation of solutions as the rst selection condition to ensure the selection of convergent pareto solution sets. then, the second selection strategy is adopted to ensure the diversity of solution sets. unlike dominance-based moeas, indicator-based evolutionary algorithms (ibeas) [9] is also popular, e.g., hypervolume indicator [10], r2 indicator [11]. indicator parameters are used to solve convergence and distributed performance problems of solution sets. different from the rst two kinds of multi-objective evolutionary algorithms, decomposition-based multi-objective evolutionary algorithms are proposed. a typical algorithm is moea/d algorithm [12], in addition, there are a great many of variants algorithms, e.g., [13, 14]. the moea/d algorithm converts the multiobjective optimization problem into a scalar subproblem and obtains the value of the decomposed single objective function. and this algorithm has been demonstrated efcient in solving mops. generally speaking, these algorithms have two common but often contradictory goals: minimizing the distance of solutions to the optimal frontier and maximizing the distribution of solutions at the optimal frontier. although moea/d algorithm can get good pareto frontier. however, when the number of non-dominated solutions is more than the number of selected solutions, more than the number of solutions will be deleted randomly. this is not conducive to preserving the best individuals, and will reduce the convergence of the solution. in order to solve the above problems, we adopt different deletion strategies to increase the convergence and diversity of the nal approximate pareto frontier. at the same time, for the operation that moea/d offspring may replace more than one parent, this paper adopts the strategy of rst substitution and stop [14]. the rest of this paper is organized as follows. section 2 briey reviews the related basic concepts and the moea/d algorithm. in section 3, the strategy of differentiated deletion and the improved algorithm of moea/d-dfs are introduced concisely. section 4 shows the results and analysis of the proposed algorithm. section 5 concludes this paper with a summary. 2 preliminaries and background 2.1. basic concepts generality, an mop maybe stated as minimization problem and dened as follows: (1)where x denotes a solution vector in the feasible solution space ω, and f (i = 1, 2, …, m) is the ith objective to be i minimized. then, basic concepts used in multi-objective optimization problem will be briey introduce. denition 1: iff i {1, 2, …, m}, f (u) ≤ f (v), and j {1, 2, …, m}, f (u) i i i < f (v). in this case, vector u is said to dominate another vector i v, denoted by . u p v denition 2: , the decision vector x*î ω is the iff,*xxx$îw/p pareto optimal. denition 3: the pareto optimal set, ps, is the non-dominated solution set. denition 4: the pareto frontier, pf, is the objective function of the non-dominated solutions. 2.2. introduce of moea/d in the paper of moea/d algorithm, three based on decomposition approaches are introduced. it includes chebyshev decomposi t ion approach, and has a corresponding weight vector for any pareto optimal solution. therefore, different pareto optimal solutions can be obtained by altering the weight vector. the process of moea/d algorithm is as follows: in the initialization part, the population p with the scale of n is generated randomly, and the weight vector λ , …, λ are 1 n uniformly distributed. meanwhile, the nearest t individuals of each individual can be obtained by euclidean distance, and multi-objective optimization decomposition algorithm based on differentiated selection strategy original research paper yan xiaofan college of computer science and technology, tianjin polytechnic university, tianjin, 300387, china x 127gjra global journal for research analysis computer science decomposition-based multi-objective evolutionary algorithm can obtain effective solution sets for solving multi-objective optimization problems. however, the random way of selecting individuals is not conducive to the preservation of good solutions and reduces the convergence speed of the algorithm. in order to solve this problem, a multiobjective optimization decomposition algorithm based on differentiated selection strategy (moea/d-dfs) is proposed. the differentiated selection strategy adopted by the algorithm is to select the non-dominant solution from population, using the method of individual selection in nsga-ii. meanwhile, the strategy of rst substitution and stopping is adopted when the offspring replace parent. it is conducive to enhancing the diversity of the population. the experimental results of zdt test function shows that the algorithm is superior to other algorithm in convergence and diversity, and has certain advantages in solving performance. abstract keywords : decomposition-based; multi-objective; genetic operator; selection strategy. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 128 x gjra global journal for research analysis the nearest t neighborhood individuals of each individual can be obtained. then, the objective function value of each individual and the ideal point z of the population are obtained. the non-dominant solution in the population is called elite population ep. in the update part, the paternal population generates the offspring population p by genetic operators. two paternal individuals are randomly selected from their neighborhoods. then, using simulated binary crossover (sbx) and polynomial mutation operation (pm) to generate offspring. the offspring individual are compared with the individuals in the neighborhood of the paternal generation. when the offspring individuals are superior to the paternal individuals, the offspring individuals replace the paternal. the ideal point is updated and the non-dominant solution set ep in the updated population is selected. combining ep and ep, the nal nondominant solution set is selected. the update part is iterated until the stop condition is satised, and then the nal ep is obtained. since in the update section, one offspring may replace more than one parent, which will reduce the diversity of the population. in this paper, we adopt the replacement operation of rst substitution and stop. 3 proposed algorithm in this section, the proposed-deposition-based multiobjective evolutionary algorithm with differential selection strategy (moea/d-dfs) will be introduced in detail. algorithm 1: moea/d-dfs input: n: population size; t: the number of the weight vectors in the neighborhood of each weight vector. output: ep: elite population. 1. generate an initial population p randomly. 2. generate a uniform spread of n weight vectors λ , …, λ .1 n 3. work out the t closet weight vectors to each weight vector. for each i= 1, …, n, set b(i) = {b , …, b }, where λ , …, λ1 t b1 bt are the t closest weight vectors to λi 4. initialize the ideal point z*. 5. initialize the elite population (ep) 6. while the termination criterion is not satised do 7. for i = 1, …, n 8. r andomly select two indexes k, l from b(i), and generate a new solution y. 9. compare offspring y with the t closet points of its parent using tchebycheff values. 10. update the ideal point z*. 11. update of population p. 12. get a new elite population ep. 13. merge ep into ep and adopt differential selection strategy to obtain individuals. 14. end for 15. end while the pseudo-code of moea/d-dfs is given in algorithm 1. steps 1-5 are the initialized part. the population p with size n is initialized in step 1. step 2 is to generate a uniformly distributed weight vector λ= {λ = (λ , …, λ ) | i (1, …, n)}, i i1 im where λ = 1. in step 3, the t closest weight vectors b(i) = {b , b , i 1 2 …, b } of each weight vector are calculated, using the t euclidean distance. in step 4, the ideal point z* = {z , …, z }is 1 m initialized, and ts updated during the search process. in step 5, the elite individuals in the population are preserved in ep, that is to say, the non-dominant solution in the population is selected. steps 6-15 are iterated until the termination criterion is satised. in step 8, simulated binary crossover (sbx) [] and polynomial mutation are applied as the crossover operation to produce offspring. this cross mutation drives two parents generate an offspring. comparing the generated offspring with the individuals in the t neighborhood of the parent generation, the replacement operation of the current individual will be stopped when the replaceable parent generation is rst encountered in step 9. it is conducive to preserving the diversity of the population. in step 10,the ideal point z* is updated. then the population is updated in step 11. in step 12, the non-dominant solution set of the new population is obtained, which is denoted as ep. in step 13, ep and ep are combined to adopt differential selection strategy to obtain individuals. the obtained solution is stored in ep. this strategy adopts the method of nsga-ii [7] to select the solution. the solutions in ep are sorted nondominantly (f , f , …,) and selected layer by layer. the 1 2 selection process is as follows: initial q is an empty set, which merges individuals into q layer by layer according to non-dominant sorting. when f merges i into q and the number of individuals in q is larger than the set number, select individuals in f layer and put them into q, so i that the number of individuals in q is equals to the set number. the crowding distance [7] is used when selecting individuals in f . in this way, the q obtained is the elite population selected i from the population, where ep = q. results and analysis 4.1 unconstrained zdt problems zdt test function series is used to verify the effectiveness of the proposed moea/d-dfs algorithm. next, zdt test function series.is introduced. table 1. zdt test function 4.2 metric and setting the inverted generational distance (igd) is a comprehensive performance evaluation index. it is used to evaluate the volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra test function functional formula parameter zdt1 tx = (x , …, x ) [0, 1 n n1] , n = 30 zdt2 tx = (x , …, x ) [0, 1 n n1] , n = 30 zdt3 tx = (x , …, x ) [0, 1 n n1] , n = 30 zdt4 tx = (x , …, x ) [0, 1] 1 n n-1[-5, 5] , n = 10 zdt6 tx = (x , …, x ) [0, 1 n n1] , n = 10 1 1 2 2 1 ( ) ( ) ( ) * ( ) 9 ( ) 1 * ( 1) ( ) ( ) 1 ( ) n ii f x x f x g x h x g x x n f x h x g x = = = = + = å 1 1 2 2 1 ( ) ( ) ( )* ( ) ( ) ( ) 1 ( ) f x x f x g x h x f x h x g x = = æ ö = -ç ÷ è ø 1 1 2 1 1 1 ( ) ( ) ( ) * ( ) ( ) ( ) *sin(10 ) ( ) 1 ( ) ( ) f x x f x g x h x f x f x x h x g x g x p = = = 1 1 2 2 2 2 1 ( ) ( ) ( ) * ( ) ( ) 91 10cos(4 ) ( ) ( ) 1 ( ) n n i ii i f x x f x g x h x g x x x f x h x g x p = = = = = + = å å 6 1 1 1 2 0.25 2 2 1 ( ) 1 exp( 4 )(sin(6 )) ( ) ( ) * ( ) ( ) 1 9 ( 1) ( ) ( ) 1 ( ) n ii f x x x f x g x h x x g x n f x h x g x p = = = æ ö ç ÷= + ç ÷è ø æ ö = ç ÷ è ø å convergence and distribution performance of algorithm. igd is one of the most widely used indicators [15]. the true pareto frontier is needed to calculate the igd value of the obtained solution set. for zdt test function, the igd calculation requires normalizing the given set of solutions at ideal and extreme points. for any algorithm, the nal nondominated solutions is named s and the true pareto frontier is named z. then, the igd metric is calculated as follows: where d(z , s ) is the euclidean distance between the points z i i i and s . the smaller the value of igd, the better s.i in order to ensure the reliability of the experiment results, the parameters of the algorithm are set as follows. the number of population individuals p is set to 100, which means n = 100. the number of iterations it is set to 250. the probability of crossover cr is set to 0.5 and the probability of mutation f is set to 0.02. the maximum value of t closet neighborhood is set to 15, and minimum value of t is set to 2. generally, the neighborhood size t is set to t = 0.1n. 4.3 analysis table 2 shows the experimental results of moea/d-dfs algorithm and moea/d algorithm on test functions zdt1-4 and zdt6. static analysis is used to judge the performance of each algorithm by using igd value. the smaller the igd values, the better the performance of the algorithm. table 2 shows that the performance of the moea/d-dfs algorithm is better than that of the moea/d algorithm on the whole. table 2. the igd (min, avg, max) values of the moea/d-dfs and moea/d algorithms on test functions zdt1, zdt2, zdt3, zdt4, and zdt6. figure1 shows the approximate pareto frontier obtained by moea/d-dfs algorithm and moea/d algorithm on zdt test function. from the comparison chart of fig1, the improved algorithm moea/d-dfs gives better approximate pareto frontier. compared with moea/d algorithm, the convergence and distribution of moea/d-dfs are excellent. although the zdt2 test function does not obtain a good enough set of solutions, compared with the moea/d algorithm, a sufcient number of solutions are obtained. obviously, on the test functions zdt1, zdt3, zdt4 and zdt6, the solution set obtained by moea/d-dfs has better convergence and distribution than that obtained by moea/d algorithm. figure 1. the approximate pareto frontier obtained by moea/d-dfs algorithm and moea/d algorithm on the zdt test function. 5 conclusion in order to achieve a good balance between convergence and diversity, this paper proposes an algorithm, moea/d-dfs, which adopts differently selecting strategy for population. this strategy adopts the non-dominated sorting method and gives priority to the selection of good individuals, which is conducive to enhancing the convergence of the nal solution set. meanwhile, it is benecial to enhance the diversity of the population by using the rst encounter and stop substitution operation. to prove the effectiveness of the proposed algorithm, the moea/d-dfs algorithm and moea/d algorithm are compared with zdt series of test functions. experiments show that the proposed algorithm can obtain good convergence and distribution solutions for different optimization problems. references [1] trindade b c, reed p m, herman j d, et al. reducing regional drought vulnerabilities and multi-city robustness conicts using many-objective optimization under deep uncertainty[j]. advances in water resources, 2017, 104:195-209. [2] ringkamp m, ober-bl?baum s, dellnitz m, et al. handling high-dimensional problems with multi-objective continuation methods via successive approximation of the tangent space[j]. engineering optimization, 2012, 44(9):1117-1146. [3] fleming p j, purshouse r c, lygoe r j. many-objective optimization: an engineering design perspective[j]. 2005. [4] goulart f, campelo f. preference-guided evolutionary algorithms for manyobjective optimization[j]. information sciences, 2016, 329:236-255. [5] kim m, hiroyasu t, miki m, et al. spea2+: improving the performance of the strength pareto evolutionary algorithm 2.[j]. parallel problem solving from nature-ppsn viii, 2004, 3242(4):742-751. [6] sheng w, liu y, meng x, et al. an improved strength pareto evolutionary algorithm 2 with application to the optimization of distributed generations[j]. computers & mathematics with applications, 2012, 64(5). [7] deb k, pratap a, agarwal s, et al. a fast and elitist multiobjective genetic algorithm: nsga-ii[j]. ieee transactions on evolutionary computation, 2002, 6(2):0-197. [8] deb k, jain h. an evolutionary many-objective optimization algorithm using reference-point-based nondominated sorting approach, part i: solving problems with box constraints[j]. ieee transactions on evolutionary computation, 2014, 18(4):577-601. [9] yao x , burke e k , lozano, josé a, et al. [lecture notes in computer science] parallel problem solving from nature ppsn viii volume 3242 || indicatorbased selection in multiobjective search[c]// 2004:832-842. [10] bader j, zitzler e. hype: an algorithm for fast hypervolume-based manyobjective optimization[j]. evolutionary computation, 2011, 19(1):45-76. [11] suzuki j, phan d h. r2-ibea: r2 indicator based evolutionary algorithm for multiobjective x129 gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 1 1 1 igd( , ) ( , )min z s i jj i s z d z s z = = = å test function item moea/d-dfs moea/d zdt1 min 0.01001 0.05076 avg 0.040336 0.43379 max 0.040336 0.95388 zdt2 min 0.00227 0.00008 avg 0.29614 0.001564 max 0.74984 0.00640 zdt3 min 0.04068 0.16221 avg 0.25665 0.46492 max 0.38568 0.97953 zdt4 min 0.73323 15.09150 avg 10.72729 24.05082 max 24.1546 40.12033 zdt6 min 0.00952 0.00011 avg 1.39815 2.00117 max 4.12405 5.34535 background urolithiasis is global phenomenon. mankind, since long, have tried to understand the process of calculogenesis. scientists over centuries had also tried to nd the 'wonder therapy' for dissolution of urinary calculi.though, in calculogenesis, many hypothesis has been postulated and well established, we are still not able to prevent recurrence of calculi in large number of patients due to its complex nature and poor understanding of process of calculogenesis. aims and objectives ÿ many factors are known to lead to stone formation but whether dissolution factors are also operating in the internal milieu of crystal aggregates ,is not well known ÿ supersaturation/crystallization','matrix nucleation', 'inh ibitor absence' and 'epitaxy' are well established theories to explain the process but none of these theories fully explain the phenomenon and perhaps many more factors are operating, hitherto, not described till now. ÿ we have tried to nd an analogy of sedimentary rock formation in the sea with urinary stones where evidences of spontaneous dissolution like 'pitting', 'weathering' and 'erosions' are seen many times along with well known formation phenomenon material and methods a scanning electron microscopic (jeol 840) study was carried out from 30 upper and lower urinary tract calculi removed by surgery, in department of urology,ims,bhu,varanasi. ultrastructure was observed using scanning electron microscopy to study the aggregation phenomenon of crystal sediments and phenomenon of weathering or dissolution of crystals x-ray diffraction analysis was also done in same calculi to know the chemical compound composition. study performed also in collaboration with department of geology & metallurgy, banaras hindu university , varanasi, india. observations ÿ pure stone comprised 73.33 % of total number ÿ among pure stones calcium oxalate monohydrate accounted for 60%, dihydrate 10% and struvite3.33% ÿ in ultrastructural study in sem many geological pheno menon were observed with their potential therapeutic applicability at magnication of 750x to 2500x ÿ stone appeared in well crystalline or poorly crystalline or semi crystalline form. ÿ crystals were euhedral, subhedral or anhedral ÿ the deposition phenomenon observed were 'crystal complexing', 'syntaxy', 'epitaxy' ÿ simultaneous many dissolution phenomenon like 'etch ing', 'erosion 'or 'weathering ' were observed which were akin to sedimentary rocks formation in the deep sea ÿ our sem study shows the evidence of 'etching,' 'erosion', or dissolution of calculi studied. ÿ etching was demonstrated in crystals of pure oxalate calculi as well as pure phosphate calculi ÿ dissolution like weathering in sedimentary rocks is seen in 11 of 22 calculi of pure oxalates,2 of 2 calculi of mixed oxalates and all calculi of mixed phosphates ultrastructural evidences of stone in formation phase with well developed crystals evidences of spontaneous dissolution: dissolution (weathering) in face of a platy crystal dissolution (weathering) of a large crystal spontaneous dissolution of renal calculi-a myth or reality original research paper dr. a.k. sanwal assistant professor, department of urology, m.l.b. medical college, jhansi medical science urolethiasis has been of interest to mankind from many centuries. many theories has been postulated for biochemical process of stone formation. spontaneous dissolution of stones has been known and rarely reported. we have found evidence of spontaneous dissolution of urinary caluculi in our ultra structural study and have put analogy with sedimentary rocks of sea which are also known to have such ultra structural phenomenon. abstract keywords : calcium oxalate, kidney stones, spontaneous dissolution volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. sanjay chaube* associate professor, department of surgery, m.l.b. medical college, jhansi *corresponding author prof. v.n.p. tripathi exprofessor and head, department of urology, imh, bhu, varanasi medical college, jhansi 58 x gjra global journal for research analysis geological phenomenon of dissolution: etching and fracture on crystal fracture on face of a large crystal evidences of spontaneous dissolution: large cofn lid crystal in dissolution phase crystal plate in dissolution phase discussion does it work like sedimentary rocks: ÿ it is well known in mineral-logy that “minerals are in active equilibrium with their surroundings only in the environ ment in which they form(law of mineral instability, keller1989) ÿ in ambient ionic atmosphere of human kidney, the urinary calculi will also be in meta stable condition in respect to its pore water i.e. urine in interstics of calculi and pore water leading to either deposition of precipitates or dissolution depending on type of reactions taking place geological phenonmenon seen in calculus ultr asructure like sedimentary rocks: ÿ slow partial dissolution may results in itch pits ÿ corrosion or weathering may results from more rapid transport of minerals ÿ it appears that calculus in the milieu interior involves itself in dynamic chemical process whether leading to deposition or erosion time to time crystal formation or dissolution: ÿ these phenomenon are also inuenced by surface free energy property of the crystal(hurst1981). ÿ euhedral crystal faces possess low surface energy and are less likely to undergo surface corrosion or dissolution while high index crystal (subhedral or anhedral) are more likely to be inuenced by dissolution phenomenon weathering in sedimentary rocks: analogy with sedimentary rocks: ÿ “diagenesis” is sum of those process by which originally sedimentary deposits attempt to reach equilibrium with their environment ÿ though, owing to inuence of organic substances, matrix and bacteria, process of diagenesis may be arrested or modied, if suitably applied, this process may be potentially manipulated to “weather” or dissolve a human calculi. conclusion ÿ a compatible analogy can be drawn between human rocks and sedimentary rocks formation in nature ÿ ultra structural observations of 'weathering',' pitting', 'erosion' seen in human calculi indicate spontaneous dissolution phenomenon taking place in human body like sedimentary rocks is a reality and not a myth. ÿ we propose sedimentary rock analogy in human body as we have so many evidences of same type of bodily rock formation in human body. ÿ further well designed studies are required to look into this fascinating aspects of calculogenesis references: 1. spontaneous dissolution of renal calculi.j.s.elliot,j.urol.sep.1954 2. khan s.r.et al sem of calcium oxalate crystal formation in experimental nephrolithiasis.lab inv.1979 3. khan sr et al identication of urinary stone and sediment crystal by sem and x-ray microanalysis. j.urol.1988 4. malek rs et al observation on the ultrastructure and genesis of urinary calculi. j.urol.1977 5. spectre m et al ,ultrasructure and pathogenesis of urinary calculi,bju,1978 6. sohnel et al ,ne structure of calcium oxalate monohydrate renal calculi,nephron,1993 7. ryal rl,scientic basis of calcium oxalate urolithiasis prediction and precipitation, world j.urology,1993 8. sedimentary petrology-an introduction to origin of sedimentary rocks,metucker2009,books,google,com 9. s e d i m e n t s , d i a g e n e s i s a n d s e d i m e n t a r y r o c k s t r e a t i s e o n geochemistry,ftmackenzie2005,books,google,com 10. said abdallah al-mamari.etiology of urolithiasis.urolithiasis in clinical practice pp 57-111| cite as 11. vishal n ratkalkar, md and jack g kleinman, md.mechanisms of stone formation.published in nal edited form as: clin rev bone miner metab. 2011 dec; 9(3-4): 187–197. doi: 10.1007/s12018-011-9104-8 12. rodgers al.physicochemical mechanisms of stone formation.urolithiasis. 2017 feb;45(1):27-32. doi: 10.1007/s00240-016-0942-1. epub 2016 dec 7. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 59gjra global journal for research analysis introduction diabetes mell i tus type 2 (dm) is a chronic, noncommunicable, systemic metabolic disease and it is known as one of the major international public health issues. the world health organization declared diabetes mellitus as an 1epidemic. poorly controlled diabetes and periodontal diseases shares 2an signicant association . previous studies have suggested that periodontal infection and dm have a two-way relationship . according to the international diabetes federation, maximum people having diabetes lives in low 2and middle-income group countries. periodontal disease is characterized by loss of connective tissue and bone support, which eventually might lead to tooth loss. 3 löe, stated that periodontal disease is the sixth most common 4 complication of dm, whereas lalla et al., reported that dm is the strongest risk factor for periodontal infection compared to the other systemic conditions such as hypertension. moreover, it has been demonstrated that individuals with periodontal pocket ≥6mm are 3.5 times more likely to develop t2dm than 5those having periodontal pocket <6mm . by now there is strong evidence suggesting that the prevalence and severity of periodontal disease are higher among t2dm patients when 6,7compared with non-diabetic individuals . few studies have reported on no difference in periodontal disease between 8individuals with and without t2dm . whereas some studies have reported worse periodontal condition among poorly 6,7 controlled t2dm patients , others have disconrmed an association between periodontal disease and metabolic 9,10control it has been demonstrated that the number of decayed, missed and lled teeth (dmft) is higher among individuals with than 11 12without t2dm . moreover, leung et al., have found the risk of dental caries to be twice as high in t2dm patients compared to healthy controls. a number of factors have been investigated to explain the reasons for the inuence of dm on the periodontium and they 13include: the altered host immune response the role of 14cytokines; as well as the implication of advanced glycation 15end-products . a huge number of both diagnosed and undiagnosed patients with dm are not aware of the possibility of developing periodontal diseases which would ultimately result in tooth 16loss . it is believed that a study of tooth loss in diabetic patients would create greater awareness amongst patients and health providers on the role of periodontal health in the care of diabetic patients this study was conducted around a tertiary medical institute's adjoined territory ( having a dental / dentistry department ) , its urban & rural health centres aiming to assess the number of missing teeth and to examine the relationship between age and tooth-loss in diabetic patients. methedology after local ethical committee approval study was done over a period of 4 months .a cross sectional analytical study was conducted around a tertiary medical institute's adjoined territory, urban & rural health centres in raipur district ( rims medical college hospital ) the total amount of people to be part of the sample was 201 diabetic patients and an equal number of non-diabetic patients as control were chosen by random sampling a study of association between diabetes mellitus and tooth loss among diabetic patients original research paper dr. manisha malviya dept of dentistry, raipur institute of medical sciences, raipur , cg , india dental science introduction: there are evidences on literature correlating diabetes mellitus type 2 with tooth loss. considering the necessity of understanding the role dentition plays on welfare and daily life of diabetic people, this study was done around a tertiary medical institute's adjoined territory, urban & rural health centres aiming to assess the number of missing teeth and to examine the relationship between age and tooth-loss in diabetic patients. method: this study was to assess the number of missing teeth and to examine the relationship between age and tooth-loss in diabetic patients. the study consisted of 201 diabetic patients and an equal number of non-diabetic patients as control. selfadministered questionnaires were distributed and this was followed by an oral examination of each patient; number of missing teeth were recorded in a data collecting sheet. study was designed as a cross sectional analytical study . information was analysed by using the microsoft excel and spss 20. study was conducted around a tertiary medical institute's ( having a dental unit ) adjoined territory, urban & rural health centres. results: study subjects were within age-group 35 -75 years for diabetics and 30 – 68 years for non-diabetics. the mean number of missing teeth in diabetics was 5.18 ± 0.70 while non-diabetics had 3.17 ± 0.53 which was statistically signicant when pvalue was ≤ 0.005. diabetic patients, within the age-group of 35-44 had 3.21 mean missing teeth and those within the agegroup of 64-75 years had 7.31 mean missing teeth. conclusion: the average mean number of missing teeth in the diabetic patients and the control subjects increased gradually as patients grew older but tooth loss was more signicant in the diabetics. within the limitations of this study, tooth loss is more in diabetic patients than nondiabetics and increases more in diabetics as both groups grow older. abstract keywords : tooth loss , diabetic patients , age , periodontal disease dr. mehul trivedi* professor , dentistry *corresponding author dr pradip k chourasia statistician / biostatistician , school of studies in statistics , pt. ravi shankar shukla university , raipur , cg volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr jyoti v tote dept of dentistry, raipur institute of medical sciences, raipur , cg , india 16 x gjra global journal for research analysis subjects who were more than 18 years and above at the time of the examination, voluntary participation with consent , conrmed diabetic and controlled of other systemic diseases like hypertension , hypothyroidism , chronic kidney diseases etc were chosen for the study . patients excluded are subjects who would not participate voluntarily, have systemic conditions that could have any similar / simulating conditions like diabetes mellitus (e.g. lupus, blood diseases, hiv/aids), known smokers, subjects who have used antibiotics in the last one month and pregnant study subjects a detailed interview sheet was lled by respondents consent , a predesigned questionnaire was used for that purpose containing information such as age, sex, occupation, marital and educational status. in both the diabetic and non-diabetic group, blood sugar level was conrmed from patient's results using random blood sugar levels and hba1c % . questions were asked to determine the previous health status of periodontal tissues and respondents were required to answer in simple terms in local languages ( hindi & chhattisgarhi ) questions such as “have you ever had swelling in the gums ?”, “have you ever extracted a tooth because of swlling and pain ”. questions were asked to determine the previous health status of periodontal tissues and subjects were required to answer “yes” or “no”. for each participant, clinical examination of all teeth (except rd3 molars) and soft tissues of the oral cavity was performed immediately after completion of the interview. subjects were examined sitting in an upright position under over-head electric light and the number of teeth present and missing were counted and recorded to assess tooth loss. tools used for the examination were (n22) color coded probe 2-4-6-8-10-12 mm markings, (nab2) color coded nabors furcation probe 36-9-12 mm markings, curette, mirror, probe, tweezers and cotton rolls. plaque index , mobility index, probing depth & root surface caries were recorded coronal caries was 17measured using dmft index data was lled in microsoft excel sheet , and analysis was done using spss 20 (version 20 ; spss inc., chicago, il, usa), comparisons were made by chi-square test. all statistical tests were two-sided and performed at a signicance level of � = 0.05. results total of 201 people took part in this study, most of the individuals in this research (59.42%) presented only with hypertension, , with an average age of 54.83 (± 11.99), varying between 35 and 83 years. the number of subjects in this study was 402 (four hundred and two) which was made up of an equal number diabetics and nondiabetics. diabetic patients consisted of 99 males (49.3%) and 102 (50.7%) females while the non-diabetics were 96 males (47.8%) and 105 (52.2%) females. the age-group of the diabetics was 30-75years old with a mean age of 40.6 ± 10.3 and the non-diabetic had age from 30-68years old with a mean age of 38.4 ± 10.5 years old. the mean fasting blood glucose recorded for non-diabetics was 69.86 ± 13.71 and 112.39 ± 23.51 at 2 hours post-prandial. the diabetic group had a mean of 122 ± 15.37 recorded as fasting and 206.94 ± 18.60 at 2 hrs post-prandial. the mean number of missing teeth in diabetics was 5.18 ± 0.70 while non-diabetics had 3.17 ± 0.53 which was statistically signicant when p-value was ≤ 0.005. diabetic patients, within the age-group of 35-44 had 3.21 mean missing teeth and those within the age-group of 64-75 years had 7.31 mean missing teeth. discussion the normal fasting blood glucose is below 100 mg/dl , 100 mg/ dl-125 mg/dl is indicative of pre-diabetes and above 126 mg/dl is diabetes mellitus. below 140 mg/dl 2hours postprandial is normal, the blood sugar level recorded in this study at 2 hrs post-prandial implied that the patients may have type 2 diabetes mellitus. the mean number of missing teeth reported in this study was statistically signicant with a steady increase as patient grew older. this is in agreement with the world health organization (who) statement that up to age thirty four (34), teeth are usually extracted as a result of caries but later as a result of 18periodontal disease as the individual grows older. the reason for these higher number of tooth loss in diabetic patients has been attributed to a lack of knowledge of the undesirable bi-directional relationship between diabetes mellitus and periodontal disease such that hyperglycemic environment will result in periodontal disease and periodontal disease on the other hand, will increase insulin 19resistance which could lead to tooth loss if left unchecked . mechanisms such as the production of advance glycation end-product, cytokines and the alter host microora may contribute independently or synergistically and eventually lead to periodontitis as a complication of diabetes 13,14,15mellitus . the present study conrmed the hypothesis that clinical indicators of periodontal disease, furcation involvement, mobility of teeth and number of teeth present as well as the oidp discriminated between t2dm patients and their nondiabetic controls. the hypothesis that poorly controlled and long duration-t2dm patients presented with more oral disease and oidp compared with their well-controlled and short duration counterparts was partly conrmed in this study. thus, mobility index and dental caries were the only clinical indicators that discriminated signicantly between the subgroups of t2dm cases. diabetic patients with poor metabolic control should be seen more often in the dental clinic, especially if periodontal disease is already present because periodontal treatment comprising motivation and debridement of periodontal pockets would resulted in improved metabolic control of the diabetes mellitus and decrease in tooth loss [24]. thus, patients with well-controlled diabetes mellitus who have good oral hygiene and who are on regular periodontal preventive appointments have the same risk of severe periodontitis and tooth loss as non-diabetic patients. conclusion: the mean number of missing teeth reported in this study was statistically signicant it is in agreement with the world health organization's statement that up to age thirty four (34), teeth are usually extracted as a result of caries but later as a result of periodontal disease as the individual grows older. the dental surgeon has an important role in the early detection of clinical features of diabetes mellitus in patients reporting to the dental clinic for oral health care. early treatment of oral infections like periodontal diseases is an effective way of preventing tooth loss. further studies should be carried out to nd more results. acknowledgements would like to thank dr. rahul kewal kumar , asst professor , community medicine for his always available guidance . funding: no funding sources conict of interest: none declared ethical approval: the study was approved. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 17gjra global journal for research analysis references 1. smyth s, heron a. diabetes and obesity: the twin epidemics. nat med 2006;12:75-80. 2. taylor gw. bidirectional interrelationships between diabetes and periodontal diseases: an epidemiologic perspective. ann periodontol 2001;6:99-112. 3. löe h (1993 jan) periodontal disease. the sixth complication of diabetes mellitus. diabetes care 16: 329–334. 4. lalla e, lamster ib (2012) assessment and management of patients with diabetes mellitus in the dental ofce. dent clin north am 56: 819–829. 5. morita i, inagaki k, nakamura f, noguchi t, matsubara t, et al. (2012 feb) relationship between periodontal status and levels of glycated hemoglobin. j dent res 91(2):161–6 91: 161. 6. campus g, salem a, uzzau s, baldoni e, tonolo g (2005 mar) diabetes and periodontal disease: a case-control study. j periodontol 76: 418–425. 7. tsai c, hayes c, taylor gw (2002 jun) glycemic control of type 2 diabetes and severe periodontal disease in the us adult population. community dent oral epidemiol 30: 182–192. 8. ribeiro fv, de mendonça ac, santos vr, bastos mf, figueiredo lc, et al. (2011 aug) cytokines and bone-related factors in systemically healthy patients with chronic periodontitis and patients with type 2 diabetes and chronic periodontitis. j periodontol 82: 1187–1196. 9. santos vr, lima ja, miranda ts, feres m, zimmermann gs, et al. (2012 mar) relationship between glycemic subsets and generalized chronic periodontitis in type 2 diabetic brazilian subjects. arch oral biol 57: 293–299. 10. alpagot t, silverman s, lundergan w, bell c, chambers dw (2001 jun) crevicular uid elastase levels in relation to periodontitis and metabolic control of diabetes. j periodontal res ;36(3):169–74 36: 169–174. 11. tanwir f, altamash m, gustafsson a (2009) effect of diabetes on periodontal status of a population with poor oral health. acta odontol scand 67: 129–133. 12. leung wk, siu sc, chu fc, wong kw, jin l, et al. (2008) oral health status of low-income, middle-aged to elderly hong kong chinese with type 2 diabetes mellitus. oral health prev dent 6: 105–118. 13. lamster ib, lalla e, borqnakke ws, taylor gw (2008) �e relationship between oral health and diabetes mellitus. j am dent assoc 139: 19s-24s. 14. lalla e, lamster ib, feit m, huang l, spessot a (2000) blockage of rage suppresses periodontitis-associated bone loss in diabetic mice. j clin invest 105: 1117-1124. 15. hughes fj (1995) cytokines and cell signaling in the periodontium. oral dis 1: 259-265 16. ochoa sp, ospina ca, colorado kj, montoya yp, saldarriaga af (2012) periodontal status and tooth loss in diabetic patients at the university hospital san vicente de paul. biomedica 32: 52-59. 17. world health organization: oral health surveys, basic methods, ed 4. geneva, world health organization, 1997. 18. who 6clentlc group on epidemiology, etiology and prevention of periodontal diseases (1978) epidemiology, etiology and prevention of periodontal disease: a report of who sclentlc group [meeting held in moscow from 23 nov-2 dec.1977]. world health organ tech rep ser no.621 geneva. 19. azodo cc (2009) current trends in the management of diabetes mellitus: �e dentist’s perspective. journal of postgraduate medicine 11: 113-129. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 18 x gjra global journal for research analysis introduction acute appendicitis is dened as inammation of vermiform appendix and is one of the commonest cause of abdominal pain seen in emergencies, and being the most common surgical emergencies encountered in the world particularly among the young adults and children. no single sign, symptom or diagnostic test conrms the diagnosis of acute appendicitis accurately in every cases. although acute appendicitis has typical clinical presentation in 70% of the cases, about 30% of the patients have an uncertain preoperative diagnosis due to which there is negative laparotomy in as high as 20-25% cases. the rate of such negative laparotomy is even higher (3545%) in females of childbearing age, because of the pelvic organs and complications of pregnancy in this group. various diagnostic modalities are different scoring systems, and ultrasono graphy, contrast studies, computed tomography (ct) and mri. out of which only contrast enhanced computerized tomography (cect) of abdomen can diagnose the condition with very high sensitivity and specicity but it is not feasible to have this investigation done for each patient suspected to have appendicitis, particularly in countries with limited resources in 2010, a new scoring system was proposed by the d e p a r t m e n t o f g e n e r a l s u r g e r y a t t h e r a j a isteripengirananaksaleha (ripas) hospital, brunei darussalem, which comprise 14 parameters for clinical diagnosis of acute appendicitis for asian population. the scoring system showed a sensitivity and a specicity of 97.5% and 81.8%. respectively. the present study was therefore planned to correlate ripasa scoring system, which is based on purely clinical and laboratory ndings and radiological investigations such us ultrasound (usg) abdomen and pelvis, and contrast enhanced computer tomography (cect) keeping in mind to effectively reduce the negative appendicectomy rate. materials and methods all patients admitted in general surgery department undergoing open appendicectomy, mgm government hospital,trichy for a period of 2 year . ripasa score, usg abdomen and pelvis and contrast enhanced computer topography are done to all patients undergoing emergency open appendectomy under regional or general anaesthesia. ripasa score table no 1:scoring parameters of ripasa score comparative study of ripasa score vs radiological investigations on diagnosis of acute appendicitis original research paper dr. sri hari m.s ,associate professor,department of generalsurgery,kapv govt.medical college,trichy. general surgery introduction: acute appendicitis is dened as inammation of vermiform appendix and is one of the commonest cause of abdominal pain seen in emergencies.the present study was planned to compare ripasa scoring system, which is based on purely clinical and laboratory ndings vs radiological investigations such us ultrasound (usg) abdomen and pelvis, and contrast enhanced computer tomography (cect) keeping in mind to effectively reduce the negative appendicectomy rate. materials and methods: all patients admitted in general surgery department undergoing open appendicectomy, mgm government hospital,trichy for a period of 2 year . ripasa score, usg abdomen and pelvis and contrast enhanced computer topography are done to all patients undergoing emergency open appendectomy under regional or general anaesthesia. results: p value on comparing ripasa vs usg abdomen shows a statistical signicance ripasa score. p value on comparing ripasa vs cect abdomen shows no statistical signicance. conclusion: the current study suggests that cect is the optimum diagnostic tool for acute appendicitis compared with ripasa and usg abdomen. abstract keywords : appendicitis,ripasa score, appendectomy. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. d. sivakumar* m.s,assistant professor ,department of genera surgery,kapv govt.medical college,trichy. *corresponding author dr. r. veesar vignesh postgraduate, department of general surgery,kapv govt. medical college, trichy. dr. b. tharini postgraduate, department of general surgery,kapv govt. medical college, trichy socring parameters score male 1 female 0.5 age < 39 1 age > 40 0.5 rif pain 0.5 migratory pain 0.5 anorexia 1 nausea and vomiting 1 duration of symptoms < 48 hrs 1 duration of symptoms > 48 hrs 0.5 rif tenderness 1 rif guarding 2 rebound tenderness 1 rovsing sign 2 fever 1 raised wbc 1 negative urin alanysis 1 foreign nric 1 total 17.5 < 5.0 probability of acute appendicitis is unlikely 5.0 7.0 low probability of acute appendicitis 38 x gjra global journal for research analysis observation and results in the study 200 patients who underwent open appendectomy in mahatma gandhi memorial government hospital, trichy, patients were assessed with ripasa score, and usg abdomen and pelvis, and cect abdomen and nally compared with postoperative histopathology reports analysis of ripasa score vs hpe report : table no-2: analysis of ripasa score vs hpe report among 200 patients studies, 179 ( 89.5% ) patients has a ripasa score > 7.5, and 21 ( 10.5 % ) patients had a score < 7.5.when applied ripasa score for the patients who underwent open appendectomy, the sensitivity, specicity, positive predictive value and negative predictive value, accuracy were, 94.59%, 73.33 %, 97.77%, 52.38% and 93% respectively. analysis of usg abdomen vs hpe report : table no-3: analysis of usg abdomen vs hpe report among 200 patients studied, 148 ( 74% ) patients were positive for acute appendicitis and about 52 ( 26% ) patients were negative for acute appendicitis on use abdomen and pelvis. sensitivity, specicity, positive predictive value and negative predictive value and accuracy for usg abdomen and pelvis for diagnosis of acute appendicitis is, 75.68%, 46.67%, 94.59%, 13.46% and 73.50% respectively. analysis of cect abdomen vs hpe report : table no-4: analysis of cect abdomen vs hpe report among 200 patients studies, 182 ( 91% ) patients were diagnosed with acute appendicitis by cect abdomen and 18 ( 9% ) patients were ruled out appendicitis by cect.sensitivity, specicity, positive predictive value and negative predictive value and accuracy for cect abdomen and pelvis for diagnosis of acute appendicitis is, 97.30%, 86.67%, 98.90%, 72.22% and 96.50% respectively. ripasa vs usg abdomen : table no-5: ripasa vs usg abdomen for all cases, ripasa score and usg abdomen results were derived and calculated, and these results were compared in terms of sensitivity, specicity, npv, ppv and accuracy. the following were the results ripasa score vs cect abdomen : table no-6: ripasa score vs cect abdomen for all cases, ripasa score and cect abdomen results were derived and calculated, and these results were compared in terms of sensitivity, specicity, npv, ppv and accuracy. the following were the results out of 200 patients studied, sensitivity, specicity and accuracy for diagnosing acute appendicitis were 94.59%, 73.33% and 93% respectively, for ripasa score and 97.30%, 86.67% and 96.50% respectively, for cect abdomen, with p value 0.453. discussion : in the current study of adults, with abdominal pain, who underwent open appendicectomy, with cutoff values of 7.5 for ripasa score, and usg abdomen criteria yielded sensitivity, specicity, and accuracy of 94.59%, 73.33% and 93% (ripasa) and 75.68%, 46.67% and 73.50% (usg abdomen), respectively, for diagnosing acute appendicitis. the ripasa score had a signicantly higher diagnostic accuracy compared with usg abdomen in the current study for diagnosing acute appendicitis. the ripasa score contains parameters such as age and sex, which could increase the accuracy, and the ripasa score also contains more parameters that could aid with the differential diagnosis of acute appendicitis. all 14 parameters of the ripasa score are easily obtained from good clinical histories, examinations and investigations, and ripasa score is easy to implement without additional costs compared with usg abdomen, therefore the ripasa score may be more appropriate for the diagnosis of acute appendicitis. computed tomography is thought to be important in the diagnosis and differential diagnosis of acute appendicitis, however, no studies to date directly compare the ripasa score with ct in the diagnosis of acute appendicitis. in the current study, the sensitivity, specicity and accuracy of cect were signicantly higher than those of the ripasa score for diagnosing acute appendicitis. there were statistically signicant differences in diagnostic accuracy, sensitivity and specicity between msct and ripasa score, indicating that msct is an important supplement to ripasa score. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 7.5 11.5 probability of acute appendicitis is high > 12 definite acute appendicitis hpe report total p value yes no ripasa score >7.5 175 4 179 0.180 <7.5 10 11 21 total 185 15 200 sensitivityspecicity ppv npv accuracy 94.59% 73.33% 97.77% 52.38% 93.00% hpe report total p value yes no usg yes 140 8 148 <0.0001 no 45 7 52 total 185 15 200 sensitivity specicity ppv npv accuracy 75.68% 46.67% 94.59% 13.46% 73.50% hpe report total p value yes no cect yes 180 2 182 0.453 no 5 13 18 total 185 15 200 sensitivity specicity ppv npv accuracy 97.30% 86.67% 98.90% 72.22% 96.50% ripasa score >7.5 count 138 41 179 <0.000 1% within ripasa score 77.1% 22.9% 100.0% <7.5 count 10 11 21 % within ripasa score 47.6% 52.4% 100.0% total count 148 52 200 % within ripasa score 74.0% 26.0% 100.0% usg total p value yes no cect total p value yes no ripasa score >7.5 count 175 4 179 0.549 % within ripasa score 97.8% 2.2% 100.0% <7.5 count 7 14 21 % within ripasa score 33.3% 66.7% 100.0% total count 182 18 200 % within ripasa score 91.0% 9.0% 100.0% x 39gjra global journal for research analysis this may be because the ripasa score lacks highly specic parameters, and in many other diseases (including inammation of the caecum and/or ascending colon, gastrointestinal perforation, and right ureter calculus), a few abnormal parameters that are included in the ripasa score often develop. results : the current study suggests that cect is the optimum diagnostic tool for acute appendicitis with sensitivity, specicity and accuracy of 97.30%, 86.67% and 96.50% respectively, followed by ripasa with sensitivity, specicity and accuracy of94.59%, 73.33% and 93% respectively. usg abdomen has sensitivity, specicity and accuracy75.68%, 46.67% and 73.50% respectively, showing the effectiveness of ripasa score and cect over usg abdomen in diagnosing acute appendicitis. p value on comparing ripasa vs usg abdomen shows a statistical signicance of < 0.0001, showing effectiveness of ripasa score. p value on comparing ripasa vs cect abdomen shows no statistical signicance, i.e p value – 0.549, and showing effectivenss of cect over ripasa socre. conclusion : in conclusion, the current study suggests that cect is the optimum diagnostic tool for acute appendicitis compared with ripasa and usg abdomen. the study also showed that the ripasa, an easy and a bedside scoring system, may be a superior diagnostic scoring system compared with the usg abdomen for acute appendicitis, which is important in hospitals where cect scans or 24*7 reporting radiologist are not readily available. references : 1. cuscheri a. the small intestine and vermiform appendix. in: cuschieri a, giles gr, mossa ar, eds. essential surgical practice, 3rd ed. oxford: butterworth heinermann, 1995:1297-1329. 2. stephens pl, mazzucco jj. comparison of ultrasound and the alvarado score for the diagnosis of acute appendicitis. connecticut med. 1999 mar;63(3):13740. 3. kalan m, talbot d, cunliffe wj, rich aj. evaluation of the modied alvarado score in the diagnosis of acute appendicitis: a prospective study. ann roy coll surg eng. 1994 nov;76(6):418. 4. chong cf, adi mi, thien a, suyoi a, mackie aj, tin as, et al. development of the ripasa score: a new appendicitis scoring system for the diagnosis of 9. acute appendicitis. singapore med j. 2010 mar 1;51(3):220. 5. fitz rh. perforating inatmmation of the vermiform appendix; with special reference to its early diagnosis and treatment. am j med sci. 1886;92:321-46. 6. mcburney ch. iv. the incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. ann surg. 1894 jul;20(1):38. 7. ochsner aj. a handbook of appendicitis, 2nd ed, chicago: gp engelhard & company;1906. iqbal j, khan mh, ulmukim r, nisar a, iqbal m. alvarado score in the diagnosis of acute appendicitis. 2009;25(3);180-4. 8. bhabatosh d, singh g, sambhajikh, lekshmipriya l, singh rl, sharma lk. comparison between ripasa and alvarado score in the diagnosis of acute appendicites. int j curr res. 2016(8);1:25538-546. 9. addiss dg, shaffer n, fowler bs, tauxe rv. the epidemiology of appendicitis and appendicectomy in united states. am j epidemiology; 132: 910-25. 10. flum dr, koepsell t. the clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis arch surg 2002; 137(7): 799-804. 11. mardan maa, mufti ts, khattak iu, chikunda n, alshayeb aa, mohammad am et al. role of ultrasound in acute appendicitis. j ayub med coll 2007; 19(3): 72-9. 12. chong cf, adil miw, thien a, suyoi a, mackie aja, tin as et al. development of the ripasa score: a new appendicitis scoring system for the diagnosis of acute appendicitis. singapore med j 2010; 51: 220-5. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 40 x gjra global journal for research analysis introduction dysmenorrhea is very common gynecological problem in women of reproductive age worldwide .reports of dysmennorhea are greatest among individuals in their late teens and 20s and usually deckling with age . although dysmenorrhea is not life threatening, it can be painful for many adolescents .it begins with the rst ovulatatory cycle and occurs about two years after menarche and most of the severe episodes occurs before 25 years of age (1) .dysmenorrhea word is derived from greek words dys meaning difcult, painful or abnormal, meno meaning month and rrhoea meaning ow that means painful menstrual ow. (2) the painful cramping sensation in the lower abdomen is often accompanied by some other symptoms including sweating ,lower backache ,fatigue ,diarrhea ,headache ,nausea ,vomiting , dizziness and in severe cases syncope etc (3,4) it is one of the leading cause of recurrent short term absenteeism of young women in school and workplaces , affecting their performances , social and sports activities (5) this situation has not only signicant impact on personal health but also have a global economic impact . (6) unani scholars have also discuss the various causes and management of dysmenorrhea under the chapter of waj-e rahim, dared-e-rahim,usre tamth ,uterine pain (4) they worked on the theory of temperament and succeeded in locating the relationship between disease , various humours and disturbance in temperament . according to unani scholars, it is the altered temperament (sue mijaz) that causes obstruction in ow of menstruation uid that results difcult menstruation. (7). treatment is therefore, aimed directly at restoring balance to patient's temperament and humours. there are different method of treatments and regimen used to minimize the ef fec ts o f dysmenorrhea inc luding pharmacological, non pharmacological such as taking non steroid anti inammatory drugs (nasaid), herbal dietary therapies, yoga meditation, and acupuncture. even through primary dysmenorrhea is not a life threat but can affecting the quality of female's life and in case of severity it might lead to disability and inefciency. moreover dysmenorrhea can cause mental problems of the female resulting in their loneliness and reduced participation in different social activities. in adolescents, moderate to severe pain that affects life style and does not respond to pharmacological treatment requires professional attention and appropriate diagnosis of possible underlying pelvic disease. the exact prevalence of dysmenorrhea is difcult to determine because of variety of diagnosis criteria and the subjective feature of the symptoms .in many countries primary dysmenorrhea is the principal cause of recurrent short term absenteeism in young girls and women. the objective of the present study was to assess the menstrual pattern and its associated symptoms and the prevalence of dysmenorrhea among young both married and unmarried girls coming for the treatment at central research institute of unani medicine, lucknow. material and method this is an institute based cross sectional study especially design to assess the incidence of dysmennorhea and its distress , impact, discomfort and complications .the study was conducted on 233 young women attending general out patients department ( female ) of central research institute of unani medicine , basaha kursi road lucknow from april 2018 to november 2018 . the young women come with complaints of menstrual discomfort and associated symptoms from one month to ve years duration .the symptoms of lower back pain , lower abdominal pain , leg cramp , polyurea , anorexia ,nausea , vomiting and generalized weakness before and during the menstrual cycle . a detail obstetric and gynecological history along with general history and previous medical illness .the study was conducted on the basis of some questionnaire / case record form, which was designed especially for the study, data was recorded on a standardized pre designed questionnaire. and women were given treatment according to their complaints. they were treated by the drugs available in central research institute of unani medicine luck now, and the drugs are sharbat bazooro motadil, sharbat-e-deenar, habb-e-rewand, habb-e tinkar, habb-e-mubarak, habb-e-shifa, habb-e-mudir and habb-ebanadiq-ul-bazoor etc. distribution according to marital status table 1 incidence of dysmenorrhea and its distress among young women in lucknow original research paper dr. najmus saher reaserch ofcer, central research institute of unani medicine lucknow. medicine dysmenorrhea is very common gynecological problem in women of reproductive age worldwide. it begins with the rst ovulatory cycle and occurs about two years after menarche. although it is not life threatening, it can be painful for many adolescents .it is one of the leading cause of recurrent short term absentee in school and work place. objective of the present study is to assess the menstrual pattern and its common associated symptoms, at central research institute of unani medicine lucknow. an institute based cross-section was done during the april 2018 to november 2018 on 233 participants come to the institute for their treatment of dysmenorrhea and their associate symptoms. data were recorded on standardized pre design questionnaire for the study. at the end of the study it is found that the low back pain is the most common (95.27%) complaints before and during the menstrual cycle, and after that leg cramp (91.84%) , lower abdominal pain (83.69%) , nausea (62.23%) , headache (57.08%) , generalized weakness (51.07%) , poly urea (46.35%) , fever (49.78%) and anorexia (49.78%). the result of the study revealed that highest common symptoms are low back pain. abstract keywords : volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. maqbool ahmad khan* deputy director central, central research institute of unani medicine lucknow. * corresponding author marital status number of participants percentage unmarried 169 72.53 married 64 2746 total 233 100 104 x gjra global journal for research analysis distribution according to dietary habits table 2 distribution according to socio economic status table 3 classication according to education level table 4 classication according to living area table 5 classication according to life style table 6 classication according to general appearance / look table 7 classication according to built table 8 classication according to sign and symptoms of dysmenorrhea table 9 data collection and management the data collection tools used in the study was adopted from studies and prepared in english, this was asked to the in local language and then ll in english .the questionnaire has three parts which focuced on socio demographic characteristics and menstruation characteristics and the treatment given to the participants. result and discussion table no 1 shows the marital status of the participants ,out of 233 there are 64 participants have marital status and other 169 have unmarried status .the married participants are 27.46 % and unmarried are 72.53 % , the data shows that the incidence of the disease is more prone in unmarried than married . the table no 2 shows the distribution according to dietary habits ,it reveals that maximum number of participants follow the non vegetarian diet , it reects the relation between diet and prevalence of the disease .there are 173 (74.25 %) out of 233 follow the non vegetarian diet and 60 (25.25 % ) participants follow the vegetarian diet . a study done by nastaran naja et al to evaluate dietary pattern relation to menstrual pain .in this study , the results indicate that adherence to snacks pattern is associated with an increased risk of moderate to severe dysmenorrhea during menstruation among young women . the diet characterized by high consumption of sugars, salty snacks, sweets and desserts, tea and coffee, salt, fruits juices and added fat (labeled as “snacks” pattern), is associated with an increased risk of dysmenorrheal among young women (8). further study is needed to evaluate the dietary habits relation with the disease. table number 3 is classied according to socio economic status of the participants, there are only 21 participants out of 233 were belongs to high income group. table number 4 shows distribution according to education level of the participants ,there are ill literate to post graduate degree holders are participated in the study ,07 (03.00%) participants are ill literate and had no formal education, never gone to rdschool .1(00.42%) participants had got education up to 3 class, 21 (09.01%) participants out of 233 had got education up thto 5 class .there was 06 (02.57 %) participants had obtain the theducation up to 6 class, 10 (02.29%) participants out of 233 thhad the education up to 7 class , 17 (7.29%) out of 233 th th & 10thparticipants had get education up to 8 class . up to 9 class ththere were 20 (8.58%) 0ut of 233 and 10 class 34 (14.59%) participants respectively. only 4 (01.71%) participants have th thobtained their formal education up to 11 class , and up to 12 class 38 participants (16.30%) 0ut of 233. highest number of participants have got their formal education up to graduation level, there are 70 (30.04%) out 233, and only 5 (2.14%) participants have their education up to post graduation level. table number 5 is classied according to living area it means urban and rural accordingly. there are highest number of participants living in sub urban area that's are 94 participants out of 233 (40.34%) and after that living in urban area 86 out of 233 participants (36.90%). 47 (20.17%) participants had come volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dietary habits number of participants percentage vegetarian 60 25.75 non vegetarian 173 74.25 total 233 100 socio-economic status number of participants percentage high 21 9.01 middle 170 72.96 low 42 18.02 education level number of participants percentage nil 7 03.00 3rd class 01 00.42 5th class 21 09.01 6th class 06 02.57 7th class 10 04.29 8th class 17 07.29 9th class 20 08.58 10th class 34 14.59 11th class 04 01.71 12th class 38 16.30 graduation 70 30.04 post graduation 05 2.14 living area number of participants percentage metro 06 02.57 urban 86 36.90 suburban 94 40.34 rural 47 20.17 total 233 100.00 life style number of participants percentage active 52 22.31 moderate 120 51.50 sedentary 61 26.18 total 233 100.00 appearance number of participants percentage healthy 200 85.83 unwell 31 13.30 ill 01 00.42 aesthetic 01 00.42 total 233 100.00 built number of participants percentage bulky/fatty 20 08.58 muscular 16 06.86 short 10 04.29 normal 82 35.19 tall 19 08.15 thin 86 36.90 total 233 100.00 sign and symptoms number of participants percentage low back pain 222 95.27 leg cramp 214 91.84 lower abdomen pain 195 83.69 nausea 145 62.23 headache 133 57.08 general weakness 119 51.07 poly urea 108 46.35 fever 115 49.35 anorexia 115 49.35 total 100.00 x 105gjra global journal for research analysis from rural area and only 06 (02.57%) participants had come from metro area .highest number of participants come from urban area it reects that urban people are mare conscious about their disease. table number 6 were classied according to life style of the participants ,because in modern era it is related to life style .life style a-is divided into three categories that's are active, moderate and sedentary .highest prevalence of the disease observed in moderate life style there are 120 (51,50%) participants subsist the moderate life style out of 233 , 61 (26.18%) participants out of 233 participants were subsist sedentary life style and rest 52 (22.18%) participants habituated to follow active life style. table number 7 classied according to over all look and general appearance of the participants that's was divided into four group aesthetic ,healthy, ill and unwell .only 1 (00.42%) was observed the aesthetic and same observed ill out of 233 participants during the study, 200 (85.83%) participants observed healthy appearance out of 233 and 31 (!3.30%) shown their appearance unwell . table number 8 shows the distribution according to built of the participants which is very important to nd out the dysmenorrheal. there were observed fatty 20(08.58%) participants out of 233, muscular 16 (06.86%) out of 233, thin 86(36.90%) , short 10(04.29%) out of 233, tall 19(08.15%) out of 233 and normal built 82(35.19%) out of 233 of the participants. graph 1& table number 9 shows the symptoms appeared before and during the menstrual cycle, it reects lbp (low back pain) is the most recurrent symptoms in young adolescent women, out of 233 ,there was reported by 222 (95.27%) participants only 1(04.29%) participants reported the she did not experienced the low back before and during the menstrual period. leg cramp is reported by 214 (91.84%) out of 233 participants. low abdomen pain is reported by the 195 (83.69%) and 38 participants had no experienced the low abdominal pain before and during the menstrual cycle. 145 (62.23%) out of 233 observed the nausea before and during the menstrual cycle, 88(37.76%) participants were did not observed the nausea. headache is reported by 133 (57.08%) participants out of 233 and 100 (42.91%) participants had no experience of headache before and during the menstrual cycle. out of 233 participants 119 (51.07%) felt generalized weakness before and during the menstrual cycle 114 (48.92%) participants did not feel the headache. the symptom of poly urea was experienced by 108 (46.35%) participants and 125 (53.64%) had no experienced the poly urea during and before the cycle. fever is the very prominent feature of dysmenorrheal if it is occur before bad during the menstrual cycle , there was 115 (49.35%) suffered fever and 118 (50.64%) did not feel fever before and during the menstrual cycle . anorexia was experienced by 116 (49.78%) participants and not reported by 117 (50.21%) out of 233 participants. conclusion in this study it is found overall incidence and prevalence of dysmenorrheal among young girls of lucknow district and surrounding areas urban, rural, sub urban and metro areas. menstruation is physiological and important milestone for young women. large number of participants experienced dysmenorrheal with their associated symptoms i-e low back pain, low bad pain, nausea, generalized weakness, poly urea, anorexia and fever .some of the participants were using medication to control their dysmenorrheal and associated symptoms they did not know about the adverse effect of the drugs. acknowledgements authors would sincerely thanks to participants and their guardians for cooperation to full ll the questionnaires during the data collection in general out patient department of central research institute of unani medicine, lucknow, and director general of the central council for research in unani medicine, new delhi. referances 1. dawood .m.y.1987: dysmenorrhea and prostaglandins in: gold, j.j .josimovich (eds) gynecologic endocrinology. 4th ed new york: plenum press 405 2. montoya.j.s .cabezza,a.h.rojas o.m navarreteand r.c and keeve m .a.v menstrual disorder in adolescents .bol med hosp infant mex. 2012.69 (1) 6072 3. tan .k and wan.l . a prevalence study of dysmenorrhea in female resident age 115-54 y clement . ann aced med .1992 .21;323-327 4. ibn sina,2007 :al qanoon fil tib (urdu translation by kantoori g.h ), vol 2 ,idara kitabul shifa ,new delhi 340-341 . 5. wilson, c. emmand .j .and maneld.c .the relationship of calculated percent body fat ,sports participation ,age and place of residence on menstrual patterns , adolesc health care . 1985 j. 5;248-253 . 6. dawood .m .y, ibuprofen and dysmenorrhea, am .j .med 1984 .77 (1a )87-94 7. ibn sina, 2010 ,al qanoon fil tibb (urdu translation by kantoori g.h) new delhi ,ejaz publication house, 447-448 ,1096,1118 8. nastaran naja , hamidreza khalkhali , and rasoul zarrin , major dietary patterns in relation to menstruation pain : a nested case control study bmc women's health (2018) 18:69 http: //doi.org/10.1186/s12905-018-0558-4 volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 106 x gjra global journal for research analysis introductionthe mixed solvency concept can serve as a milestone for solubility enhancement and therefore deserves an urgent attention of the scientic community to assess its efciency and applicability. according to maheshwari, each and every substance present on earth possesses solubilizing power be it a solid, liquid or gas. some substances are good solvent for some and at the same time bad solvent for others. objectivethe main objective of present research is to show that solids also possess solubilizing power. in the present research, melted dimethyl urea (at 135�c) was employed for dissolution of indomethacin without using any organic solvents (therefore eco-friendly method). materials and methodindomethacin api was generous gift from m/s alkem laboratories ltd.,mumbai. indomethacin tablets were procured from the local market. all other chemicals were of analytical grade.the instrument used was shimadzu uvvisible spectrophotometer (model uv-160a) with 1 cm matched silica cells. experimental methodssolubility studiesthe solubility of indomethacin at roomtemperature was found to be 0.36 mg/ml. using approximate method of solubility determination, it was found that more than 800 mg indomethacin was dissolved by one gram of melted dimethyl urea(at 104 °c). calibration curve10gm dimethyl urea was taken in a 500ml volumetric ask and it was heated carefully on heating mantle. as soon as dimethyl urea was melted, 50 mg of standard sample of indomethacin was added and the ask was shaken to dissolve the drug. intermittent heating and shaking was done for complete dissolution of drug. then, 400 ml of hot distilled water (90� c) was transferred carefully (little at a time) to the volumetric ask and the contents are shaken for about 5 minutes. then, the ask was allowed to cool to attain the room temperature. then, the volume was made up 500ml with distilled water. this was the stock solution of drug (100µg/ml),by appropriate dilution of this stock solution with distilled water, standard solutions of the drug (5,10,15,20,25µg/ml) were prepared and their absorbance were noted at 265 nm against the respective reagent blanks and using these values, the calibration curve was obtained. proposed method20 tablets of nalidixic acid, formulation i were weighed and crushed to get a ne powder. 10gms of dimethyl urea was kept in a 500ml volumetric ask and the ask was carefully heated on heating mantle to melt the dimethyl urea. after complete melting of dimethyl urea, tablet powderequivalent to 50mg of drug was transferred to the ask and the ask was shaken for 10 minutes with intermittent heating and shaking. then, 400ml of hot (90� c) distilled water was carefully (little at a time) added to the ask and the ask was shaken for about 5 minutes. then, the ask was allowed to cool to attain room temperature and the volume was made up to mark with distilled water. after ltration through whatmanlter paper no.41, 5ml ltrate was diluted to 50ml with distilled water and the absorbance was noted at 265 nm against reagent blank. using calibration curve the drug content was computed. similar treatment was done for formulation ii. all analyses were performed thrice. recovery studiesrecovery studies taking 15 mg and 30 mg of pure drug as spiked drug together with pre-analysed tablet powder (equivalent to 50 mg) were performed using the same proposed method. results and discussionthe aqueous solubility of indomethacin at room temperature was 0.36 mg/ml whereas the solubility of indomethacin in melted dimethyl urea was found to be 83.33mg per gram of melted dimethyl urea at 104 °c. it is evident from table i that the percent drug estimated in formulation i and ii were 99.33 ± 1.112 and 98.07 ± 1.843, respectively. the values are very close to 100, indicating accuracy and precision of the proposed method. further, table ii shows that the range of percent recoveries varied from 98.96 ± 0.854 to 100.95 ± 1.557which are again very close to 100, indicating the accuracy of the proposed method. proposed analytical technique is supported signicantly by small values of solid as solvent melted dimethyl urea as solvent to analyse indomethacin capsules spectrophotometrically at 265 nm (mixed solvency concept) original research paper maheshwari r. k department of pharmacy, shri g.s institute of technology and science, indore, india452003 engineering in the current attempt of research, novel method for spectrophotometric estimation of indomethacin in capsules using melted dimethyl urea as solvent was developed. the main objective behind research is to show “solids also possess solubilizing power”. the current study deals with novel spectrophotometric analytical technique for quantitative estimation of indomethacin in capsules using melted dimethyl urea as solvent. according to the theory proposed bymaheshwari, each& every substance possessessolubilising power, susbstance may be a gas, solid or liquid. dimethyl ureaimbibes large solubilizing power to indomethacin and having approximate solubility more than 800 mg per gm of melted dimethyl urea whereas aqueous solubility of indomethacin is 0.36 mg/ml at room temperature. calibration curve of indomethacin was plotted by recording the absorbances of standard solutions of drug. the absorbances were observed at 265 nm against respective reagent blanks.the percent label claims were found very close to 100 (99.33 ± 1.112 and 98.07 ± 1.843) indicating accuracy of the proposed method.percent recoveries estimated by the proposed method are close to 100 with signicant low values of percentage deviation and standard error.thus, it may be concluded that proposed method is simple, safe and precise and excludes use of toxic organic solvents. abstract keywords : mixed solvency, solubilizing power, spectrophotometric analysis, niacinamide, nalidixic acid. padiyar. a* department of pharmacy, shri g.s institute of technology and science, indore, india452003 *corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 20 x gjra global journal for research analysis conclusion the mixed solvency concept can be successfully employed in analytical estimation of various drugs. a large number of poorly water-soluble drugs having absorption maxima above 250 nm can be tried for estimation by this method. such solvents (dimethyl urea) can be tried in place of costlier and toxic organic solvents. references 1. r. k. maheshwari, s. c. chaturvedi & n.k. jain, “application of hydrotropic solubilization phenomenon in spectrophotometric analysis of hydrochlorothiazide tablets,” indian drugs, 42(8), august 2005, p. 541-544. 2. r. k maheshwari, solid as solvent”“novel approach for spectrophotometric estimation of nalidixic acid tablets using solids (eutectic liquid of phenol and niacinamide) as solubilizing agents (mixed solvency concept), the pharma review 2015;113-117 3. r. k. maheshwari, “solid as solvent”novel spectrophotometric analysis of tinidazole tablets using melted phenol as solvent, asian journal of pharmaceutical research 2015;5(1):21-24. 4. stuart f, gibaldi m. effect of urea on solubility, role of water structure. int. j. pharm; 1967. 56, 370-375. 5. jain nk, agrawal rk, singhai ak. formulation of aqueous injection of carbamazepine. pharmazie, 1990; 45, 221-222. 6. jain nk, singhai ak, jain s. hydrotropic solubilization of ketoprofen. pharmazie, 1996; 51, 236-239. 7. jain nk, singhai ak, jain s. enhanced solubilization and formulation of an aqueous injection of piroxicam. pharmazie, 1997; 52, 942-946. 8. suzuki h, sunada h. mechanistic studies on hydrotropic solubilization of nidipine in nicotinamide solution. chem. pharm. bull, 1998; 46, 126-130. 9. silva et al, hydrotropic solubilizaton, thermochemica acta, 1999; 328, 161167. 10. simamora p, alvarez jm, yalkowsky s. solubilization of rapamycin. int. j. pharm., 2001; 212, 25-29. 11. rawat s, jain nk. hydrotropic solubilization of some cox-2 inhibitors. indian drugs, 2006; 43, 565-574 12. maheshwari rk. novel application of hydrotropic solubilization in the spectrophotometric analysis of piroxicam in solid dosage form. indian drugs, 2006; 43, 683-685. 13. jain n.k, nahar m. formulation and evaluation of saquinavir injection .ind. j. pharm. sc, 2006; 68, 608-614. 14. maheshwari rk. mixed hydrotropy in spectrophotometric analysis of aceclofenac. the indian pharmacist, 2007; 6, 67-69. 15. sanghvi r, evans d, yalkowsky sh . stacking complexation by nicotinamide: a useful way of enhancing drug solubility. int. j. pharm, 2007; 336, 35 16. gupta s, maheshwari rk. novel application of mixed solvency concept in the development of fast release formulation of poorly water soluble drug using liquisolid technique and its evaluation. s.g.s.i.t.s, indore, 2011. 17. jain r, maheshwari rk, george p. formulation development and evaluation of controlled release tablets of lamotrigine using mixed solvency concept. bulletin of pharmaceutical research 2015; 5(1):14-9. 18. maheshwari r, shilpkar r. formulation development and evaluation of injection of poorly soluble drug using mixed solvency concept. international journal of pharma and biosciences ,2012; 3, 179-189. 19. chandan c, maheshwari rk. mixed solvency concept in reducing surfactant concentration of self emulsifying drug delivery systems of candesartan cilexetil using d‐optimal mixture design. asian journal of pharmaceutics (ajp) 2014; 7 (2). 20. maheshwari rk, karawande v u. application of novel concept of mixed solvency in the design and development of oating microspheres of furosemide. international journal of pharmacy and pharmaceutical sciences 2013; 15, 167-195. 21. rajagopalan r. formulation and evaluation of paracetamol syrup made by mixed solvency concept. scholars research library 2012; 4 (1), 170-174. 22. gupta p, maheshwari r k. formulation development of dry syrup and dry injection for reconstitution of a poorly water soluble drug (ornidazole) using mixed solvency concept and their evaluation, 2016; 5991. 23. mehtani d, maheshwari r k. formulation development and optimization of niosomes using mixed solvency approach for transdermal delivery of poorly soluble drug and its evaluation s.g.s.i.t.s, indore, 2011. 24. yadav n, maheshwari rk. formulation development of microspheres using mixed solvency concept: design development and optimization of controlled release microsphere of furosemide by mixed solvency concept, s.g.s.i.t.s, indore, 2012. 25. agrawal a, maheshwari r. formulation development and evaluation of in situ nasal gel of poorly water soluble drug using mixed solvency concept. asian journal of pharmaceutics (ajp) 2011; 5 (3); 131-140. 26. gour v, garg a, shukla a, yadav a k. development and evaluation of metronidazole injection by mixed solvency approach. asian journal of biomaterial research 2016; 2 (1), 38-45. 27. maheshwari r k, agarwal s. formulationdevelopment and evaluationof in situ nasal gel of poorly water soluble drug using mixed solvency concept. asian journal of pharmaceutics; 5(3), 131-140. 28. george p, maheshwari rk. formulation development of dry dosage forms of a poorly water soluble drug (cexime tihydrate) using mixed solvency concept and their evaluation. dept of pharmacy, s.g.s.i.t.s, indore,2015. 29. sirole m, maheshwari rk. formulation development of non-aqueous ear drop of gatioxacine and ooxacine using mixed solvency concept. s.g.s.i.t.s.,indore,2012. 30. soni i, maheshwari rk. formulation development of fast release solid dispersions of poorly water soluble drugs, gatioxacin and naproxen, employing novel npplication of mixed solvency concept and their evaluations. dept of pharmacy, s.g.s.i.t.s, indore, 2015. 31. jatwa d, maheshwari r k. formulation development of solid-seeds based capsule dosage form of diazepam using novel application of mixed solvemcy concept and its evaluation. s.g.s.i.t.s, indore, 2012. 32. maheshwari rk, chaklan n. novel pharmaceutical application of mixed solvency for solubility enhancement of piroxicam, development of its solid dispersions and fast dissolving oral lm. s.g.s.i.t.s, indore, 2009. 33. maheshwari rk, putl iwala m, padiyar a. novel approach for spectrophotometric estimation of naproxen tablet dosage form using solids (eutectic liquid of phenol and niacinamide) as solubilizing agents (mixed solvency concept).asian journal of pharmaceutical research, 2015; vol 5, issue 1, 25-28. 34. abdelbary ga, amin mm, abdelmoteleb m. novel mixed hydrotropic solubilization of zaleplon: formulation of oral tablets and in-vivo neuropharmacological characterization by monitoring plasma gaba level. journal of drug delivery science and technology 2016; doi : 10.1016/j.jddst.2016.03.014. 35. maheshwari rk, shah ap, pandey l, tiwari sp. “solid as solvent”: novel spectrophotometric analytical technique for quantitative analysis of tinidazole tablets using solids (eutectic liquid of phenol and metformin hydrochloride) as solubilizing agents (mixed solvency concept).the pharma innovation journal 2016;5(3):01-02. 36. soni lk, solanki ss, maheshwari rk. studies on mixed solvency concept in formulation development of oral solution (syrup) of poorly water soluble drugs. journal of harmonized research in pharmacy 2015; (4), 305-315. 37. singh a, maheshwari rk. “solid as solvent”-novel spectrophotometric analytical technique for quantitative estimation of piroxicam in tablets using solids (eutectic liquid of phenol and lignocaine hydrochloride) as solubilizing agents (mixed solvency concept). world journal of pharmaceutical research, volume 5, issue 2, 1560-1567. 38. maheshwari rk, vamoriya p, joshi s, kori s. “solid as solvent”-novel spectrophotometric analysis of metronidazole tablets using phenol as solvent .european journal of biomedical and pharmaceutical sciences, http://www.ejbps.com 2015; volume: 2, issue: 4, 1240-1247. 39. maheshwari rk, jain r, george p. formulation development and evaluation of controlled release tablets of lamotrigine using mixed solvency concept. an ofcial publication of association of pharmacy professionals, bulletin of pharmaceutical research 2015; 5(1): 14-19. 40. jain dk, patel v, banjare l, jain n, maheshwari rk. “solid as solvent”novel technique for spectrophotometric analysis of ornidazole tablets using melted phenol as solvent. asian journal of biomedical and pharmaceutical sciences. 41. jain s, maheshwari rk, nema rk, singhvi i. development and validation of simple spectrophotometric method of quantization of ondansetron hydrochloride in solid dosage formulations using hydrotropic solubilization technique. international journal of pharmaceutical sciences and drug research, 2017; 9(5)210-213. 42. maheshwari rk, solanki ss, soni lk. “solid as solvent”novel spectrophotometric analytical technique for furesemide tablets using solids(eutectic liquid of phenol and niacinamide) as solubilizing agents(mixed solveny concept). international journal of advances in pharnaceutical research . 43. padiyar a, maheshwari rk, jain s. formulation and development of high concentration diclofenac sodium injection using mixed solvency concept volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra tablet formulation label claim per tablet (mg) % label claim estimated (mean±sd) % coefcient of variation standard error i 25 99.33±1.112 1.119 0.642 ii 25 98.07 ± 1.843 1.879 1.065 statistical parameters viz. standard deviation, percent coefcient of variation and standard error (table ii). table 1: analysis of commercial tablets of nalidixic acid with statistical evaluation (n=3) tablet 2:results of recovery studies with statistical evaluation (n=3) tablet formulation drug present in preanalyzed table powder taken (mg) pure drug added (spiked)(mg) % recovery estimated (mean ± sd) % coefcient of variation standard error i 50 15 100.78± 0.775 0.769 0.448 i 50 30 98.96± 0.854 0.863 0.493 ii 50 15 99.44± 1.086 1.092 0.627 ii 50 30 100.95± 1.557 1.542 0.899 x 21gjra global journal for research analysis and its evaluation. international journal of advanced pharmaceutics, 2016; vol 6, issue 2, 78-84. 44. jain s, maheshwari rk, nema rk, singhvi i. development and validation of simple uv-spectrophotometric method of quantization of domperidone in solid dosage formulation using mixed solvency concept, research and reviews: a journal of design and discovery, volume 4, issue 2. 45. jain s, maheshwari rk, nema rk, singhvi i. development and validation of simple uvspectrophotometric method of diazepam in bulk and solid dosage formulation using mixed solvency concept, international journal of current pharmaceutical research, 2017; vol 9, issue 6,. 46. jain s, maheshwari rk, nema rk, singhvi i. development and validation of simple uvspectrophtometric method of quantization of nifedipine in solid dosage formulation using mixed solvency concept, world journal of pharmaceutical research, volume 6, issue 13, 1014-1021. 47. maheshwari rk, dahima r.“solid as solvent”: novel spectrophotometric analytical technique for quantitative estimation of tinidazole in tablets using solids (eutectic liquid of phenol and lignocaine hydrochloride) as solubilizing agents (mixed solvency concept). journal of drug delivery and therapeutics, 2017;7(3):127-130 48. maheshwari rk, padiyar a, putliwala m. utilization of mixed solvency concept in spectrophotometric analysis of cexime trihydrate tablets. international journal of pharmaceutical research and analysis, vol 5, issue 1, 1-3. 49. maheshwari rk. “solid as solvent”novel spectrophotometric analysis of tinidazole tablets using phenol as solvent. asian journal of pharmaceutical research,2015;vol5,issue1,21-24 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 22 x gjra global journal for research analysis cooperatives are de�ned as 'autonomous associations of persons united voluntarily to meet their common economic, social and cultural needs and aspirations through a jointly owned and democratically-controlled enterprise'. all cooperatives subscribe to a set of values and principles that support the social and people-focused nature of their activities. they are operated democratically by their members. whether customers of the business, workers or residents, members have an equal say and a share of the pro�ts. cooperatives are a powerful economic and social force, present in most countries of the world and in most sectors of the economy. the cooperative movement counts more than a billion members. the 2030 agenda for sustainable development explicitly recognizes co-operative enterprises as important players within the private sector to achieve the sdgs; co-operatives are partners to global, national, regional and local institutions to achieve sustainable development; the international cooperative alliance has identi�ed targets within the 17 sdgs of most relevance to co-operatives, grouped into three main action areas: eradicating poverty, improving access to basic goods and services and protecting the environment and building a more sustainable food system. problems of home-based women artisans home based women workers fall into two categories: (i) dependent workers who work on a piece rate and usually produce for a subcontractor or middle persons in a contract chain; and (ii) independent home based workers or own-account workers who produce goods for direct sale through street stalls, shops or the local village and sometimes to traders or sub contract (haq, 2003) the unplanned home-based workers represent an important part of working population. there are large number of income producing activities are included in home-based sector in which mostly women workers are engaged. beedi making, textile, garment making, food processing, craft, coir work, dairy and chikan embroidery are included in these activities. both in rural and urban areas, there is given very little importance to this unorganized sector and the signs of this sector are; the working conditions are unspeakable, the wages are extremely low and workers face great worries and exploitations. home based industrial work is one of the least regulated, least managed and risky, systems of industrial production however a large number of women workers are tired in this sector just because of lack of personal resources, like education and awareness, non-availability of employment opportunities, and normative practices which control women's mobility outside home. (sarna & shukla, 1994) liberalization has improved the employment opportunities for women in some sectors especially in the crafts sector. so there are increased the number of women in participation of home-base craft sector like in embroidery, lace making, weaving and printed textiles. in some cases empowerment of women also increases but in most cases, the working condition of the women workers is poor and they are paid less than men. (krishnaraj, 1992 cited by rao, 2005) women have a great work load in their lives; they have a double burden, to earn income from their work and also have to ful�ll their domestic responsibilities. they laboring the whole day; generally they work 12 to 16 hours per day and losing their time and energy both. (durand, 1975 cited by united nations economic and social commission for asia and the paci�c, 1987) being a embroidery skilled worker, their work requires women to sit long hours in the same position that resulting in eye, back bone, shoulders as well as other mental and emotional problems depending upon the physical environment in which these women live and work. (sarna &shukla, 1994) wage discrimination is obvious and usually common against women in asia. wage rates are as low as one-third or it may be observed that women always paid less of those paid to men. in jobs also, there are described carefully to discriminate the labour practices involved; female positions typically require few skills and give poor salary. (united nations economic and social commission for asia and the paci�c, 1987) in handicrafts the embroidery work is a traditional art but many women faced some difficulty of marketing their skill. generally simple embroidery piece do not have sale value except it is the part of some readymade garments, complete form and other gift items. then these workers must rely on the other persons to sale out for their exclusive crafts. generally these persons are shop keepers, designers and exporters. women of home-base producers also face cooperatives and the sdgs: focus on gender equity and women's empowerment on handicraft industry original research paper dr. s. v. akilandeeswari icssr-post doctoral fellow, department of cooperation, gandhigram rural institute – deemed to be university, dindigul, management in today's economic condition, earning of a common man is not sufficient for the livelihood of the family. he has to be supported by the family members especially women in the family and decisions to be taken with their consent. now, their income has now signi�cantly increased. according to some of the women artisans, they are now able to sustain the family economically without the support their male counterpart. but, women artisans need support from the government for their development like focus around livelihoods, social development and good environment so that they can access to essential goods and services, meeting basic needs, higher productivity, sustainable earnings and greater empowerment. empowerment is ful�lled when they have knowledge on account of health, education and affordable access to other public services such as justice, housing, civil rights, security, information and communications. hope these women artisans will attain that very soon. women work round the clock, in the process of crafting the articles then the male artisans but it is not considered or recognized. as these women artisans do not have a proper organised set up, schemes have not reached them. to address these and other related issues, the study is proposed with success case of women cooperatives and how it can be implemented with women handicraft artisans. abstract keywords : cooperatives, empowerment, women artisans, sustainable development goals. dr. c. pitchai* professor, department of cooperation, gandhigram rural institute-deemed university, dindigul, *corresponding author x 3gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 difficulty in this context because they are unadvertised and commonly people don't know them so they have only those customers to know them personally. (gyanendra & dastidar, 2000) crafts production is culturally recognized activity. the skills present in the economic sector and many women adopt and practice it. but they don't get to recognition and value not in the economy and not in the household level. they don't have any �nancial records, on average it accounts for less than one per cent of a household's income. this is not much to lead toward progress. there are too much women who participate in home-craft production but they just have little impact on it. there is also no visibility of proper place or infrastructure for marketing home-produced crafts. (freedman & wai, 1988) in some traditional industries like jute and cotton textile, mechanization has contributed in the rejection of female employment. women represent 90 percent of the workers in these industries such as the making of embroidery. but intermediaries and middlemen who provide the raw materials and market the �nal product, make them badly exploited by only paying the women minimal wages. (bhatty n.d.; indian council of social science research, 1975 cited by united nations economic and social commission for asia and the paci�c, 1987) case studies of women empowerment and cooperatives the indian farmers fertilizer co-operative limited (iffco) in india is supporting women's economic participation. the cooperative pledges to promote self-help groups for women and arrange training programmes to improve women's skills in beekeeping, tailoring, embroidery, adult education, fruit and vegetable preservation, and computer literacy, among others. the self-employed women's association (sewa) is a national union of 1.5 million informal women workers in 14 states of india founded in 1972. sewa operates through unions and cooperatives democratically run by women members. starting with a �nancial services cooperative and a garment production cooperative, sewa today promotes 115 cooperatives across india. the sewa cooperative federation has 15 billion as members cooperatives in the artisanal, dairy, agriculture, �nancial, service and vendor sectors. the federation helps women organize and register their own cooperatives, supports new cooperatives, builds women's capacities to run their businesses, advocates at the political level for cooperative support and offers mentoring, marketing and networking opportunities. kilimanjaro cooperative bank limited (kcbl) in tanzania is owned by cooperatives, most of whom engage in coffee farming. a top cash crop, coffee production is a male dominated industry, due to practices that restrict women land ownership and inheritance, though women do most of the farm work without payment or membership bene�ts from the cooperative. to empower women, the international labour organization's coop africa office, kcbl and kenya natural foods cooperative (knfc) partnered to provide soft loans and training to select women's cooperative groups to help them diversify into crops not dominated by men. at the end of the project, 268 women were growing nontraditional produce such as mushrooms, dried fruit and rosella �owers, bene�ting from reduced prices for inputs bought collectively and from new market linkages with the tourism sector. sdg 5: gender equality and women's empowerment through cooperative ÿ the cooperative difference gender equality and women's empowerment stand alone as a goal, but are also integral to all dimensions of inclusive and sustainable development. here the women are organized; their need and wants are identi�ed. ÿ women engage exponentially more in unpaid domestic work and care than man and are vastly underrepresented in leadership positions. ÿ in a review of 67 countries with data from 2009 to 2015, less than a third of seniorand middle-management positions were held by women. ÿ the cooperative model is well-suited to advancing women's economic participation in three key ways: increasing access to employment and work, enabling economic democracy and agency and boosting leadership and management experience and have an equal voice in decision-making processes. ÿ according to a recent study, nine of the biggest 100 cooperative and mutual insurers in the world have women ceos, compared to only one of the top 100 stock company insurers. ÿ co-operative enterprises all subscribe to the principle of voluntary and open membership, meaning that anyone can join a co-operative without fear of discrimination. ÿ these key aspects of the co-operative identity help make them drivers of gender equality and women's empowerment. ÿ the co-operative form of enterprise facilitates women's participation in local and national economies. ÿ through credit unions and co-operative �nancial institutions, women can save and get access to �nancial services. ÿ the establishment of women's co-operatives are on the rise, particularly among domestic workers, who are often marginalized women in vulnerable economic and social situations. ÿ co-operatives also help create employment, education, and training opportunities for women and girls who are usually excluded from the economy. they were provided need based training so that the women's talent will be exhibited for their economic development. ÿ women also strengthen their leadership skills through cooperation by not only participating in their organization's governance, but by making decisions for members and their communities that increase their image as leaders and change makers. ÿ the levels of membership among women in co-operatives are proof of their potential for achieving sdg 5 as their active participation and involvement along with governance, decision making and participation. cooperative implementation in action many cooperatives are committing to achieve greater gender parity in their boards of directors and membership base: those companies are ÿ cic insurance group in kenya, vancity and the co-operators in canada, and reset social co-operative, formula servizi, politecnica engineering and architecture social co-operative, and la collina social co-operative in italy. ÿ co-operatives uk, the national apex organisation representing co-operatives in the united kingdom, has pledged by 2020 to work with its members to achieve the goals of the co-operative women's challenge, a campaign which seeks to ensure that women are fairly represented at all levels in the british cooperative movement. ÿ the goals include fair representation in democratic structures, more women in senior management roles, and campaign for gender equality across the economy and society. conclusion: problems faced by these women artisans and their economic condition is very poor as there are unorganized, so how to prosper them were taken for study, they can develop themselves as well as their community in economic growth, create job opportunity and business enhancement and a source of livelihood of women artisans. craft tourism can be developed. concerning the industry the tours can be developed, but smaller villages including craft places in rural areas are still in the process of getting attention from tour operators and customers to become the new potential area/destinations for craft centre with cooperatives. the country needs to make the balanced linkage between villages, government including both local and central authority, tour companies, 4 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 universities and other stakeholders to strengthen this new type of craft tourism. ngos should help the home based women workers to shape cooperatives. these cooperatives should supply raw materials, make sure appropriate and timely payments, arrange for the credit and support in design development. (pitchai, 2013). there is an immediate need to arrange female workers into cooperatives and other organizations where production and marketing are included. government institutions or voluntary welfare organizations must come forward to reduce such exploitation of women (akilandeeswari, 2014). references: 1. akilandeeswari, s.v and c. pitchai. (2014). improvisation of pottery industry and the rural artisans by marketing the products on the web, innovative facades in ecommerece, isbn no: 978-93-81723-26-5, pp. 108-112. 2. chatterjee and ohd ashraf dar (nov 2011), “yojana”,issn-no-0971-8400.p19,benzborah.p. bhagawati k.m. (july-september 2003), “artfedits activities in the development of handloom and handicrafts of assam”, cooperative perspective, volume.38, no.2, pp 38. 3. batra. g.s., dangwal. r.c. (2003), “entrepreneurship and small scale industriesnew potentials”, deep & deep publication p private limited, delhi,110027. 4. kama raju,t. santhoshranganath.n (2010). “marketing of handicrafts: a case study of brass items manufacturing units in srikakulam district of andhrapradesh”, indian journal of marketing, september, pp48 5. pitchai. c. r.gopalasamy and s.v.akilandeeswari. (2013). innovation: a panacea for cooperatives in india with particular reference to the state of tamilnadu, innovative cooperative ventures/initiatives, proceedings and papers of 30th annual national convention, dominant publishers and distributers pvt ltd, new delhi, 2015, pp. 6273. 6. sanjay mohapatra(2011). “problems associated with artisans in making of handicrafts in orissa”, india management review: an international journal, volume 6, number 1. 7. http://www.epch.in/moredetails.htm last accessed on 19.01.2015 8. http://planningcommission.nic.in/plans/stateplan/upsdr/volchap_b4.pdf last accessed on 06.02.2015 9. http://www.poompuhar.org/pro�le.aspx last accessed on 06.02.2015 10. http://www.women in handicrafts industry a study of sikkim mittal publications.html 11. sood, anubha, “craft as sustainable livelihood option in rural india” http://www.women artisan.html 12. http:\www.rural tourism project at asharikandi.html 13. women and handicrafts: myth and reality. seeds: 1981 ;(4):1-16.the contribution of wo m e n i n h a n d i c r a f t s c u l t u r a l s t u d i e s e s s a y, 2 3 r d m a r c h , 2 0 1 5 , �le:///c:/users/sony/desktop/the%20contribution%20of%20women%20in%20h andicrafts%20cultural%20studies%20essay.html x 5gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 introduction the liver is a unique organ that is connected in series between the portal system and lungs. in patients with liver diseases and / portal hypertension, constituents of venous blood arising from both liver and the portal system can directly injure the pulmonary vasculature and endothelium. pulmonary vascular complications in liver disease or portal hypertension have long been documented in the form of porto-pulmonary hypertension (poph) and hepato-pulmonary syndrome (hps) producing important morbidity and mortality, including the setting of liver transplantation. there has been increasing recognition of the importance of these pulmonary vascular complications of liver disease, with increasing realization that these complications inuence survival before, during and after transplantation. porto-pulmonary hypertension (poph) is best dened as pulmonary arterial hypertension (pah) associated with portal hypertension, whether or not the portal hypertension is due to underlying liver disease. hepato-pulmonary syndrome (hps) is characterized by triad of arterial deoxygenation, intrapulmonary vascular dilatation and liver disease. hps can occur with any degree of liver disease, ranging from well compensated chronic liver disease without cirrhosis to noncirrhotic portal hypertension and cirrhosis. in previous studies cardiac catheterization was used to diagnose pah in patients of cld. recently echocardiography, a non invasive technique, is used to diagnose pah. echocardiography is a simple non invasive technique which replaced invasive catheterization to rule out hepato pulmonary syndrome. the primary objective of our study was to check for the prevalence of pulmonary hypertension in the patients of chronic liver disease by trans-thoracic echocardiography, presenting to the medicine in patient department, with or without symptoms suggestive of cardio-vascular involvement. we also analyzed causative factors prevailing in the region (bundelkhand) for causing cld. objectives ÿ the primary objective of our study was to check for the prevalence of pulmonary hypertension in the patients of chronic liver disease by trans-thoracic echocardiography, presenting with or without symptoms suggestive of cardiovascular involvement. ÿ to plan for further study to see effects of available drugs for pulmonary hypertension with chronic liver disease and the use of the presence of pulmonary hypertension as one of the criteria for referral to liver transplant. material and methods this cross sectional study was conducted on patients to study the incidence of pulmonary hypertension in patients of chronic liver disease original research paper dr. rajat jain associate professor department of medicine, m.l.b. medical college, jhansi x 87gjra global journal for research analysis general medicine background : cirrhosis and portal hypertension have been found to be associated with pulmonary hypertension and pulmonary dysfunction. several clinical studies have demonstrated 20% higher prevalence of pulmonary hypertension in patients with advanced liver disease and portal hypertension. there has been increasing recognition of the importance of these pulmonary vascular complications of liver disease, with increasing realization that these complications inuence survival before, during and after liver transplantation. aim of the study: the primary objective of our study was to check for the prevalence of pulmonary hypertension in the patients of chronic liver disease by transthoracic echocardiography, presenting with or without symptoms suggestive of cardiovascular involvement. the secondary objective of this study was to plan for further study to see the effects of available drugs for pulmonary hypertension on patients with pulmonary hypertension with chronic liver disease and the use of presence of pulmonary hypertension as one of the criteria for referral to liver transplantation. material and methods: this study was conducted in medicine department of mlb medical college, jhansi from may 2018 to may 2019. 90 patients of chronic liver disease were taken as subjects and 75 age and sex matched patients without cld were taken as controls. based upon their symptoms, the subjects were divided into 2 groups:group a – patients of cld presenting with symptoms suggestive of cv involvement and group b – patients of cld presenting without symptoms suggestive of cv involvement observation: in our study, there were 72 male patients (42 in group a, 30 in group b) and 18 female patients (12 in group a and 6 in group b). majority of the patients were above 40 years of age (60 out of total 90 patients). the cause of cld in majority of the subjects (50%) was chronic alcoholism, in 30% it was chronic hepatitis-b while 20% had other causes. 40% of our subjects were found to have pulmonary hypertension, 44.44% of all the patients of group a and 33.33% of all patients of group b. conclusion: there is high incidence of pulmonary hypertension in patients of cld and alcohol addiction is the most common cause of cld in bundelkhand region. trans-thoracic echocardiography is a simple and non-invasive technique for diagnosis of pulmonary hypertension. abstract keywords : portal hypertension, pulmonary hypertension, echocardiography. dr. zaki siddiqui* assistant professor department of medicine, m.l.b. medical college, jhansi *corresponding author gauri naryani medical student, m,l,b, medical college, jhansi. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra swati azad medical student, m,l,b, medical college, jhansi. sanya jain medical student, k.i.m.s., karad. 88 x gjra global journal for research analysis admitted to the medicine wards of maharani laxmi bai medical college, jhansi after obtaining ethical clearance from the institutional ethics committee. informed consent was taken from the participants prior to the study. in our study, 54 patients of chronic liver disease presenting with symptoms suggestive of cardiovascular involvement and 36 patients without these symptoms were screened by clinical examination, blood investigations, usg abdomen, chest xray, ecg and trans-thoracic echocardiography [the following symptoms breathlessness, pedal edema, cough, dizziness, palpitations, chest pain were considered to be suggestive of cardio-vascular involvement]. we also examined 75 age and sex matched controls [excluding cld]. we excluded patients of interstitial lung disease (ild), chronic obstructive airway disease (coad), valvular heart disease, cardiomyopathy and pulmonary tuberculosis both from the study and control groups. a total of 90 patients of cld and 75 controls were examined using the echocardiography machine of our department ( hitachi aloka alpha 6) pndt/act/94/2016, for rv dimensions, contractibility and evidence of pulmonary hypertension or rv systolic function by tricuspid valve annular motion technique. grading of pulmonary artery hypertension by echo cardiography: 2srvp = 4*trv + rap 2pap = 4*trv srvpsystolic right ventricular pressure; trvtricuspid regurgitation velocity; rapright atrial pressure; pap pulmonary artery pressure] calculation of rap other factors included right atrial volume index, inferior vena cava diameter, eccentricity index, presence of pulmonary embolism and tapse in grading. data collected was entered into excel. chi-square and fischer's exact test were done for qualitative data. bivariate analysis was done to identify selected risk factors for the outcome. observations table 1: demographic variables among patients of group a and group b in our study, there were 72 male patients (42 in group a, 30 in group b) and 18 female patients (12 in group a and 6 in group b). majority of the patients were above 40 years of age (60 out of total 90 patients). chart 1: graphical representation of male :female ratio among patients of group a and group b chart 2: graphical representation of causative agents of cld. chart 3: graphical representation of age distribution in group a group b. table 2: prevalence of pulmonary hypertension in patients of group a and group b chart 4: graphical representation of severity of rv enlargement chart 5: graphical representation of prevalence and severity of pulmonary artery hypertension (pah) volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra severity spap mild >35 mmhg moderate >50 mmhg severe >60 mmhg ivc diameter (cm) response to sniff ra pressure (mmhg) ≤2.1 >50% collapse 3 ≥2.1 <50% collapse 8 >2.1 <50% collapse 15 variables group a (n=54) group b (n=36) controls (n=75) sex male female 42 12 30 6 60 15 age <40 years >40 years 18 36 12 24 25 50 residence urban rural 36 18 9 27 present absent group a 24 (44.44%) 30 (55.55%) group b 12 (33.33%) 24 (66.67%) controls 04 (5.33%) 71 (94.66%) 26.66% of our subjects (24 out of 90) were found to have mild pah, 3.33% (3 out of 90) had moderate pah, while none of the subjects in our study had severe pah as assessed using trans thoracic echo cardiography. in our study, all of the subjects of both the groups were found to have normal ndings of ecg, chest x-ray and right ventricular systolic function. chart 6: graphical representation of usg abdomen ndings chart 7: graphical ndings of usg ndings of liver discussion chronic liver diseases (clds) are a set of diseases characterized by decreased hepatic function as a result of chronic inammation or insult to the liver. these can progress through stages of brosis to the end stage disease, cirrhosis. cirrhosis is irreversible and is dened by brosis, damage and regeneration of hepatocytes, altered hepatic architecture and decreased hepatic function. the patients of clds may suffer from complications like hepato-renal syndrome, hepato-pulmonary syndrome and porto-pulmonary hypertension. pulmonary hypertension is the resting mean pulmonary arterial pressure in excess of 25mmhg. pulmonary involvement is common in patients with portal hypertension and can manifest in diverse manners. changes in pulmonary arterial resistance, manifesting either as hepato-pulmonary syndrome or porto-pulmonary hypertension (pphtn), have been increasingly recognized in these patients in recent years. porto-pulmonary hypertension is combination of portal hypertension and pre-capillary pulmonary hypertension. several clinical studies and autopsy ndings have demonstrated a 20% higher prevalence of pulmonary hypertension in patients with advanced liver disease and portal hypertension, the histological ndings of which show features similar to those seen in pulmonary hypertension from other causes. in our study, we screened 90 patients of chronic liver disease for symptoms suggestive of cardio-vascular complications and presence of pulmonary hypertension by chest x-ray, ecg, echocardiography along with the routine blood investigations and usg abdomen. the ndings of chest x-ray and ecg were normal in all of the subjects. the ultrasonography of abdomen revealed that all of our patients had ascitis, 70% (66 out of 90) patients had splenomegaly, 13.33% (12 out of 90) patients had hepatomegaly, 3 .33% (3 out of 90) pat ients had hepatosplenomegaly while the rest had small liver with course echo-texture. 44.44% of patients of group a (i.e. those with symptoms of cv involvement) were found to have pulmonary hypertension and 33.33% of patients of group b (i.e. those without symptoms of cv involvement) indicating that even in the absence of symptoms pulmonary hypertension can be present in patients with chronic liver disease. it was also found that presence of pulmonary hypertension was not in relation with the severity and duration of cld. conclusion 1) the study concludes that there is high incidence of pulmonary hypertension in patients of cld 2) trans-thoracic echocardiography is a simple and noninvasive technique for diagnosing pulmonary hypertension in patients of cld 3) alcohol addiction is the most common cause of cld in bundelkhand region (preventable cause) 4) presence of pulmonary hypertension does not correlate with the severity of underlying liver disease (to be conrmed by further studies). references: 1) savale l et al, presse med. 2014pulmonary hypertension in liver diseases 2) adriana v. gurgheah and iona a. tudorpulmonary hypertension in patients with hepatic cirrhosis and portal hypertension, en echographic study 3) lamps lw, carson k, bradley al, pinson cw, johnson je, coogan ac, hunter eb, clavien pa, washington mkpulmonary vascular morphological changes in cirrhotic patients undergoing liver transplantation. 4) ss salviliver disease and pulmonary hypertension. 5) rowen k. zetterman – pulmonary complications of cirrhosis 6) mateo porrisaguilar, jose t altemirano, aldo torre-delgadillo, michael r charlton and andres duarterajo : pulmonary hypertension and hepatopulmonary syndrome : a clinician oriented overview 7) lewis j rubin : pulmonary hypertension 8) micheal j krowko, robert robriguezroisin, alvar agusti: hepato-pulmonary disorders : gas exchange and vascular manifestations in chronic liver disease. 9) luke s.howard, julia grapsa, david dawson, micheal bellamy, john b.chambers, navroz d. manasi, petros nihoyannopoulos and j. simon r. gibbs: echocardiographic assessment of pulmonary hypertension: standard operating procedure. x 89gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction shushkaakshipaak is one of the sarvagat vatapittajanya vyadhi. yata\ kuxinatam dar]nar]xavatmaivalaaokxnao caaivaladsa-nam yata\ | saudar]nam yata\ pa`itabaaoqanao ca sauykxaixapaakxaopahtam tadixa ||26|| (sau.{. 6ó26) the disease in which the eye lids become dry and hard and remain always closed, the vision becomes cloudy and hazy eyelids is called the sushkakshipaak. aschyotan : {ynaoca saita r]paa: syau: savao-~ao vaoya inascaya:| vaatao ita@tam taqaa isnagqa m ipa<ao maqaursaitalama\ || (yaao.r.nao~araoga 341) in aschyotan procedure acharya has described use of snigdha and madhur rasatmaka dravya in vata pittajanya vyadhi. yashtimadhu:yayti ihmaa gaur] svaadi caxauyyaa balavana-krta\ | sauisnagqaa sauk`xlaa koxsyaa svayaaipa<aainalaasa`ijata || va`nasaaoqaivayaccid-tarynaaglaanaixayaapaha | (baa. pa`.) being madhur & snigdha it is pittaghna and being guru snigdha and madhur it is vataghna however it is kaphakar. local – being daha shamak, vedana sthapak, shothahara. its lepa should be applied to vranashotah and allergic rasha due to insect bite. this eye diseases are commonly occurs due to heena, ati and mithya yog. eg. excess use of computer, polluted air, viewing of tv and excess out door work, excessive driving. so, in aschyotan procedure acharya has described use of snigdha and madhur rasatmaka dravya in vatapittajanya vyadhi. so, yashtimadhu is vata pittaghna, caksusya and having properties of snigdha guna and it is easily available. so, i am going to choose yashtimadhu aschyotan as treatment for shushkaakshipaak. materials and methods materials: drug: yashtimadhu aschyotan. the content are yashtimadhu method:a) method of preparation of: yashtimadhu 40mg + water 640ml ─∆→ kwath 160ml →aschyotan b) dose and time of administration of drug accordingly. adult: 1 drop of each eye 3 time daily for 28 days. c) duration: 28 days inclusion criteria total 30 patient were taken for this study ÿ the patients having signs and symptoms of dry eye like, ÿ dryness of eye, burning sensation, blurring of vision, itching, redness ÿ irrespective of age, sex. ÿ the patient above the age of 12 year and below 80 years will be selected. exclusion criteria ÿ below 12 years and above 80 years are not selected. ÿ congenital anomalies of eye ÿ abnormal structure and function of eyelid. ÿ aschyotan ayogya ÿ severe cases of dry eye. yashthimadhu drug sample use of yashtimadhu aschyotan in shushkakshipaak. original research paper dr. nikhil dilip chaudhari m.s.(shalakya-tantra netrarog), associate professoe in dept. of shalakya-tantra, r. b. ayurvedic medical college & hospital, agra, uttar pradesh. ayurveda in this present era, the human life style has been drastically changed. he has to use his eyes extensively, for thorough study of various objects or close inspection of minute objects, reading, writing, heavy computer work, internet surng continuous reading, watching t.v.,continuous driving on bike with working in industries, hot areas, tropical areas, eyes opened exposed to pollutants, late night duties like watchman etc. especially, young have to work hard, in doing study and other activities and various poisonous gases are excreted by the vehicles, industries also air pollution is dominating. directly or indirectly they are harmful to eyes. considering the situation and the subject i have selected a universal problem of the eye that has been affecting a large number of people around the world called as dry eye syndrome having a resemblance with a disease called as shushkakshipaak. sushrutacharya had described sushkakshipaak as the disease in which the eye lids become dry and hard and remain always closed, the vision becomes cloudy and hazy eyelids is called the sushkakshipaak. according to acharya vagbhat vata and pitta dosha predominance is described by vagbhat also the symptoms are more severe as compared to sushruta like different types of pain and burning sensation, following dryness of eyes, foreign body sensation etc. to explain the effect of yashtimadhu aachyotan on sushkakshipaak we need to take consideration of rasa, veerya, vipak, guna and doshaghnata of yashtimadhu that is madhur & snigdha it is pittaghna and being guru snigdha and madhur it is vataghna however it is kaphakar. it is exactly opposite to shushakashipaak dosha. abstract keywords : shushakashipaak, yasshtimadhu, aachyotan volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 72 x gjra global journal for research analysis yasshtimadhu aachyotan result ÿ 21 males and 9 females patient were taken for the study. ÿ it was found that maximum patients were found in the age group of 21 to 30 yrs. (16 patients.) ÿ it was highlights that maximum patients who suffered belong to service class were as few patient belong to the student category as per the observation. ÿ so it can be said that the people in service class have grater chances of suffering from the diseases. ÿ symptom of rukshata, netradaha, avil darshana, darun pratibodhan, aaraktata are recovers in 14day. ÿ the data shows in table, suggests that highly signicant efcacy for the tfbut test. discussion now on considering the various stastical data available through the patients that we have conducted the trial. we have found following things, data analysisage it was found that the mean age of patients were 27 yrs. this may also indicate that the people of such age have verities of exposures to the causative factors as mentioned in the text. sex it was found that males have more afnity towards this diseases as compared to female in early age as they are more exposed to the stimulating factors like environmental pollution, excessive computer usage occupation it was clearly found that the persons in the services class are more affected as compared to the house wife's, followed by the student category have been also predominantly affected by the disease. because of services class have continuously out door work or computer users. coming to the statistical part based on the signs and symptoms. rukshata (dryness) on considering the symptom of rukshata, it was found that, in trial group, symptom of rukshata is found in 29 patient (96.66%).after treatment the symptom of rukshata reduced totally in 27 patient (90.00%) and 2 patient (6.66%) had mild form of rukshata. and statistically yashtimadhu aaschotan were highly signicant this is due to madhur rasa, madhur vipaak, snigdha guna and chakshushya property of yashtimadhu. netradaha (burning sensation) on considering the symptom of netradaha of the eye it was found that, the symptom of netradaha is found in 30 patient (100%). after treatment the symptom of netradaha reduced totally in 25 patient (83.33%) and 5 patient (16.66%) had mild form of netradaha. this is due to madhur rasa, madhur vipaak, sheeta veerya & dahashamak property of yashtimadhu to reduced the netradaha. avil darshana (blurring of vision) it has been found that the symptom of avil darshana, the symptom of avil darshana is found in 20 patient (66.66%). after treatment the symptom of avil darshana reduced totally in 19 patient (63.33%) and 1 patient (3.33%) had mild form of avil darshana. this is due to madhur rasa, rasayan & balya property of yashtimadhu, the symptom avil darshana is reduced. darun pratibodhan (unable to open & close eye with ease) on considering the symptom of darun pratibodhan it was found that, the symptom of darun pratibodhan is found 13 patient (43.33%). after treatment the symptom of darun pratibodhan is reduced totally in 13 patient (43.33%) i.e. all patients are get relief of darun pratibodhan. as yashtimadhu which have shoshahara, vranapaha, kandugna property and snigddha, sheetal guna they must be controlling this symptom which are able to heal the surface and bring smoothness. aaraktata (redness) on considering the symptom of aaraktata of the eye it was found that, the symptom of aaraktata is found in 29 patient (96.66%). after treatment the symptom of aaraktata reduced totally in 11 patient (36.66%) and 18 patient (60.00%) had mild form of aaraktata. the shita veerya and pittashamak property of yashtimadhu had reduced the symptom of aaraktata. tear im break up time in tfbut test it was found that, 19 patients had tfbut between 7 to 8 sec, 11 patients had 9sec. while after treatment all patient shows tfbut between normal range. so it is well understood that normal range of tfbut test i.e.>10sec. the improvement is satisfactory. samprapti and its vighatana:shushkakshipaak -dosha – here vata is dominant and there is anubandha of pitta and rakta. for the vighatana of above samprapti, yashtimadhu aashchotan is used which have the following properties-1) – snigdha – a snigdha guna of the yashtimadhu is guna volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 73gjra global journal for research analysis opposite to ruksha and is vatashamak. hence, it reduces symptom of rukshata (dryness). 2) madhur– madhur rasa of yashtimadhu, helps in rasa vatashamana as well as pittashaman. along with snigdha of madhur ras is also pitta and vatashamak. hence, it reduces symptom of rukshata (dryness), netradaha (burning sensation) & avil darshana (blurring of vision). 3) sheetayashtimadhu is sheet in virya, which veeryaagain is pittaghna.so it works as dahashamak , raktaprasadan. i.e. it reduces netradaha (burning sensation) & aaraktata (redness). 4) – madhuryashtimadhu is madhur rasatmaka & vipaka the vipaka is also madhur which is also vatapittashamak. hence, it reduces symptom of rukshata (dryness), netradaha (burning sensation) & avil darshana (blurring of vision). 5) from all the above points the doshaghnata yashtimadhu dravyas are vatapittaghna in nature. 6) : chakshushya : the chakshushya prabhava of prabhav jeevaniya gana is well known. so taking into consideration all the rasa, virya, vipaka, guna and prabhav of the ingredients of yashtimadhu eye drops, the principle effect is mainly vatapitta shamak and because of these properties vitiated vata and pitta are pacied. besides this prabhava of jeevaniya gana is chakshushya which is again useful for well being of eyes and benecial in many eye diseases for samprapti vighatana of shushkakshipaak. 7) from the all the above discussion it becomes clear that the treatment is very much effective in samprapti vighatana of shushkakshipaak. conclusion the aim of our study is to evaluate the effect of yashtimadhu eye drop in shushkakshipaak. the results are based in the relief of various symptoms, increase in tear lm break up time test readings and the data is collected in standard performa. both the statistical analysis and percentage of relief is calculated and presented in the chapter of observation and following conclusion is presented on this basis. ÿ the clinical features of shushkakshipaak are closely related to dry eye syndrome. ÿ both the treatment groups i.e. yashtimadhu eye drop and moisol eye drop are equally effective during the period of treatment and statistically both are signicant. except in aaraktata (redness) symptom the control group is more signicant than the trial group. ÿ yashtimadhu eye drop is benecial as its marked relief over symptoms and the ingredients of this preparation are easily available. ÿ in treatment, patients had given tips to avoid causes of shushkakshipaak is very effective. e.g.regular blinking of eye, avoid direct exposure to air conditioners, coolers, hot air, avoid contact lenses, avoid kajal, avoid rubbing of eye , etc. ÿ yashtimadhu eye drop can be considered as a good alternative treatment in dry eye syndrome. ÿ so, considering the results of the study, the use of yashtimadhu eye drop can be recommended as lubricating eye drops. ÿ yashtimadhu eye drop has no adverse reaction observed during the treatment. ÿ in future, this work may be valuable clue and required in this direction with large sample size and larger duration of follow up days to establish the effect of yashtimadhu eye drop in shushkakshipaak. reference th 1. charaksamhita :agnivesh edited by brahmanand tripathi, 4 edn., chauckambha sanskrit series, varanasi, 1996. 2. dravya guna vigyana : a c h a r y a p r i y a v a t s h a r m a , p u b l i s h e d b y chaukhambha bharti academy, varanasi. th3. handbook of ophthalmology :4 ed”, b.m. chatterjee edn by prof. j.s. roy, cbs, publishers & distributor sahadara, delhi 110032. 4. sushruta samhita :sushrut, indited by k-avira dr. ambikadatta shastri, iith edn.1997, choukhamba sanskrit sansthan,varanasi-221001. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 74 x gjra global journal for research analysis introduction intra-abdominal infections have been well recognized throughout the history of medicine and are very commonly encountered in pediatric surgical practice (1). peritonitis, by de�nition, is in�ammation of the peritoneum (2). peritonitis remains a major cause of mortality and morbidity in the pediatric age group, especially in countries like india where a large proportion of the population belongs to the poor socio-economic category and facilities and resources are often lacking in primary and secondary care centers (1). in the west and developed countries, the major causes of peritonitis in newborns are necrotizing enterocolitis (nec) and spontaneous or focal intestinal perforation (fip), both of which are diseases largely affecting a vulnerable group of premature low birth-weight neonates. these conditions have become increasingly common with increasing survival of extremely small, premature newborns in nurseries in developed countries (3, 4). other major causes of peritonitis in newborns include idiopathic or spontaneous gastric perforation, gastrointestinal perforation secondary to neonatal intestinal obstruction, and meconium peritonitis (1, 5). in infants and older children, the majority of cases of childhood peritonitis are due to perforated appendicitis (16) while other causes include trauma (5), meckel's diverticulum (5, 7), postoperative adhesions, and intussusceptions (5). however, in developing countries like india, the causes, epidemiology, and presentation of peritonitis may be quite different (1). survival rates of premature very low birth-weight (vlbw) infants are still not very high, even in tertiary care centers, and they do not constitute a very high percentage of neonates admitted in nurseries. in addition, a very large percentage of the population lives in poor socioeconomic conditions, with very little access to proper sanitation and hygiene. in this scenario, diarrheal diseases and other infections of the gastrointestinal tract are very common, increasing the risk of secondary peritonitis due to perforations of the gastrointestinal tract (1). thus, newborns as well as infants constitute a group of very high-risk vulnerable children for the development of peritonitis. there are very few reports of peritonitis in newborns and infants from asian countries (8-11) and to our knowledge, apart from an earlier study of peritonitis in the pediatric age-group reported from our center (1), no detailed study has been reported from india. materials and methods study type : descriptive observational study study population : newborn (0 days) to 1 year age sample size : minimum of 60 consecutive cases from the start of the study period inclusion criteria : case definition : cases ful�lling the criteria of peritonitis suspected clinically and con�rmed by surgery or by investigations exclusion criteria : patients who have undergone either closed drainage or open surgery at another institution prior to presentation at our center. immunocompromised patients the patients included in the study will be divided into 2 groups (group a) newborns (< 30 day age), and (group b) 1 month to 1 year age. patients from both groups will undergo thorough clinical evaluation. history taking will include antenatal history including the results of any maternal antenatal investigations, and the perinatal history.a thorough clinical examination will be performed. all the study candidates will be subjected to the following investigations: investigations: 1. plain radiographs of the abdomen and chest 2. ultrasound (us) of the abdomen, 3. complete blood counts : total counts, differential count 4. renal function tests [rft] (blood urea, serum creatinine), serum electrolytes, serum calcium management the management protocol will depend on the results of clinical evaluation and the results of the preliminary investigations. the protocol will include initial resuscitation, correction of dehydration and hypovolemia, and antibiotic therapy. initial antibiotic therapy will be empiric surgical management in patients, undergoing surgery, operative �ndings and details of the operative procedure performed was recorded in detail. regular postoperative assessment was performed and the occurrence of any complications recorded in detail. the ultimate outcome was recorded. observations sixty patients in the age-group of newborn (0 days) to 1 year age, diagnosed with peritonitis on the basis of the clinical picture, a study of peritonitis in newborns and infants original research paper dr jitendra grover assistant professor department of surgery j k hospital , bhopal surgery background. to determine the characteristics of peritonitis in newborns and infants in relation to the epidemiology, clinical picture and to study the clinical outcome in newborns and infants admitted with peritonitis methods the patients included in the study were divided into 2 groups (group a) newborns (< 30 day age), and (group b) 1 month to 1 year age. patients from both groups underwent thorough clinical evaluation ,lab. tests and outcome was seen and documented. in patients, undergoing surgery, operative �ndings and details of the operative procedure performed was recorded in detail. regular postoperative assessment was performed and any complications recorded in detail. the ultimate outcome was recorded. results approximately half the nec-pt and nec-ft patients survived (45.46 % and 40%) while as many as 8/ 9 fip patients, of whom 8 were ft, survived (88.9 %). preterm babies with cp had the highest mortality (100 %). conclusion though nec was a major cause of intestinal perforation in neonatal age group but it was signi�cantly higher in incidence in cases of perforation peritonitis in children up to the age of one year .focal intestinal perforation was also a major cause of intestinal perforation but factors causing it were different from that of nec. abstract keywords : necrotizing enterocolitis,diarrhea, neonate dr qutubuddin ali* assistant professor department of surgery j k hospital , bhopal *corresponding author x 49gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 radiological features, intraoperative �ndings and laboratory data, admitted in the department of pediatric surgery form the material for this study. diagnosis group a n=44 (%) group b n=16 (%) necrotizing enterocolitis(nec) 21 (47.7) 4 (25) focal intestinal perforation(fip) 9 (20.45) 5 (31.25) meconium peritonitis(mp) 3 (6.8) primary peritonitis(pp) 1 (6.25) idiopathic gastric perforation(igp) 1 (2.2) 1 (6.25) not operated (no) 3 (6.8) 2 (12.5) total n=44 n=16 table 1 case profile and clinical presentation table 2. presenting symptoms in group a patients. group n (%) abdominal distension vomiting nonpassage of stools diarrhea fever nec pt 11(100) 4(36.36) 1(9.09) − 1(9.09) ft 9(90) 5(50) 5(50) 4(40) 3(30) fip pt 1(100) 1(100) 1(100) − − ft 8(100) 3(37.5) 1(12.5) 1(12.5) mp pt − − − − − ft 2(66.66) 3(100) 1(33.33) − − cp pt 2(100) 2(100) 1(50) − − ft 4(80) 2(40) 1920) igp pt − − − − − ft 1(100) 1(100) 1(100) − − no 3(100) 1(33.33) 2(66.66) − total (n=44) 41(93.18) 22(50) 14(31.81) 4(9.09) 5(11.36) table 3. important clinical signs in group a patients (n=44) group n (%) abdominal distension erythema visible bowel loops abdominal tenderness absent bowel sounds nec pt 11(100) 5(45.45) 3(27.27) 2(18.18) 10(90.90) ft 5(50) 3(30) − 1(10) 5(10) fip pt 1(100) 1(100) − 1(100) 1(100) ft 8(100) 2(25) − 4(50) 7(87.5) mp pt − − − − − ft 2(66.66) − − − 2(66.66) cp pt 2(100) − 1(50) − − ft 4(80) − 1(20) 2(40) igp pt − − − − − ft 1(100) − − 1(100) 1(100) no 3(100) − 3(100) total 37(84.09) 11(25) 4(9.09) 10(22.72) 31(70.45) table 4 overall results of management of group a patients group total number mortality (%) nec pt 11 6(54.54) ft 10 6(60) fip pt 1 0 (0) ft 8 1(12.5) mp pt − − ft 3 1(33.33) cp pt 2 2(100) ft 5 0(0) igp pt − − ft 1 1(100) no 3 3(100) total 44 20(45.45) approximately half the nec-pt and nec-ft patients survived (45.46 % and 40%) while as many as 8/ 9 fip patients, of whom 8 were ft, survived (88.9 %). preterm babies with cp had the highest mortality (100 %). table 5. complications recorded during management of group a patients. group sepsis meningitis resp failure renal failure ivh dic apnoea sudden cariac arrest nec pt 6 1* − 1* 1* 1* − − ft 5 − − − − − − 1 fip pt − − − − − − − − ft 1 − − − − − − − 50 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 mp pt − − − − − − − − ft 1 − − − − − − 1* cp pt 2 − 1* − − − − − ft 1 − − − − − − − igp pt − − − − − − − − ft 1 − − − − − − − no 3 − − − − − − − total 20 1* 1* 1* 1* 1* 1+1* table 6 results of investigations, surgical findings, and outcome in group b patients (n=16) pt .no hb (gm %) platelet count χ 10³ pneumoperitoneum site of perforation gangrene procedure outcome δ 1 < 10 9 yes --− d 2 < 10 400 yes stomach -perf closure d igp 3 < 10 614 yes sigmoid colon -perf closure a fip 4 < 10 23 yes sigmoid colon -perf closure d fip 5 < 10 947 no dehiscence of rectal stump -colostomy a sp 6 >10 492 yes ileum ileum ileostomy a nec 7 <10 342 no -dj-ic laprotomy d pan-nec 8 <10 22 no -dj-ic laprotomy a pan-nec 9 >10 203 yes --laprotomy a pp 10 <10 205 yes --− d 11 <10 208 no ileal stricture leak -ra +ileostomy d sp 12 <10 486 yes descending colon ileocolic intussueption ra a sp 13 >10 22 yes dj-ic laprotomy d pan-nec 14 >10 57 no ileum -perf closure a fip 15 <10 558 yes sigmoid -perf closure a fip 16 <10 89 yes ileum -ra a fip results in 14 cases (31.81 %), the peritoneal �uid did not grow any isolate and was sterile. the most common bacterium isolated was e. coli, in 10(22.72%) of cases .the other bacteria that were isolated were kliebsella sp. in 4 cases (9.09%), coagulase negative staphylococcus in 2 cases (4 .54%), e n te ro co cc i sp. in 3 cases (6 .81%), enterobcteriaceae sp. in 1 case (2.27%), acinetobacter sp. in 2 cases (4.54%) and citrobacter sp. in 1 case (2.27%). in two cases one each in nec-pt and nec-ft group candida sp. was isolated from peritoneal �uid. in 5 cases (31.25 %), peritoneal �uid was sterile and did not grow any isolate. the most common bacterium isolated was e. coli in 4 (25%) of cases .the other bacteria that were isolated were kliebsella sp. in 2 cases (12.5%), enterobcteriaceae sp. in 1 case (6.25%), citrobacter sp. in 1 case (6.25%) and pseudomonas sp in 1 case (6.25%). signi�cantly, coagulase negative staphylococcus, enterococci sp and acinetobacter sp. did not grow in peritoneal �uid of patients from group b. bacteria were isolated from blood of patients with peritonitis except in 17 cases (38.63%) where blood culture was sterile. the most common isolate was e. coli in 7 cases (15.90%).other isolates were kliebsella sp. in 6 cases (13.63%),acinetobacter sp in 4 cases (9.09%), enterococcus sp. in 4 cases (9.09%), coagulative negative staph. sp. in 3 cases (6.81%), staphylococcus aureus in 2 cases (4.54%), staphylococcus haemolyticus in 1 case (2.27%). fungal isolates namely candida were isolated from 3 patients, one each in igp-ft, cp-ft, and in one patient who was not operated. in 7 patients of group b (43.75 %), blood culture did not grow any isolate and was sterile. e. coli and kliebsella sp were isolated in 2 patients each (12.5%), acinetobacter sp in 1 case (6.25%), enterobacter sp. in 1 cases (6.25%), coagulative negative staph. sp. in 1 cases (6.25%), and staphylococcus aureus in 1 case (6.25%). staphylococcus haemolyticus and enterococcus sp were not isolated in any patient belonging to group b. statistical analysis the data of the present study were fed into the computer and after its proper validation, checking for error, coding and decoding were compiled and analysed with the help of spss 11.5 software for windows. appropriate univariate and bivariate analysis and anova (analysis of variance) for more than two means were carried out 2 using t-test and � test were calculated and tested. all means are expressed as mean + standard deviation. the critical values for the signi�cance of the results were considered at 0.05 levels. statistical analysis was done using independent t-test to analyze relation of weight at presentation, duration of symptoms, hemoglobin level at presentation and history of diarrhea with that of mortality individually. none of the relations were found to be signi�cant individually. binary logistic regression was used to analyze cumulative relation of above mentioned factors with mortality. discussion the patients were broadly classi�ed according to the age at presentation and were divided into two groups: group a: < 1month age (0 to 30 days, n= 44 cases, 73.33 %), and group b: 1 month1year age (16 cases, 36.36%). patients were categorized on the basis of operative �ndings into broad groups, namely necrotizing enterocolitis (nec) [n=25, 41.66%], focal intestinal perforation (fip) [n=14, 23.33%], meconium peritonitis (mp) [n=3, 5%], complicated peritonitis (cp) [n=10, 16.66%], and idiopathic gastric perforation (igp) [n=2, 3.33 group a patients among the clinical signs, abdominal distension was the most common sign across all subgroups of patients and was seen in 84.09 % of cases followed by absent bowel sounds in 70.45 % of cases. the least common sign was visible bowel loops, seen in only 9.09 % of cases. abdominal wall erythema was seen in 8 out of 21(38.09 %) cases of nec while similar �nding was seen in 3 out of 9(33.33%) cases of fip. the hemoglobin level in cases of peritonitis varied from 5.6 to 22.4 g/dl with mean ± sd of 15.15± 4.35. of the 44 cases, 4 had a hemoglobin value less than 10 mg/dl at presentation and all of these patients were in the nec group. platelet count varied from 13 x 51gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 to 496 × 10³/ cu mm with mean ± sd of 176.27± 137.52. of the total 44 cases 16 (36.36%) platelet count less than 100 ×10³/cu mm at presentation. of the cases with thrombocytopenia at presentation, 11 out of 16 (68.75 %) were in the nec group and 3 out of 16 (18.75 %) were in the fip group. the values of total leukocyte count varied from 1.7 to 39 × 10³/ cu mm with a mean ± sd of 9.80± 7.73 ×10³ /cu mm .ten patients had leucopenia at presentation out of which 6 were in the nec group. operative findings forty-one of the 44 patients of group a underwent surgical exploration as part of the management. the most common site of bowel perforation was the ileum in 18 patients (40.90%) followed by the jejunum in 5 patients (11.36 %). the transverse colon and the sigmoid colon were the next common sites of bowel perforation with 4 patients (9.09 %) each. ileum was the most common small bowel involved in nec in 11 of the 21 patients (52.38%) (figure 7) followed by the colon in 6 patients (28.6 %; transverse colon-3, descending colon-1, and sigmoid colon-2), and the jejunum in 2 patients (9.5 %). in patients with fip, the sites of perforation were jejunum in 1 patient and the ileum in 2 patients. in as many as 5 of the 11 patients with fip (45.4 %) who underwent surgery, the perforation was in the colon (ascending, transverse, and descending colon-1 each, and sigmoid colon-2). one 13-day old baby was operated for a perforated appendix with peritonitis . the most common associated condition along with peritonitis in group a patients was ileal atresia seen in 3 patients , followed by jejunal atresia in 2 patients.the same patient had ileal atresia with malrotation .of the 3 cases of mp, one patient had giant cystic meconium peritonitis (gcmp) (case no-27), while one patient each had mp with ileal atresia (case no-44) and jejunal atresia (case no18).the two cases with extensive intestinal gangrenous involvement of the bowel were in the nec-ft group. all these patients had gangrene of small bowel from dj to ic junction . history of top feed was present in both these cases of pan-nec (nec totalis). operative procedures for group a patients forty-one of the 44 patients underwent surgical exploration . twenty-six patients (59.1 %) underwent primary exploration and of these, 25 cases (96.15%) had weight at presentation more than 1.5 kg. eighteen cases (40.9 %) had peritoneal drainage (pd) performed, and of these 18 cases, 4 patients (22.22%) had weight at presentation less than 1.5 kg. three cases (16.66 %) had peritoneal drainage alone as these patients were considered too unstable for laparotomy. fifteen cases (83.33%) underwent subsequent laparotomy after 1-8 days (mean= 3.6 days). in 26 patients (59.1 % of the total), primary surgery was performed, while in 15 patients (34.1 %), a formal laparotomy was performed after a period of initial stabilization with insertion of a tube drain into the peritoneal cavity and other supportive measures. of the 25 patients who underwent primary surgery 9 (36%) patients died, while in patients who had a peritoneal drainage (pd) prior to de�nitive surgery 8 out of 15(53.33%) patients died. bowel resection with primary anastomosis (ra) was performed in 16 of the 41 patients (39 %). these included 5 patients with nec, 3 with fip, 2 patients with mp, and 6 patients with cp. primary closure of a perforation was performed in 4 patients, while as many as 20 patients (48.8 %) underwent a diverting stoma (ileostomy in 11, a colostomy in 9) after resection of ischemic and/ or gangrenous bowel. in fip-pt group, 1 patient had both perforation closure and ileostomy done (case no-13). in this group, one patient had an ileal perforation with a gastrointestinal stromal tumor (gist) (case no14). in cp-ft group ra with ladd's procedure was done in two cases (case no-11&21). in one case of mp with poor general condition, the �rst procedure was only drain placement and, subsequently, surgical excision of the meconium cyst with a proximal ileostomy was performed (case no-27). in both patients with pan-nec (nectotalis), peritoneal lavage with placement of a drain was performed without any resection of bowel or construction of a stoma. comparison of mortality with different surgical procedures showed that out of the 16 patients who had ra, 7(43.75%) died, while 2 out 4 (50%) who had simple closure of the perforation(s) died, 6 out 11(54.54%) who underwent ileostomy died, 1 out of 9(11.11%) of patients who had a colostomy died. approximately half the nec-pt and nec-ft patients survived (45.46 % and 40%) while as many as 8/ 9 fip patients, of whom 8 were ft, survived (88.9 %). preterm babies with cp had the highest mortality (100 %).the commonest complications recorded were sepsis in 20/ 44 patients (45.5 %) while one patient each developed meningitis, renal shutdown, intraventricular hemoorhage (ivh), and disseminated intravascular coagulopathy (dic). group b patients (age 1 month to 1 year) group b consisted of 16 patients (26.66% of total patients). the mean age at presentation was 106.87 days. the male to female ratio was 4.3: 1. all the sixteen patients belonged to low socioeconomic status with mean weight± sd at presentation of 3.64± 1.03 kg. signi�cant feeding history of top feed was noted in 9 patients (56.25%).a history of diarrhea was present in 10 patients (62.5%), the duration of diarrhea before presentation ranging from 3 days to, in one patient, recurrent diarrhea for 360 days. vomiting was seen in 2 patients (12.5%), and a history of unexplained fever was present in 4 patients (25%). one patient had dermatitis enteropathica , seen usually in chronic malnourished patients. one patient had history of administration of concoction (ghutti) for the treatment of diarrhea. investigations revealed mean± sd hemoglobin at presentation of 9.2± 1.89 mg/dl. value of less than ten was seen in 12 patients (75%). free intraperitoneal gas was seen in 11 patients (68.75%) (figure 11).final diagnosis was made after laprotomy and patients were classi�ed into broad groups of necrotizing enterocolitis (nec) 4 patients (25%), focal intestinal perforation (fip) in 5 patients (31.25%), idiopathic gastric perforation (igp) in one patient (6.25%), primary peritonitis (pp) in one patient (6.25%). an important �nding was secondary peritonitis (sp) in 3 patients (18.75%) and in these patients, peritonitis occurred as a complication of surgery performed for another condition within a week prior to development of peritonitis. in one patient sp followed dehiscence of a rectal stump closed after surgery for hirschsprung's disease, and in 2 patients, sp resulted from an anastomotic leak after repair of an ileal stricture [1 patient] and an ileocolic anastomosis for intussusceptions. two patients (12.5%) could not undergo formal laparotomy due to poor general condition and were managed by insertion only of a peritoneal drain (pd). out of 4 patients with the diagnosis of nec, 3 had pan-nec (nec totalis) with gangrenous small bowel from dj to ic junction (figure 12 & 13). in the fip group, 3 patients had perforation in the sigmoid colon (figure 14), and 2 patients in the ileum. one patient had primary peritonitis (pp) in whom although there was in�ammation of the bowel, no perforation in the bowel was identi�ed. the patient with igp had a large perforation in the posterior wall of the stomach (figure 15).of the total 16 patients,14 were operated (87.5%) and 5 patients died (pan-nec-2, fip-1, igp-1, and 1 patient with sp. comparative analysis of mean weight at presentation and mortality in various groups was done using independent “t” test after equal variance assumed by levene's test. the p value was 0.5 which was > .05 hence the association of mean weight at presentation and mortality was not signi�cant.comparative analysis of mean duration of symptoms and mortality in various groups was done using independent “t” test after equal variance assumed by levene's test. the p value was 0.9 which was > .05 hence the association of duration symptoms and mortality was not signi�cant. comparative analysis of gestation age and mortality in various groups was done using independent “t” test after equal variance assumed by levene's test p value was 0.02 which was < .05 hence the association of gestation age and mortality was signi�cant. 52 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 logistic regression was used for cumulative comparison of gestation age, weight at presentation and duration of symptoms with mortality in various groups and base value were weight: 0.501, gestation age: -0.203 and duration of symptoms:-0.080 signi�cant results are considered when a positive value is derived .weight at presentation showed a positive value in regression and hence can be regarded as signi�cant. the constant value was 6.3 which was >1 which showed that the association was not nulli�ed but other factors were also in�uencing mortality apart from those mentioned in the comparative analysis. conclution though nec was a major cause of intestinal perforation in neonatal age group but it was signi�cantly higher in incidence in cases of perforation peritonitis in children up to the age of one year .focal intestinal perforation was also a major cause of intestinal perforation but factors causing it were different from that of nec. references 1. chadha r. peritonitis in children, in gupta dk, sharma s (eds): pediatric surgery diagnosis and management, chapter 48. new delhi, jaypee brothers medical publishers 2008: 544-563. 2. wittman dh, walker ap, condon re. peritonitis and intraabdominal infection, in schwartz s, shires g, spencer f (eds): principles of surgery (ed 6). new york, ny, mcgraw-hill 1991: 1449-1483. 3. boston ve. necrotising enterocolitis and localized intestinal perforation: different diseases or ends of a spectrum of pathology. pediatr surg int 2006; 22: 477-484. 4. st. peter sd, ostlie dj. necrotizing enterocolitis, in hocomb iii gw, murphy jp (eds): ashcraft’s pediatric surgery (ed 5), philadelphia, saunders elsevier chap 33. 2010: 461-476. 5. grosfeld jl, molinari f, chaet m, engum sa, west kw, rescorla fj, tres scherer iii lr gastrointestinal perforation and peritonitis in infants and children: experience with 179 cases over 10 years. surgery 1996; 120: 650-656. 6. solomkin js, wittman dw, west ma, barie ps. intraabdominal infections, in schwartz si, tom shires g, spencer fc, daly jm, galloway ac (eds): principles of surgery (ed 7), chap 32. new york, ny, mc-graw hill 1999: 1515-1550. 7. hwang h, murphy jj, gow kw, magee jf, bekhit e, jamieson d. are localized intestinal perforations distinct from necrotizing enterocolitis ? j pediatr surg 2003; 38: 763-767. 8. cass dl, brandt ml, patel dl, nuchtern jg, minifee pk, wesson de. peritoneal drainage as de�nitive treatment for neonates with isolated intestinal perforation. j pediatr surg 2000; 35: 1531-1536. 9. tam al, camberos a, applebaum h. surgical decision making in necrotizing enterocolitis and focal intestinal perforation: predictive value of radiologic �ndings. j pediatr surg 2002; 37: 1688-1691 10. camberos a, patel k, applebaum h. laparotomy in very small premature infants with necrotizing enterocolitis or focal intestinal perforation: postoperative outcome. j pediatr surg 2002; 37: 1692-1695. 10. lessin ms, schwartz dl, wesselhoeft cw jr. multiple spontaneous small bowel anastomosis in premature infants with multisegmental necrotizing enterocolitis. j pediatr surg 2000; 35: 170-172 11. patra s, vij m, chirla dk, kumar n, samal sc. unsuspected invasive neonatal gastrointestinal mucormycosis: a clinicopathological study of six cases from a tertiary care hospital. journal of the indian association of pediatric surgeons. 2012; 17: 153-156 12. snyder cl, gittes gk, murphy jp, sharp rj, ashcraft kw, amoury ra. survival after necrotizing enterocolitis in infants weighing less than 1,000 grams: 25 years experience at a single institution. j pediatr surg 1997; 32: 434-437 13. ehlrich pf, sato tt, short bl, hartman ge. outcome of perforated necrotizing enterocolitis in the very low birth weight neonate may be independent of the type of surgical treatment. am surg 2001; 67: 752-756 14. kumar v, chattopadhyay a, bhatt n, rao plng. spontaneous biliary perforation presenting as gastric outlet obstruction. ind j pediatr 2001; 68: 361-363 x 53gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 introduction merkel cell carcinoma is a rare neuroendocrine malignancy arising in the skin. majority of tumor present on face, head extremities and trunk and secondary sites are skin lymph nodes, liver, lung and brain. it appears as esh colored bluish red nodule .sun exposure and having weak immune system effect the risk of merkel cel carcinoma. human polyoma virus is thought to be etiologic agent in signicant proportion. most often develops in older people case71yr old male patient presented with swelling over scalp region and with itching, crust formation. mri brain reveals moderately large diffusely inltrating soft tissue lesion involving the scalp on right side extending from the level of coronal suture anteriorly for approx. 5.0 cm. no evidence of calvarial erosion seen. patient underwent wide excision scalp and split thickness skin skin graft. hpe was suggestive of merkel cell tumor of scalp skin. patient had not taken any further treatment and again after 6month similar lesion developed over the adjoining margins with swelling over the bilateral neck region . his ct brain and neck revealed recurrent mitotic nmodules involving left para median scalp associated with metastatic lympha den op athy in the tyrunk patient again underwent wide excision with rnd with left sond with right parotid lobectomy. hpe reveals recurrence of scalp skin. ihc-cytokeratin ck-20 synapt op hysin chromogranin a (focal) c-kit. patient received imrt to neck 2gy of 30 fraction and mould brachytherapy to scalp 34gy in 10 fraction. patient is on follow up without any signs and symptom. discussionmerkel cell are derived from neural creast and function as slowly adapting type 1 mechanoreceptors. its a rare neuroendocrine tumor it presents as painless skin nodule with defuse margin with intact epidermis . regional lymph node are seen ij approx. 30% of patients.dd includes leukemia amelanotic melanoma metastatic carcinoma pyogenic granulomas bcc. conclussion merkel cell carcinoma is exceedingly rare but possible tumor and can be successfully managed with excision and radiotherapy. references 1. https://europepmc.org/article/med/29072302 2. https://cancerres.aacrjournals.org/content/77/13_supplement/3532 3. h t tps : / / jamane twork .com/ journa ls / jamadermato logy /ar t i c le abstract/1881921 4. https://www.sciencedirect.com/science/article/pii/s0959804916325266 a rare case presentation :merkel cell carcinoma of scalp with secondary neck. original research paper dr ramesh arya hod radiation oncology and superintendent government cancer hospital and mgm medical college indore x 7gjra global journal for research analysis oncology keywords : merkel cell, polyoma virus, imrt, brachytherapy volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. vipin kumar dubey* pg resident government cancer hospital and mgm medical college indore *corresponding author 72.dr.suganya.s online.cdr introduction prosthetic rehabilitation of the defective parts in the oral and maxillofacial region have developed extensively in the recent past and have brought about signicant improvement in the quality of life of the patients. newer concepts in the eld of prosthetics have extended beyond the boundaries of maxillofacial region to rehabilitate even the other parts of the body. hand prosthesis is one such arena, where various studies and attempts are being made to make the prosthesis not only esthetic but also to make it functional and dynamic. although the esthetic demands are being met by the use of silicones, making the prosthesis functional is still a challenge. this design puts forth the concept of hinge joints in ngers alike the natural anatomy of the ngers and hence the prosthesis is made dynamic. the basic prosthetic principles are combined with electronics which will improve the efciency of the prosthesis, making it functional. electromyographic impulses from the individual (volunteer) is synchronized to the prosthetic hand and functional movements are brought about by microcontrollers and sensomotors. therefore, this article brings out an idea to combine electronics and mechanics that will pave way in the evolution of new age functional hand prosthesis. materials and methods basic structural design of the hand was obtained by cad ®cam designing of the ada (open bionics ) prototype. the design was converted into stl format to proceed with 3d designing and the entire structure was milled from polyurethane bone blocks as it had the properties of enhanced exibility that could allow for adequate motions and is biocompatible. the prosthetic hand design comprises of individual nger componentsand hollow segments to place the motors [figure 1,2,3,4,5,6,7]. figure 1 3d design of hand base figure 2 3d design of nger components electromyographic synchronization in the fabrication of dynamic 3d printed hand prosthesisan original study original research paper noorul rizwana. a post graduate;department of prosthodontics; srm dental college; ramapuram;chennai-600089. x 3gjra global journal for research analysis prosthodontics aim: to fabricate a dynamic hand prosthesis using simple sensomotors and programming it using electromyographic synchronization to achieve functional movements at minimal cost. materials and methods: the primary design of the prosthesis was done digitally and it was simulated using 3-d printing and milled with light weight polyurethane material. for incorporating the dynamic movements into the prosthesis, motors and electromotors (ex sensomotors) which worked based on the hex code programming were used. these additives allowed free movements and functional movements in the prosthesis. using electromyography (emg) healthier neuromuscular coordination was synchronized from a volunteer to the prosthesis. electromyography worked based on the recording of muscle amplitude in microamperes with two sensors. one sensor transmitted the actual amplitude levels of healthier muscular movements while the other sensor intensied or deranged the value based on the muscle threshold of the individual. the amplitude values were recorded in c code programming format, which is human interfacing language. this was then compiled into the assembly programming for the ease of evaluation. results: based on the design, functional and dynamic movements were obtained in the hand prosthesis, using the synchronized emg signals, which improved the efciency of rehabilitation. conclusion: functionally active hand prosthesis at minimal cost will pave way for rehabilitating patients and improving their quality of life. abstract keywords : dynamic prosthesis, sensomotors, electromyography, hex code programming. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra vivek shankar.p post graduate; department of prosthodontics; srm dental college; ramapuram;chennai-600089. arun kumar.cs post graduate; department of prosthodontics; srm dental college; ramapuram; chennai-600089. suganya srinivasan* reader; department of prosthodontics; srm dental college; ramapuram; chennai-600089. *corresponding author murugesan krishnan professor; department of prosthodontics; srm dental college; ramapuram; chennai-600089. peter john reader; department of prosthodontics; srm dental college; ramapuram; chennai-600089. brintha jei department of prosthodontics; srm dental college;ramapuram;chennai600089. 4 x gjra global journal for research analysis figure 3 3d design of forearm components figure 4 3d design of motor segments figure 5 3d design of elbow components figure 6 3d design of palm components figure 7 3d design of thread wheels the nger segments were attached with the rest of the components using nylon bers that allowed free hinge movements, which in turn were connected to the sensomotors. three major sensomotors, one controlling the thumb motions, one controlling the index and middle nger movements and the other controlling the ring and little nger movements were setup. the dimensions of the sensomotor controlling the thumb were of size 22.8 x 12.2 x 28.5mm withvoltage of 4.8v to 6v dc weighting 13.4 grams working at speed of 0.1 sec/60degrees (at 4.8v), 0.08 sec/60 degrees (at 6.0v). the two other sensomotors controlling the rest four ngers weigh about 1.31 oz (37.0 g) with dimensions of length:1.57 in (39.9 mm), width:0.79 in (20.1 mm) and height:1.42 in (36.1 mm).these sensomotors work at speed of 4.8v for 0.23 sec/60° and 6.0v for 0.19 sec/60° with torque of 4.8v for 44.00 oz-in (3.17 kg-cm) and 6.0v for 57.00 oz-in (4.10 kg-cm) [figure 8,9]. figure 8 fore arm components figure 9 printed prosthesis the entire components were then assembled and connected to the motherboard (arduino uno microcontroller atmega328®). the motherboardconsisted of ampliers that would send the positive and negative signals during muscular contraction resulting in functional movements of the prosthesis. three electrodes were attached to the distal end of the arm near the biceps brachii muscleof the operator, which would sense the ow of impulses within the muscles and transmit it to the motherboard to amplify and cause movements of the prosthesis [figure 10,11]. figure 10 electrodes figure 11 assembled components during relaxation of the muscles there was continuous ow of neural impulses through the muscle bers.electromyographic synchronization works by amplifying the pooled impulses during muscular contraction that would in turn cause closure of the prosthesis. initially, an arbitrary muscle threshold value was xed based on theindividual (volunteer) strength and metabolic index in arduino software. these threshold values behaved as xed units above which there will be relaxation of the prosthesis on muscle contraction and vice versa. repeated muscle contraction and relaxation resulted in opening and closing of the prosthesis also enhancing the ability to hold the objects [figure 12]. figure 12 emg synchronization results the fabricated hand prosthesis was connected to the vounteer volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra using an emg (electromyography) cord and based on the muscle contraction it was found that the prosthesis was dynamic enough to produce exion and extension of the phalanges. the functional hand was able to hold objects like mobile phone, cups, steel rods that weight upto 1000 grams. discussion technology is one area, which keeps traversing through time, leading to various developments which have made human life easier.amputees, generally do not get acquired with the latest and technologically advanced prosthetic upper limb, as they are extremely expensive. in a developing country like india where road trafc accidents, public violence are unavoidable, amputation in such a scenario becomes essential. however, majority of the patients are not provided with functional upper limb prosthesis as the costs are on the higher side.various authors have put forward different concepts in providing (1)movements to the hand prosthesis. imamura et al hand's design which was developed using gaea drive in its joint driving mechanism. this hand can envelope and grasp an object mechanically, it can be used widely in factories where parts of different shapes and sizes must be handled. (2)o'toole and mcgrath designed the mechanical hand which had ease of assembly and ease of replacement of sma wires which offers more comfortable, lighter weight and quieter solution. this work can be implemented for actuation of the thumb to complete a ve ngered bio-mimetic articial hand. (3)kasim et al. introduced a new hybrid mechanism which integrates a miniature motor driven actuation, sma actuated mechanism and a passive mechanical linkage. it has highly improved the actuation and tactile sensing methods. the force generated by the actuator has been tested and is satisfactory (4)for prosthetic applications.zhang et al. made a prosthetic hand controlled by a multiprocessor controller based on fpga/dsp and its control system is composed of a nger control system and palm control system. experiments showed that users were able to successfully operate the device in the hierarchical control strategies and that the grasp success increased with more interactive control. (5)takeda h et al developed a prosthetic arm with pneumatic prosthetic hand and tendon-driven wrist using a wire drive and two small motors comprised of small pneumatic actuators, they found that the prosthetic hand was safe and exible.since the arm had a tendon-driven wrist to expand its motion space it was able to perform many operations. kuiken (6)ta el al used targeted muscle reinnervation for improved myoelectric prosthesis control in a bilateral shoulder disarticulation amputee where four independently controlled nerve-muscle units were the musculocutaneous nerve was anastomosed to the upper pectoralis major; the median nerve was transferred to the middle pectoralis major region; the radial nerve was anastomosed to the lower pectoralis major region; and the ulnar nerve was transferred to the pectoralis minor muscle. after ve months of healing myoelectric prosthesis was attached which produced better movements. (7)weir r et al developed a new multifunctional prosthetic arm and hand systems in which they have used 3 articulations and 2 motors with implantable myoelctric sensors attached to (8)peripheral nerves. carrozza mc et al did a nger with two degree of freedom for a biomechatronic articial hand with simple grippers having one or two degrees of freedom with modular design and control embedder to enhance the grasping abilities. (9)folgheraiter mi, gini g developed a human-like reex control for an articial hand based on dynamic articial neurons to simulate the neurons acting in the human reex control. the controller had a hierarchical structure. at the lowest level the receptors converted the analogical signal into a neural impulsive signal appropriate to govern the reex control neurons. after which, the articial motoneurons set the actuators inner pressure to control the nger joint position and moment producing dynamic movements .the developed hand was very exible and efcient for all kind of joints present in (10)the humanoid hand. edin bb et al developed a bio-inspired sensorization of a biomechatronic robot hand for the graspand-lift task using a contact sensor and a sensitive low-noise three-axial force sensor. this design of hand prothesis is made by using simple sensomotors connected to a motherboard using nylon bres and coupled by electromyographic synchronization. the emg impulses obtained from the volunteer was connected to the motherboard which decoded the impulses and caused movements of the ngers by means of the nylon bres. this prototype, has shown that it could perform grasping, rotating and lifting various objects that can be seen from the environment, when connecting to an individual and obtaining the myographic signals. this will not only mask the defect of the patient but also improve their psychological satisfaction by helping the user perform day-to-day activities to a certain extent. prosthetic replacement by using this hand prototype will signicantly improve the quality of life of the patients. conclusion based on the results we concluded that the hand prototype which we designed using 3d printing and synchronized to the individual's hand using electromyographic synchronization, was able to achieve functional movements like grasping and lifting objects with independent exion and extension of ngers. our results suggest that it is possible to make a dynamic functional hand prosthesis using electromyographic synchronization at an affordable cost which will enable the patients to make use of it, when compared to the commercially available robotic hand prosthesis which is very expensive. references 1. saikia a, mazumdar s, sahai n, paul s, bhatia d, verma s, rohilla pk. recent advancements in prosthetic hand technology. j med eng technol. 2016 jul;40(5):255-64. 2. o’toole kt, mcgrath mm. mechanical design and theoretical analysis of a four ngered prosthetic hand incorporating embedded sma bundle actuators. int j med health pharmaceut biomed eng. 2007;1:7. 3. kasim aa, aqilah a, jaffar a, et al. development ofuitm robotic prosthetic hand. in: proceedings ofworld academy of science, engineering andtechnology. no. 73. world academy ofscience, engineering and technology (waset).p. 1054. 4. zhang t, fan s, zhao j, et al. design and control of amultisensory ve-nger prosthetic hand. intelligentcontrol and automation (wcica), 2014 11th worldcongress, shenyang, china, pp. 3327–3332. 5. takeda h, tsujiuchi n, koizumi t, kan h, hirano m,nakamura y. development of prosthetic arm with pneumaticprosthetic hand and tendon-driven wrist. conf proc ieee engmed biol soc 2009;2009:5048e51. 6. kuiken ta, dumanian ga, lipschutz rd, miller la,stubbleeld ka. the use of targeted muscle reinnervation forimproved myoelectric prosthesis control in a bi lateralshoulder disart iculat ion amputee. prosthetorthot int 2004;28:245e53. 7. weir r, mitchell m, clark s, puchhammer g, kelley k,haslinger m, et al. newmultifunctional prosthetic arm andhand systems. conf proc ieee eng med biol soc2007;2007:4359e60. 8. carrozza mc, massa b, dario p, zecca m, micera s,pastacaldi p. a two dof nger for a biomechatronic articialhand. technol health care 2002;10:77e89. 9. folgheraiter m, gini g. human-like reex control for anarticial hand. biosystems 2004;76:65e74. 10. edin bb, ascari l, beccai l, roccella s, cabibihan jj,carrozza mc. bioinspired sensorization of a biomechatronicrobot hand for the grasp-and-lift task. brain res bull 2008;75:785e95. x 5gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction mental health is a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.mental health include the emotional, psychological and social well-being of the people. the mental health is very essential at every stage of life from the childhood to adulthood. presently mental health problems are common like any other diseases. the treatment received by persons with mental health problem may differ. it is important to know that what works for one person may not work for another. globally, on an average one in ve adults (17.6%) experienced a common mental disorder and 29.2% across their lifetime.national mental health survey of india reported that the overall prevalence of mental morbidity was 13.7% lifetime and 10.6% current mental morbidity. medication adherence is a challenge for mental health patients in every stage of their treatment. failure to adhere to medication can have a major impact on the course of illness and treatment outcomes, including increasing the risk of relapse and re-hospitalization. a study was conducted on psychotropic medication refusal: reasons and patients' perception at a secure forensic psychiatric treatment centre. two groups were selected for this study according to their ethnic background. the ndings on knowledge regarding medications among rst group was poor (24%), average (35%), good (18%) and very good (24%); while in the second group the knowledge level was poor (25%), average (31%), good (13%) and very good (31%). the reasons for medication refusal among all patients were inconvenience (34%), side-effects (22%), ineffectiveness of medication (20%) and illness (16%). non-compliance to medication is a grave and pervasive problem in the eld of mental health. compared with adherent clients, the non-adherent clients have a greater risk of symptom exacerbation and re hospitalization. the main reason is lack of awareness regarding the medication and other treatment modalities.it is necessary to impart adequate awareness regarding the medication adherence for mentally ill clients as well as for the relatives, it will reduce the rate of relapse of symptoms and rehospitalisation. materials and methods a descriptive research design using a quantitative research approach was used for this study. formal permission was obtained from institutional ethical committee. data were collected over a period of four weeks and 200 subjects satisfying the inclusion criteria were selected by simple random sampling in the follow up mental health clinics in thiruvananthapuram district. the purpose of the study was well explained to the study subjects and informed written consent was obtained. the investigator maintained good interpersonal relat ionship wi th the subjects and condentiality was maintained for each subjects. a structured questionnaire was used to collect the data. it consists of 3 parts; part 1: socio-demographic data, part 2: clinical data and part 3: knowledge regarding drug compliance results 1. distribution of mentally ill clients based on socio demographic and clinical variables ÿ in the present study, 26.5% of the mentally ill clients were in the age group of 40-49 years, majority (57%) were females, 38.5% of the subjects were hindu, 51.5% of the mentally ill clients were married, 84% were living in rural area, 75.5% of the clients belonged to nuclear family, 23.5% were having education up to primary level and 35.5% were unemployed ÿ considering the clinical variables in the present study 65.5% were diagnosed with mood disorders and 24.5% with schizophrenia. the duration of mental illness of 37.5% were more than 5 years, 30.5% were hospitalized for one to two times, 29.5% clients were taking mood stabilizers, major comorbidity (17%) found was diabetes mellitus, 59% of the mentally ill clients reported that they are not taking medication regularly and the major reason elicited was forgetfulness (52%) and feeling of wellness (27%), 73.5% clients were attending follow up clinic regularly while 26.5% not attending regularly and the major reasons shown among them was difculty in travelling (45%), no one to accompany (41.5%) and lack of family support (13.5%). 2. distribution of mentally ill client based on knowledge regarding drug compliance ÿ above gure depicts that 47% of clients were having average knowledge regarding drug compliance, 37.5% of clients were having poor knowledge and 15.5% of clients were having good knowledge regarding drug compliance. knowledge regarding drug compliance among mentally ill clients original research paper ms.shijina s ms. shijina s, lecturer, dept. of mental health nursing, sree gokulam nursing college, venjaramoodu. nursing a descriptive study dealt with knowledge regarding drug compliance among mentally ill clients attending follow up mental health clinics in thiruvananthapuram district. the objectives were to assess the knowledge regarding drug compliance among mentally ill clients, determine the association of knowledge regarding drug compliance with socio demographic and clinical variables. the result showed that 47%, 37.5% and 15.5% of clients were having average, poor and good knowledge regarding drug compliance respectively. the study infer that mental health nurse should create awareness regarding medication adherence among public and foster good practices inorder to follow all rights of medication intake, thus helping a mentally ill client to lead a productive normal life. abstract keywords : drug compliance; mentally ill client; knowledge. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra prof. mini g* prof mini g, hod, dept. of community health nursing, ananthapuri hospitals and research institute, chackai. * corresponding author 102 x gjra global journal for research analysis 3. association of knowledge regarding drug compliance with socio demographic and clinical variables ÿ signicant association was observed between knowledge regarding drug compliance and socio demographic 2 2 variables like age (χ = 22.783, p =0.001), gender (χ = 26.371, p =0.041), educational status (χ = 41.511, p = 2 0.001), occupational status (χ = 22.271, p = 0.004) and 2 income (χ = 18.113, p = 0.001). ÿ signicant association was found between knowledge regarding drug compliance and clinical variables such as 2frequency of hospitalization(χ =9.900,p=0.042), regular 2medication intake (χ =14.924, p=0.001) and regular follow 2 up (χ =9.918, p=0.007). no signicant association was observed between knowledge regarding drug compliance 2and duration of mental illness (χ =8.177, p=0.225) and 2 diagnosis (χ =7.449, p=0.682). discussion the present study reported that 47% of clients were having average knowledge regarding drug compliance, 37.5% having poor knowledge and 15.5% of clients were having good knowledge regarding drug compliance. similar ndings were observed in another study on psychotropic medication refusal: reasons and patients' perception, showed that 34% of mentally ill clients having average knowledge, 26% were had very good knowledge 16% had good knowledge and 24% were having poor knowledge. in the present study 65.5% were diagnosed with mood disorders and 24.5% with schizophrenia. the duration of mental illness of 37.5% were more than 5 years, 30.5% were hospitalized for one to two times, 29.5% clients were taking mood stabilizers, major comorbidity (17%) found was diabetes mellitus, 59% of the mentally ill clients reported that they are not taking medication regularly and the major reason elicited was forgetfulness (52%) and feeling of wellness (27%), 73.5% clients were attending follow up clinic regularly while 26.5% not attending regularly and the major reasons shown among them was difculty in travelling (45%), no one to accompany (41.5%) and lack of family support (13.5%). similar ndings were observed in a study to identify the reasons of non-compliance to psychiatric treatment, where 15.89% of clients were having schizophrenia, 2.92% were diagnosed with schizoaffective disorder and 50.5% had mood disorder. several study reports showed the notable reasons for non-compliance and they were feelings of wellness (26%), paranoia to medication (22%), lack of insight to the illness (14%), medication side effects (10% 22.17%), hopelessness of cure and poor support (8%), nancial problems (6%), no improvement (4%), too much of medication (2%), unawareness of the benets of treatment (58.15%), no affordability of drugs (32.63%), no awareness given by the doctor (01.25%) and unfriendly attitude of doctors (0.83%), seeking alternative therapy(18.1%), unavailability of drugs (18.1%), forgetfulness (10.6%) and being busy (8.6%). conclusion the present study was intended to assess the knowledge regarding drug compliance among mentally ill clients. the ndings concluded that majority of the mentally ill clients had lack of knowledge towards medications. the study was able to identify the existing trends and the major reasons for medication non adherence. the associated factors which inuence the knowledge regarding drug compliance was also elicited as part of the study. the study lays foremost importance to all psychiatric personnel especially mental health nurse working in the community as well as clinical setting to create awareness regarding the importance of medication adherence among mentally ill client and their care givers, create a positive attitude towards it and foster good practices inorder to follow all rights of medication intake and lead a fruitful life ahead. references 1. timothy j, legg c. mental health: denition, common disorders, and early signs. medical news today. 2018 [cited 16 may 2018]. available from: https://www.medicalnewstoday.com/articles/154543.php 2. harris d. medication compliance in mental health. software advice. 2018 [cited 21 may 2018]. available from: https://www.softwareadvice.com/ resources/?s=medication+compliance+in+mental+health 3. balon r. managing compliance [internet]. psychiatry times. 2002 [cited 20 may 2018] . avai lable f rom: h t tp : / /www.psychiat r ic t imes .com /schizophrenia/managing-compliance 4. roy r, jahan m, kumari s, kumar chakraborty p. reasons for drug noncompliance of psychiatric patients: a centre based study. volume 31. journal of the indian academy of applied psychology. medind.nic.in. 2005. [cited march 2017]. available from: http://medind.nic.in/jak/t05/i1/ jakt05i1p24.pdf 5. endale g a, abdela e, allele b, cheru e, amogne b. rate of nonadherence to antipsychotic medications and factors leading to nonadherence among psychiatric patients in gondar university hospital, northwest ethiopia. advances in psychiatry [internet]. 2014 [cited 16 may 2018]; article id 4 7 5 8 1 2 : 5 p a g e s . av a i l a b l e f r o m : h t t p s : / / w w w. h i n d a w i . c o m / journals/apsy/2014/475812 6. pareek b, kalia r. factors affecting non-compliance to psychotropic drugs of patients with psychosis as perceived by their family members attending the psychiatric outpatient department at selected hospital, mangalore. nursing and midwifery research journal. 2013;vol-9(2):56-62. 7. murthy r s. national mental health survey of india 2015–2016. indian j psychiatry [serial online] 2017 [cited 2018 may 30];59:21-6. available from: http://www.indianjpsychiatry.org/text.asp?2017/59/1/21/204430 8. kerala mental health report: 11.36 percent people in the state of unsound mind [internet]. the new indian express. 2018 [cited 21 may 2018]. available from: http://www.newindianexpress.com/states/kerala/2017/nov/ 05/keralamental-health-report-1136-percent-people-in-the-state-of-morunsoundmind-1692356.html volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 103gjra global journal for research analysis introduction obstetric patients admitted to an intensive care unit (icu) present a challenge to an intensivist because of normal physiological changes associated with pregnancy and puerperium, the specic medical diseases peculiar to pregnancy and the need to take care of both the mother and the foetus. most common causes of admission to an icu for obstetric patients are eclampsia, severe preeclampsia, haemorrhage, congenital and valvular heart disease, septic abortions, severe anemia, cardiomyopathy and non-obstetric [1]sepsis . aims and objectives to assess indication of abg in critically ill obstetric patients: 1. identify the indications for blood gas sampling. 2. role of arterial blood gas values and their implications to patient management. 3. ease of abg in clinical practice. 4. whether abg analysis alters diagnosis or management of optimizes quality of patient care. 5. arterial blood gas changes during the course of treatment/management of critically ill female patient materials and methods the present study was be conducted in the department of obstetrics and gynaecology in association of department of medicine of maharani laxmi bai medical college, jhansi on 300 critically ill admitted patients. selection criteria: a critically ill obstetric patient is the one who, because of normal or abnormal pregnancy, delivery and puerperium, or because of effects of systemic disease, develops complic ations threatening her life for which she needed intensive monitoring, therapy or life support system. inclusion criteria: critically ill obstetric patients who need intensive care and management. ÿ patient with low general condition and hemodynamically unstable. ÿ pregnancy specic conditions – haemorrhages, septicemia, hypertensive disorders, amniotic uid embolism, aspiration syndrome. ÿ medical diseases that may worsen during pregnancy – severe anemia, pulmonary edema, embolism/ards, hepatic dysfunction. exclusion criteria: ÿ patients with known case of heart disease ÿ patients with known case of asthma or any other respiratory disease like copd ÿ preexisting kidney disease, nephritic disease, ckd, nephrolithiasis. ÿ hiv infected patients. after taking detailed clinical history, clinical examination of the patients and relevant investigations, patients was assign a case number, and their name, age, sex, occupation socioeconomic status was be noted. a detailed antenatal and postnatal history was also be noted. investigations: routine examination: ÿ hb: ÿ tlc: ÿ dlc: ÿ p/c: ÿ rbc: contraindications to abg sampling: ÿ local infection ÿ distorted anatomy ÿ presence of arterio-venous stulas ÿ peripheral vascular disease of the limb ÿ severe coagulopathy procedure for arterial blood gas (abg) radial artery sampling: ÿ perform a modied allen test to ensure adequate collateral circulation from the ulnar artery. ÿ position the patient's hand with the wrist extended 20—30 degrees. greater extension of the wrist may impede arterial ow. ÿ identify the radial artery by palpating the pulse; choose a site where the pulse is prominent. ÿ clean the sampling site with an alcohol wipe. ÿ expel the heparin from the syringe. ÿ steady your hand on the patient's hand,; then insert the needle at 45 degrees, bevel facing up. ÿ be sure to insert the needle slowly to minimise the risk of arterial spasm. ÿ when the needle is in the artery, a ash of pulsatile blood will appear in the barrel of the needle. most abg syringes will then ll under arterial pressure. ÿ obtain at least 3 ml of blood before withdrawing precautions after sampling: ÿ once adequate blood has been obtained, remove the needle and apply rm, direct pressure to the sample site for at least 5 minutes (and until bleeding has ceased). dispose of all sharps and contaminated materials arterial blood gas monitoring in critically ill antenatal and postnatal patients original research paper dr. sanjaya sharma professor and head department of obstetrics and gynaecology of m.l.b. medical college, jhansi x 55gjra global journal for research analysis obstetrics & gynaecology arterial blood gas determinations (abgs) play an important role in diagnosing derangements in acidbase balance, oxygenation, and ventilation. frequent assessment is necessary in the management of critically ill antenatal and postnatal patients. this article reviews the technologic evolution of modern blood gas analysis and the clinical application of monitoring hydrogen ion content (ph), blood oxygen tension (po2), and carbon dioxide tension (pco2) acid base balance in the body. abstract keywords : critically ill parturient, haemodynamic, intensive care, obstetrics, pregnancy, sepsis, ventilation volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. srishti* junior resident, department of obstetrics and gynaecology of m.l.b. medical college, jhansi *corresponding author 56 x gjra global journal for research analysis appropriately. ÿ ensure no air bubbles are present in the sample, as they may compromise results. any sample with more than very ne bubbles should be discarded. the sample should be analysed promptly: if the transit time is likely to exceed 10 minutes, then the syringe should be stored on crushed ice. abg sampling was done at 0 hrs of admission and 24 hrs of admission in critically ill obstetric patients. then changes in arterial blood gas was observed according to the intervention given. outcome of patient as recovery or mortality was observed and compared. result: table 1: distribution of cases according to antepartum/ postpartum period table 2: distribution of cases according to diagnosis and its outcome out of total mortality, 15.3% of mortality occur due to obstetric hemorrhages, 11.4% of death occurred due to pregnancy induced hypertension including eclampsia, severe preeclampsia, impending eclampsia and hellp syndrome. 61.5% of mortality was due to non obstetric indirect cause. table 3: abg at 0 hr and its outcome out of total admitted patients, 56% of them were improved by doing conservative management and monitoring in icu without ventilatory support ,whereas 110(44% ) of them went on mechanical ventilation in which 33.6% of total patients survived during the course of treatment and successfully discharged after weaning from ventilator ,whereas 10.4% of total patients died while on mechanical ventilation in which most common acid base disorder was decompensated metabolic acidosis ( 38.4%)diagnosed at the time of admission. out of 250 patients,103 patients diagnosed with compensated metabolic acidosis improved successfully without ventilatory support while 28 of them required ventilation and 23% of total mortality was attributed by compensated metabolic acidosis group of patients. 30.7% of total mortality was seen in patients diagnosed with respiratory alkalosis abg analysis was done at '0' hour of admission and repeated after 24 hours while giving treatment and the results were compared between survivors and non survivors. the results were found statistically signicant (p< 0.001). non survivors showed a lower mean ph, bicarbonate, and a higher lactate and base excess than survivors. the mean ph changes from '0' to '24' hrs were found (7.04-7.14) on lower side as compared to survivors i.e7.25 at '0' hr to 7.34 at '24' hours. mean bicarbonate concentration was 10.25 -11.07 in non survivors as compared to survivors i.e 13.99 -17.14. higher incidence of lactic acidosis among non survivors with higher mean value and increase in lactate level in non survivors (from 7.13 to 7.32).whereas in survivors mean lactate level is much lower as compared to non survivor at '0' hr i.e 3.22 and decrease in mean of 1.95 when repeated at 24 hr in survivors .thus indicating lactate may be a factor useful in prognostication discussion: critical care is a bonade part of obstetric practice. a critically ill obstetric patient is the one who, because of normal or abnormal pregnancy, delivery and puerperium ,or because of effects of systemic disease ,develops complications threatening her life for which she needed intensive monitoring, therapy or life support system. care of critically ill pregnant patients presents a unique challenge as the assessment, monitoring and the treatment must take into account both maternal and fetal well being. there are different modalities and investigation for monit oring the critically ill patients in intensive care unit. one of the important investigation is arterial blood gas analysis. the process of analysis and monitoring of arterial blood gas is an essential part of diagnosing and managing the oxygen status and acid base balance of the high risk patients as well as in the care of critically ill patients in icu. our study is a prospective, observational and cohort study volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra parameters number of cases percentage antenatal 168 67.2% postnatal 82 32.8% total 250 100% diagnosis no. of cases improved without ventilation (n=140) recover on ventilation (n=84) mortality on ventilation (n=26) obstetrics 156 eclampsia (antepartum/ postpartum) 47 30 15 2 (7.6%) severe preeclampsia 15 10 4 1 (3.8%) obstetric hemorrhage 56 36 16 4 (15.3%) major postpartum hemorrhage 38 26 9 3 (11.5%) non obstetrics 94 severe anaemia related complications 37 23 11 3 (1.5%) septicemia 24 8 14 2 (7.6%) hepatic dysfunction/ hepatic encephalopathy 15 3 9 3 (11.5%) pulmonary embolism 3 0 1 2 (7.6%) ards/pulmonary oedema 7 0 3 4 (15.3%) other 8 4 2 2 (7.6%) acid base disorders improved conservatively ventilator support survivors death compensated metabolic acidosis 103 22 06 decompensated metabolic acidosis 32 54 10 metabolic alkalosis 4 2 2 respiratory alkalosis 2 6 8 total (%) 140 (56%) 84 (33.6%) 26 (10.4) acid base parameters survivors non-survivors p value mean sd mean sd ph (0 hr) 7.256 0.798 7.047 0.161 <0.001 ph (24 hr) 7.345 0.063 7.147 0.110 <0.001 paco2 (0 hr) 28.635 8.034 38.554 16.657 0.677 paco2 (24 hr) 30.026 7.318 27.775 7.213 <0.602 hco3 (0 hr) 13.993 3.144 10.254 2.554 <0.001 hco3 (24 hr) 17.144 3.635 11.075 5.710 <0.001 lactate (0 hr) 3.223 2.909 7.136 3.078 <0.001 lactate (0 hr) 1.953 1.675 7.325 5.099 0.003 be (0 hr) -11.773 5.257 -7.736 3.539 <0.001 be (24 hr) -8.887 4.21 -18.25 6.628 0.95 conducted in department of obstetrics and gynaecology in maharani laxmi bai medical college, jhansi. it is aimed to identify indications of abg sampling in obstetric patients, changes in arterial blood gas values during the course of treatment and its relation with the outcome of patients in form of survivors or mortality. obstetrics admission rate to maternal icu was 0.9% and 3.4% [2] [3]in a study done by mabie et al and lewinsohn et al respectively. age is one of important prognostic factors. in our study maximum number of patients were in age group of 25-29 years (35.6%) with second most common age group is of 21-24 yrs (33.6%). the mean age distribution of age in studies done by [4]patidar et al was 56% for the age group of 21-30 yrs and [5]14.7% for those above 30 years and that done by rochet et al was 72% for the age group of 21-30 years. these studies thus show that majority of the obstetrics patients requiring critical care in the group 21 -30 years which is comparable to ours study. in our study ,majority of patients belonged to lower socioeconomic status i.e 50.4% ,whereas 34.4% were of lower middle group and only 9.2% patients belonged to upper lower socio-economic status .only 4.8% of critically ill female patients were of upper middle class, whereas only 1.2% of them were of upper socio economic group. in our study, maximum number of critically ill patients are antepartum i.e 67.2%, whereas 32.8% of patients were of [6]postpartum. karnad et al also reported the majority rate of 21.6% in both antepartum & postpartum group. in our study, maximum no. of obstetrics admission occurred during antepartum period with maximum admission in 3rd trimester (34.4%) followed by postpartum period (32.8%). only 17% admission in 1st and 2nd trimester. these concepts of gestational age highlights the maximum occurrence of complications in 3rd trimester and postpartum period and thus the importance of close suspension of patients during these periods .distribution of gestational age (antepartum, [6]postpartum) in previous studies done by karnad et al [7](46.6%,53.3%), basket et al (18%,82%) and el soth et al. (62%,38%) was comparable to our studies. in our study, maximum number of admissions were either [8]multipara or multigravida. mentel et al and bhattacharya et [9]al showed highest mortality in women with there or more parity .thus the results in these studies are consistent with our observations of critically ill patients in multiparous group. 73.6% of the critically ill patients were referred from the primary health care centers and district hospitals of periphery showed inadequate and improper management of obstetric complications leading to high rate of morbidity and mortality in rural areas. our primary health facilities should be staffed with trained midwives supervised by obstetricians & secondary care hospitals in the state should have obstetricians and facilities for providing emergency services. out of total admitted patients, only 32.8 % patients were booked mothers while rest of 67.2% were unbooked i.e they have no anc registration ,no previous antenatal check ups and investigations. the study showed positive correlation between unbooked mothers and increase risks of maternal adverse outcomes. educating the communities at the gross roots level about the benets of receiving antenatal care and supervised delivery by skilled attendants will have a signicant impact on improving pregnancy outcomes in our locals. [7]basket et al. in studied the obstetrics patients requiring icu admission over period of 14 yrs. the study concluded that the main indications for the maternal transfer to icu are hypertensive disorders, hemorrhages, and sepsis along with medical disorders. one study conducted at parkland hospital showed that 1.7% of almost 22,000 women delivered required admission to icu and the most common indications compelling transfer are hypertensive disorders (40%) ,obstetrical hemorrhage (15%) and pulmonary insufc iency(9%). in our study 62.4% of critically ill patients admitted due to direct obstetric causes, the most common being hypertensive disorders (24.8%) including antepartum, postpartum eclampsia, severe and impending eclampsia and related complications, most common hellp syndromes. second most common indication is obstetric haemorrhages (22.4%) which includes antepartum haemorrheges, rupture uterus, ruptured ectopic pregnancy, uterine perforation, incomplete abortions etc. 15.2% are admitted due to major blood loss in post partum period (pph) . non obstetrics or indirect cause includes septicemia, severe anaemia related complications ,pulmonary insufciency due to embolism or ards and other causes. thus the present study is comparable [7]with various previous studies like baskett et al ., mahutte et [10] [11] [6]al ,.el-solh et al and karnad et al which have shown pih, maternal haemorrhages and medical disorders of pregnancy were the most common indications requiring maternal transfer to icu. the need for mechanical ventilation evaluated in the study. [7]baskett et al showed 45% of the critically ill obstetric patients required mechanical ventilation .tang et al. and lapinsky et [12]al in their studies showed mechanical ventilation was required in 12-55% of the obstetric patients admitted to an icu. .44% of the total number of patients require support of articial mechanical ventilation which is comparable to various studies. [3] [13] [14]lewinsohn et al ,tang et al . , and sriram et al reported mortality rates of critically ill obstetric patients admitted to icu in the range of 0% to 36% thus coinciding with mortality found in the present study (10.4%). direct and indirect causes of [9]maternal mortality in studies done by bhattacharya et al was [15]83.6% & 16.4%, by patel et al was 63.7 % and 36.3% and by sharma et al. was 56.3% and 437% respectively. the present study showed 34.6%. mortality due to direct obstetric causes. [5] [9] [7]rochat et al , bhattacharya et al and baskett et al . reported mortality of 18-20 % due to obstetric hemorrhages and 27-30% due to sepsis and pulmonary insufciencies. we found 15.3% mortality due to obstetric hemorrhage and 11.7% due to major pph while 11.4% due to pih. most common acid base disorder diagnosed by '0' hour abg sampling at the time of admission was metabolic acido sis(80.4%) in which 38.4% of them are diagnosed with decompensated metabolic acidosis found in patients diagnosed with hypertensive disorders, hypovolemic shock due to hemorrhages, septicaemia and shock. only 3.2% of total patients belong to metabolic alkalosis group in patients of hyperemesis gravidarum and severe diarrhoea. 6.4% of total patients belongs to respiratory alkalosis occur in patients with ards, pulmonary oedema, pulmonary embolism etc. out of total admitted patiens,56% of them were improved by doing conservative management and monitoring in icu without ventilatory support, whereas 110 (44%) of them went on mechanical ventilation in which 33.6% of total patients survived during the course of treatment and successfully discharged after weaning from ventilator ,whereas 10.4% of total patients died while on mechanical ventilation in which most common acid base disorder was decompensated metabolic acidosis (38.4%) diagnosed at the time of admission. out of 250 patients, 103 patients diagnosed with compensated metabolic acidosis improved successfully x 57gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra without ventilatory support while 28 of them required venti lation and 23% of total mortality was attributed by compensated metabolic acidosis group of patients. 30.7% of total mortality was seen in patients diagnosed with respiratory alkalosis. abg analysis was done at '0' hour of admission and repeated after 24 hours while giving treatment and the results were compared between survivors and non survivors. the results were found statistically signicant (p< 0.001). non survivors showed a lower mean ph, bicarbonate, and a higher lactate and base excess than survivors. the mean ph changes from '0' to '24' hrs were found (7.04-7.14) on lower side as compared to survivors i.e7.25 at '0' hr to 7.34 at '24' hours. mean bicarbonate concentration was 10.25 11.07 in non survivors as compared to survivors i.e 13.99 -17.14. our study showed higher incidence of lactic acidosis among non survivors with higher mean value and increase in lactate level in non survivors (from 7.13 to 7.32). whereas in survivors mean lactate level is much lower as compared to non survivor at '0' hr i.e 3.22 and decrease in mean of 1.95 when repeated at 24 hr in survivors. as compared to study done by gnnerson et [16]al out of 851 patents, 64% had metabolic acidosis and 45% had mortality. the mortality rate was highest for lactic acidosis (56%) among all causes. also when compared with albright (201) usa studies showed lactic acidosis as a prognostic indicator for increase in maternal morbidity, admission to icu (p<0.01) or acute monitoring unit (p<0.01) and longer hospital stay (p<0.01). thus indicating lactate may be a factor useful in prognostication. lactate level can serve as one of the earliest markers of damage that has been caused at tissue level. lactate accumulates as a result of anaerobic metabolism at tissue level in presence of inadequate oxygen delivery. common conditions leading to lactic acidosis in er are hypoxemia due to any reason, severe anaemia or shock. higher lactate level at the time of admission with shock were found associated with increase duration of intensive care unit stay and mortality. paladino l et [17]al in their interesting work added lactate and base decient to traditional vital signs in patients with trauma. lactate levels are considered to be an indirect marker of hemorrhage as bleeding leads to decreased tissue perfusion. they found that adding these parameters identies major injuries with a sensitivity of 76.4% than vital signs alone that were able to recognize major injuries with40.9% sensitivity. lactate level are an important marker in patients with sepsis and septic shock. our results indicates lactate level and serial estimation both are prognostically important in predicting outcome of patients. effect of interventions like inotropic supports and blood transfusion on outcome of patients and found statistically signicant. out of 26 mortality, 76.9% patients required inotropic supports 38.4% of total mortality required blood transfusion more than 5 units. conclusions with present study, we concluded that abg analysis is an important prognostic tool while monitoring critically ill obstetric patients in intensive care unit. patients with lower ph, higher lactate or lower bicarbonates at presentation are considered as high risk patients and should be shifted to icu for intensive monitoring to avoid maternal mortality. regular monitoring of abg, parameter and obsessing the changes in parameter can help providing early warning of deterioration and can judge the effectiveness of therapeutic intervention, thus an predict the good and poor outcome and duration of stay in intensive care unit references: 1. trikha a1, singh p.the critically ill obstetric patient recent concepts.indian j anaesth. 2010 sep;54(5):421-7. doi: 10.4103/0019-5049.71041. 2. mabie wc, sibai bm. treatment in an obstetric intensive care unit. am j obstet gynecol. 1990;162:1–4. 3. lewinsohn g, herman a, leonov y, klinowski e. critically ill obstetrical patients: outcome and predictability. crit care med. 1994;22:1412–4. 4. patidar arvind kumar • kumar h. s. • walke rahul v. • hirapara pushpendra h. • jakhar shankar lal • bardia m. r. evaluation of the response of concurrent high dose rate intracavitary brachytherapy with external beam radiotherapy in management of early stage carcinoma cervix.the journal of obstetrics and gynecology of india (september-october 2012) 62(5):562–565 5. rochat rw, koonin lm, atrash hk, jewett jf. maternal mortality in the united states: report from the maternal mortality collaborative. obstet gynecol. 1988;72:91–7. 6. karnad dr, lapsia v, krishnan a, salvi vs. prognostic factors in obstetric patients admitted to an indian intensive care unit. crit care med. 2004;32:1294–9. 7. baskett tc, sternadel j. maternal intensive care and near-miss mortality in obstetrics. br j obstet gynecol. 1998;105:981–4. 8. mantel gd, buchmann e, rees h, pattinson rc. severe acute maternal morbidity: a pilot study of denition for a nearmiss. br j obstet gynecol. 1998;105:985–90. 9. bhattacharya s. a study on maternal mortality in silchar medical college and hospital. j obstet gynecol india. 2001;51:67–70. 10. mahutte ng, murphy-kaulbeck l, le q, solomon j, benjamin a, boyd me. obstetric admissions to the intensive care unit. obstet gynecol. 1999;94:263–6. 11. el-solh aa, grant bj. a comparison of severity of illness scoring systems for critically ill obstetric patients. chest. 1996;110:1299–304. 12. lapinsky se, kruczynski k, seaward gr, farine d, grossman rf. critical care management of the obstetric patients. can j anaesth. 1997;44:325–9. 13. tang lc, kwok ac, wang ay, lee yy, sun ko, so ap, et al. critical care in obstetrical patients.an eight year review. chin med j (engl) 1997;110:936–41. 14. sriram s, robertson ms. critically ill obstetric patients in australia: a retrospective audit of 8 years’ experience in a tertiary intensive care unit. crit care resusc. 2008;10:124. 15. patel da, gangopadhay s, vaishnav sb. maternal mortality at karamsadthe only rural medical college in gujarat. j obstet gynecol india. 2001;51:63–6. 16. kyle j gunnerson, melissa saul, shui he & john a kellum.lactate versus nonlactate metabolic acidosis: a retrospective outcome evaluation of critically ill patients.critical care volume 10, article number: r22 (2006). 17. paladino l, sinert r, wallace d, anderson t, yadav k, zehtabchi s. the utility of base decit and arterial lactate in differentiating major from minor injury in trauma patients with normal vital signs. resuscitation. 2008 jun;77(3):363-8. doi: 10.1016/j.resuscitation.2008.01.022. epub 2008 mar 25. pubmed pmid: 18367305. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 58 x gjra global journal for research analysis aim of the study: to assess the frequency of etiological causes of pancytopenia in north coastal andhra pradesh. objective of the study : 1. to study the clinical prole of a patient with pancytopenia. 2. to study the incidence of underlying etiology of the pancytopenia by investigating ÿ clinical features ÿ haemogram parameters ÿ serum ferritin, vitamin b12 levels ÿ bone marrow aspiration and biopsy materials and methods study design this is a prospective descriptive study done in department of general medicine king george hospital from july 2017 to june 2019. all the patients with pancytopenia seen in haemogram will be evaluated for the cause of pancytopenia and clinical history, required tests available in our institution will be done as per proforma. sample size total of 260 cases of pancytopenia as seen in haemogram are studied. of which 148 cases had bone marrow aspiration. inclusion criteria 1) patients aged >= 16 years of both sexes diagnosed with pancytopenia on haemogram 2) haemoglobin levels less than 10 g/dl 9 3) total leukocyte count less than 3.5 x 10 /l 9 4) platelet count less than 1.0x10 /l exclusion criteria 1) patients aged 15 years and less 2) diagnosed case of pancytopenia 3) patients who received chemotherapy or radiotherapy 4) patients with recent viral illness – dengue fever observations and results demographics of the study population age and sex: the age of the study population ranged from 16 years to 85 years with a mean age of 39.8 years and median age of 37 years. majority of the population belonged to age group of 20 – 30 years table 2 figure 4 the sex distribution of study population is 75 males and 73 females. there is no signicant difference in the distribution of disease in either population.   table 3 figure 5 etiological distribution of the 148 cases of pancytopenia which underwent bone marrow examination, 129 cases had a denitive diagnosis. most of the cases of pancytopenia are due to megaloblastic anaemia followed by aplastic anaemia. other causes included, malaria, hiv, tuberculosis, leukemias, hypersplenism, myelodysplasia and myelobrosis. a single case of hlh is reported. table 4 to assess the frequency of etiological causes of pancytopenia in north coastal andhra pradesh. original research paper dr malla phanindra final year post graduate, junior resident, department of general medicine, king george hospital , andhra medical college ,visakhapatnam, ap, india. general medicine keywords : dr gorijavolu mamatha* final year post graduate, junior resident , department of general medicine, king george hospital , andhra medical college , visakhapatnam, ap, india. *corresponding author dr lakshmi sowjanya assistant professor , department of general medicine , king george hospital , andhra medical college, visakhapatnam, ap,india. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra age group no. of cases <20 18 20-30 35 31-40 32 41-50 25 51-60 26 61-70 8 71-80 3 >80 1 gender no. of cases percentage male 75 51 female 73 49 diagnosis no. of cases aml 9 aplastic anaemia 16 66 x gjra global journal for research analysis figure 6 of the megaloblastic anaemia, b12 deciency is the comm onest and combined folate and b12 decency is the next common cause. table 5 figure 7 mean age of presentation is in the middle aged population. oldest is seen in aml and youngest is in hiv individuals. table 6 distribution of gender in various causes of pancytopenia seen in the study table 7 figure 8 figure 9 figure 10 clinical analysis:symptoms:most of the patients had symptoms like exertional fatigue, petechial rash, bleeding manifestations, pedal edema, fever, frequent respiratory and skin infections and bone pains. most common symptom being exertional fatigue which is seen in 83.1 % of the cases. next most common symptom is fever which was seen in 49%. table 8 signs:on thorough clinical examination, most commonly seen signs with diagnostic importance are pallor, icterus, lymphad enopathy, pedal edema, hepatomegaly, splenomegaly, bony tenderness, hyper pigmented knuckles, melena. pallor is the most common sign elicited. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra megaloblastic anaemia 65 hiv 6 hlh 1 hypersplenism 13 malaria 8 mds 5 myelobrosis 2 others 19 tuberculosis 4 grand total 148 megaloblastic anaemia no. of cases b12 deciency 43 combined b12 and folate deciency 15 folate deciency 7 diagnosis mean age of presentation aml 50 aplastic anaemia 42 megaloblastic anaemia 39 hiv 32 hypersplenism 38 malaria 37.5 mds 44 myelobrosis 45 others 32.5 tuberculosis 40.75 diagnosis % male %female aml 55.5 44.5 aplastic anaemia 43.75 56.25 hiv 50 50 hypersplenism 46 54 malaria 50 50 mds 40 60 megaloblastic anaemia 55.4 44.6 myelobrosis 50 50 others 47.3 52.7 tuberculosis 25 75 symptom number of patients percentage fatigue 123 83.1 fever 73 49.3 bleeding 35 23.6 purpuric rash 25 16.8 bone pain 13 8.7 frequent infections 43 29 x 67gjra global journal for research analysis figure 11 figure 12 hematological and laboratory findings for every case of pancytopenia, a haemogram with peripheral smear along with hiv, smear for malarial parasite and bone marrow aspiration is done. in patients with dry tap, bone marrow biopsy is done to conrm the cause. table 11 table 12 table 13 most of the peripheral smear ndings of rbc were dimorphic followed by microcytic rbc. table 14 bone marrow cellularity showed hypercellular marrow in most of the aspiration ndings. the next common is normocellular marrow. 5 of the cases had drytap for which bone marrow biopsy was done as part of further evaluation. table 15 volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra sign number of patients percentage pallor 146 98.6 lymphadenopathy 24 16.2 pedal edema 19 12.8 hepatomegaly 18 12.1 splenomegaly 35 23.6 table 9 bone pains were seen in 44.4% of aml patients and 40% of myelodysplastic syndrome which was less than 10% in other causes. bleeding manifestations were most commonly seen in patients with hypersplenism. recurrent skin and respiratory tract infections were more common in aplastic anaemia, myelodysplastic syndrome and hiv. icterus was most commonly associated with malaria. it was seen in 62.5% of cases. lymphadenopathy was frequently seen in tuberculosis and hiv. symptoms aplastic anaemia megaloblastic anaemia aml hiv hypersplenism malaria mds myelobrosis others tb total 9 16 65 6 13 8 5 2 20 4 fatigue 100 81.25 83 100 70 87.5 40 50 90 100 table 10 fever 66.6 43.75 38.5 100 38.5 87.5 60 50 53 75 bleeding 22.2 25 23 16.6 38.5 25 0 0 21 50 purpuric rash 11.1 18.75 17 33.3 38.5 12.5 0 0 10.5 0 bone pains 44.4 6.25 4.6 0 7.6 0 40 0 0 0 infections 22.2 43.75 29 100 23 0 40 0 15.7 25 pallor 100 100 98.5 100 92.3 100 100 100 100 100 icterus 33.3 6.25 23 33.3 46 62.5 20 0 0 25 lymphadenopathy 22.2 18.75 10.7 50 15 0 0 0 15.8 100 pedal edema 33.3 6.25 10.7 16.6 15 12.5 0 0 15.8 25 hepatomegaly 11 0 13.8 0 38.5 25 0 0 0 0 splenomegaly 22.2 6.25 18.5 0 100 87.5 0 0 0 0 diagnosis hb tc platelets mcv mch mchc aml 3.9 2566 26667 90.25 29.7 31.7 aplastic anaemia 4.725 2173 32063 95.42 31.12 32.7 megaloblastic anaemia 4.5 2438 43100 102.7 29.5 31 hiv 5.25 2572 44500 80 27.8 33.2 hypersplenism 4.9 2431 42154 81 24 27.6 malaria 4.78 1910 42375 92 27.5 30.5 mds 4.76 2128 40200 90.2 29.1 28.7 myelobrosis 4.1 1850 26000 99 32.65 32.7 others 5.2 2714 42579 78 23.6 29 tuberculosis 4.95 2355 54000 80 25.7 29.5 diagnosis b12 folate ferritin aml 432 18 60 aplastic anaemia 307 18 50 megaloblastic anaemia 145 8.9 37 hiv 672 7.1 64.7 hypersplenism 736 14.3 37.46 malaria 690 14.5 56.25 mds 449 10.4 53.6 myelobrosis 287 19 93 others 420 11.7 52.9 tuberculosis 340 10.75 22.75 megaloblastic anaemia mcv b12 levels folate levels ferritin b12 deciency 102 110 13 42 folate deciency 110 458 0.63 34 combine b12 and folate deciency 100.5 100 0.97 25 peripheral smear nding no. of cases normocytic 20 microcytic 41 macrocytic 16 dimorphic 71 bone marrow cellularity no. of cases normocellular 37 68 x gjra global journal for research analysis figure 13 discussion frequency of etiologies of pancytopenia varied in different population groups. this can be attributed to multiple factors such as diagnostic criteria, geographical distribution, follow up, genetic factors, infectious diseases in that particular area and exposure to drugs. denition of pancytopenia itself is very vague as the cut-off values varied in various institutions. in our study male and female distribution is more or less similar in frequency and etiological causes. total of 148 cases (n=148) were studied. all the cases t the criteria taken into the study. haemoglobin<10g%, wbc total count<4000/cu-mm, platelets < 100,000/cu-mm. haemogram, peripheral smear, bone marrow examination, b12 levels, folate levels, smear for malarial parasite, hiv, ultrasound examination were done apart from thorough history taking and clinical examination. most common age of presentation is the third decade (35 cases) which correlated with other studies like arvind jain et 38 39 40al , khunger et al and khodke et al .male female ratio in the present study is 1.03 which is concordant with some of the indian studies. table 16 in our study most common cause for pancytopenia is megaloblastic anaemia with 65 cases (43.9%) the next common causes were aplastic anaemia with 16 cases (10.8%) and hypersplenism with 13 cases (8.7%). 19 cases (12.83%) in our study couldn't be attributed to any cause due to lack of further diagnostic modalities. megaloblastic anaemia is the most common cause of pancytopenia in our study. it is seen in 43.9% of the cases. this is in concordance with studies of khodke et al, khunger et al, tilak et al, premkumar m et al, and gayathri et al. whereas in studies of varma et al, kumar et al, santra et al aplastic anaemia is the most common cause.zhou rh et al. stated that biopsy specimen will be more informative than an aspiration cytology regarding marrow cellularity, inltration, residual hemopoietic cells, qualitative and quantitative abnormalities of megakaryocytes showing myelodysplastic features in aml cases. table 17 most common symptom seen in present study is fatigue (83.1%), followed by fever(49.3%). most common sign is pallor(98.6%) followed by splenomegaly(23.6%). tejaswini et al52 had fever as the most common symptom which is seen in 30.66%of cases whereas sithwath hyat et al study showed fatigue (97.64%) as the most common symptom and pallor(97.64%) as the most common sign which correlated with the present study. gupta et al had fever as the most common symptom which was seen in 64.28% fatigue was seen in only 34.28%. table 18 hypocellular 16 hypercellular 90 dry tap 5 study male:female ratio kumar et al41 2.1 khunger et al39 1.2 santra g et al42 1.5 gayathri b n et al43 1.2 vandana et al44 0.83 present study 1.03 study country no. of cases most common cause nd 2 most common cause international agranulocytosis and aplastic anaemia study 48group israel &europe 1987 319 aplastic anaemia (52.7%) mds(4.5%) 49keisu and ost israel and europe 1990 100 neoplastic disease, radiation (32%) aplastic anaemia(1 9% 40khodke et al . india 2000 50 megaloblastic anaemia (44%) aplastic anaemia (14) 41kumar et al india 2001 166 aplastic anaemia (29.51) megalobla stic anaemia (23%) 39khunger et al india 2002 megaloblastic anaemia (72%) aplastic anaemia(2 3%) 62premkumar india 2008 140 megaloblastic anaemia (60.7%) leukemia (9%) aplastic anaemia (8%) 42santra et al india 2010 111 aplastic anaemia (22%) hypersple nism (11%) 43gayatri et al india 2011 104 megaloblastic anaemia (71.04) aplastic anaemia(1 8.26) rashmi kushwaha et 50al india 2012 60 aplastic anaemia (38.3) megalobla stic anamia (21.7%) 51sweta et al india 2014 100 megaloblastic anaemia (66%) aplastic anaemia (18%) 52tejaswini et al india 2015 75 megaloblastic anaemia (56%) aplastic anaemia (13.3%) present study india 2018 148 megaloblastic anaemia (43.7%) aplastic anaemia (10.8%) clinical feature tejaswini 52et al sitwat hayt et 53al gupta et 54al khodke 40et al present study fatigue 28% 97.64% 34.28% 83.1% fever 30.66% 52.94% 64.28% 49.3% bleeding 8% 50.58% 34.28% 28% 23.6% bone pains 44.7% 41.42% 2% 8.7% splenomegaly 37.33% 55.29% 40% 23.6% pallor 25.3% 97.64% 100% 98.6% icterus 2.66% 8.23% 23% volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 69gjra global journal for research analysis haemoglobin percentage varied from 2 to 8g%. lowest haemoglobin was recorded in a case of megaloblastic anaemia. total leukocyte count was in a range of 500 to 3800 /cu-mm with maximum cases falling in the range of 1500 – 2500 /cu-mm. platelet counts ranged from 10,000 to 1 lakh /cumm with most number of cases between 20,000 and 30,000 / cu-mm. the predominant peripheral smear picture was dimorphic anaemia seen in 47.97% of cases and followed by microcytic picture in 27.7%. 13.5% cases had normocytic picture and 10.8% had macrocytic picture in peripheral smear. gupta et al found dimorphic anaemia in 35.7% cases, normocytic picture in 34% cases, microcytic in 28.57% and macrocytic in 1.43%. most commonly seen bone marrow aspiration picture in the present study is hypercellularity with megaloblastic picture. gupta et al had hypocelularity as the most common nding. swapna kumari et al had hyper cellularity as the most common nding in the study. table 19 megaloblastic anaemia is the most common cause (43.9%) of pancytopenia observed in the present study. megaloblastic anaemia is predominantly due to b12 deciency. combined b12 and folate deciency is the next common cause. of the 65 cases 43 cases can be attributed to b12 deciency alone. this accounts for 66% of megaloblastic anaemia cases. 7 cases are due to folate deciency alone, which is 11%. 15 cases (23%) are due to combined deciency of folate and b12. the diagnosis of cause for megaloblastic anaemia is made by sending serum b12 levels and folate levels. b12 levels <200ng/ml and folate levels<5ng/ml are taken as deciency. table 20 next common cause for pancytopenia in the present study is aplastic anaemia. pathogenesis of aplastic anaemia is not well understood. autoimmunity targeting the stem cells is thought to be the cause. this aberrant immune response is thought to be due to environmental factors, drugs, infections and endogenous antigens. in the present study it is reported in 16 cases accounting 10.8%. this correlated with other indian studies by tejaswini et al, gayathri et al, khunger et al, khodke et al and swetha et al. only few indian studies had aplastic anaemia as the most common cause for pancytopenia. this is evidenced in studies by kumar et al, 42rashmi kushwaha et al, and santra et al . international 48 agranulocytosis and aplastic anaemia study group reported aplastic anaemia(52.7%) as the most common cause of pancytopenia. this study was done in europe and israel. further cause for aplastic anaemia cannot be investigated in the present study due to lack of resources. acute leukemias were seen in 9 cases (6%) whereas in 39 khunger et al reported an incidence of 5%. prem kumar et al. (9.2%) , bn gayathri et al. (3.85%) , compared to kumar et al.(12%). in our study all the cases were due to aml. one of the cases we got dry tap for which a bone marrow biopsy had to be done to diagnose. hypersplenism excluding malaria is seen in 13 cases which is 8.7 % of the cases. peripheral pooling and destruction of the cells by enlarged spleen caused pancytopenia. causes can be sepsis, chronic liver disease, infectious causes etc. the cause for hypersplenism is not included in the study. hypersplenism is the most common cause of pancytopenia in the study by arvind jain et aland hamid et al. arvind jain et al included malaria in the hypersplenism group. malaria is seen in 8 cases accounting 5.4% of the cases. malaria causes pancytopenia by hypersplenism, hemolysis, dic, direct bone marrow invasion by parasite and hemophagocytosis. in the present study marrow invasion by parasite was not seen. gupta et alreported malaria in 30% of the cases making it the most common cause for pancytopenia in that study. hamid et al. reported 17.3% of pancytopenia cases were due to malaria which is third most common cause. hiv caused pancytopenia in 6 cases (4%). devi p.m. et al reported hiv in 6% of the cases in her study. savage et aldid a study inzimbabwe which showed hiv as the third most common cause o f pancy topenia . hemato log ica l manifestations are diverse in hiv. they can be due to direct and indirect effects of virus, opportunistic infections, art therapy and associated malignancies.tuberculosis was seen in 4 cases (2.7%) in the present study. although tb is a rare cause of pancytopenia, it has to be considered in countries like india. it is most of the times seen in association with miliary tuberculosis. pathogenesis of pancytopenia is not well understood. tuberculous bacilli were not seen in all the cases of pancytopenia in tuberculosis. this hypothesizes that antituberculous drugs may also cause pancytopenia. tuberculosis is seen in 12.5% of the cases in the study done by arvind jain et al and 12.86% in the study done by gupta et al.myelodysplastic syndrome is diagnosed by presence of dysplastic cells and auer rods in the bone marrow. this is seen in 5 cases (3.3%) in the present study. gupta et al reported 1.73% of the cases to be mds. international agranulocytosis and aplastic anaemia study group reported mds in 4.5% nd cases making it the 2 most common cause. 2 cases of myelobrosis were diagnosed. we got a dry tap in bone marrow aspiration. biopsy was taken and reticulin stain was added anddiagnosed. one case of hlh was diagnosed. this case has increased ferritin levels of 4689 ng/ml. strengths ÿ being a descriptive observational study, information is quick to obtain and it involved low cost. ÿ the tests done in the study are routinely advised for pancytopenia as part of evaluation. hence there are no ethical issues regarding that. ÿ multiple parameters – clinical features, hematological ndings, bone marrow ndings and laboratory values are studied. ÿ sample size in the present study is comparatively higher than other studies done in this geographical area making it more signicant. limitations ÿ this study is done in a government hospital where further diagnostic modalities are not available. ÿ study sample size needs to be higher for better results. ÿ total of 260 cases of pancytopenia were found in haemogram. ÿ only 148 cases were subjected to bone marrow aspiration. these dropouts were due to fear of bone marrow examination, and improper follow up. ÿ follow up of the patients after treatment needs to be monitored for further information regarding the disease lymphadenopathy 1.3% 12.94% 12% 16.2% cellularity gupta et al54. swapna kumari et al55. present study hypocellularity 44% 6.25 11.18 normocellularity 12% 37.5 25.8 hypercellularity 28% 56.25 62.93 vitamin deciencies akinci et al56. prem kumar et al62 present study b12 deciency 58% 91.6% 66% folate deciency 29% 5% 11% combined deciency 12.3% 3.5% 23% volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 70 x gjra global journal for research analysis and diagnosis. ÿ patients with prior chemotherapy and radiotherapy were excluded for convenience. ÿ berkesonian bias might effect the results as only patients from lower social strata attend this hospital. ÿ unstable pancytopenia cases with peripheral smear showing blast cells are intentionally omitted and referred to higher centre urgently as there is no department of hematological oncology in our hospital conclusion in a prospective descriptive study “evaluation of pancyt openia in adults and correlation between peripheral smear and bonemarrow findings” done on 148 patients in department of general medicine, king george hospital, the salient conclusions are rd th ÿ pancytopenia is more common in 3 and 4 decades ÿ male:female ratio is 1.03 ÿ most common cause for pancytopenia is megaloblastic anaemia ÿ second most common cause for pancytopenia is aplastic anaemia ÿ third most common cause is hypersplenism ÿ fatigue is the most common presenting symptom followed by fever ÿ pallor is the most common sign seen in pancytopenia followed by splenomegaly ÿ bone pains are most commonly associated with leukemias ÿ tuberculosis, malaria and hiv should be ruled out in every case of pancytopenia in our geographical region. ÿ b12 deciency is the most common cause for megaloblastic anaemia followed by combined b12 and folate deciency. ÿ most common peripheral smear rbc nding is dimorphic anaemia ÿ most common bone marrow cellularity in pancytopenia is hypercellularity references 1. de gruchy gc: pancytopenia, aplastic anaemia. in de gruchy’s clinical haematology in medical practice, 5th edition. edited by firkin f, chesterman c, penington d, rush b. berlin, germany: blackwell science; 1989:119–36 2. williams dm: pancytopenia, aplastic anaemia and pure red cell anaemia. in wintrobe’s clinical haematology. 10th edition. edited by richard gl, bithel tc, john f, john wa, john nl. 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philadelphia :lippincott williams and wilkins 2004: 1397-1419. 9. khodke k, marwah s, buxi g, yadav rb, chaturvedi nk. bone marrow examination in cases of pancytopenia. journal, indian academy of clinical medicine. 2001jan-june. 2001; 2:1-2. 10. mobina ahsan dodhy, nusrat bokhari, abbas hayat. aetiology of pancytopenia, a ve-year experience ann pak inst med sci 2005 apr jun;1(2):92-5. 11. international agranulocytosis and aplastic anaemia study. incidence of aplastic anaemia, the relevance of diagnostic criteria. blood 1987; 70: 1718 21. 12. wintrobe mm clinical haematology. 8ed. philadelphia; lea and febigerth 1981: 699-915. 13. valent p. low blood counts: immune mediated, idiopathic, or myelodysplasia. haematology am soc hematol educ program 2012; 2012:485. 14. andrew chow, paul s. frenette. origin and development of blood cells. ln greer, john p(ed). wintrobe’s clinical haematology, 13th edition. philadelphia, lippincott williams & wilkins, 2014; 65-7. 15. mohamed a. yassin, abdulqadir nashwan and shehab mohamed. extramedullary haematopoiesis in patients with primary myelobrosis rare and serious complications. blood 2016;128:5490. 16. andrew chow, paul s. frenette. origin and development of blood cells. ln greer, john p(ed). wintrobe’s clinical haematology, 13th edition. philadelphia, lippincott williams & wilkins, 2014; 73-4. 17. john g. quigley, robert t. means, jr., bertil glader. the birth, life, and death of red blood cells: erythropoiesis, the mature red blood cell, and cell destruction. ln greer, john p(ed). wintrobe’s clinical haematology, 13th edition. philadelphia, lippincott williams & wilkins, 2014; 83-5. 18. g.c. de gruchy. formation of blood cells; bone marrow biopsy. ln frank firkin(ed). de gruchy’s clinical haematology in clinicl practice, 5th edition. massachusetts, blackwell science, 1989; 5-6 volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 71gjra global journal for research analysis introduction: nitrofurantoin is frequently use anti-bacterial agent for uti, especially in uncomplicated cystitis as per australian therapeutic guidelines (1). the majority of patients presented with nitrofurantoin pulmonary toxicity are elderly women (2).this could be related to women more susceptible to get urinary tract infections than men. the median age for presentation of this illness is 60 to 70 years (3). the prevalence was decreased from high in 1960 to low in 1980 .however, it is rising again due to popularity of its use as urinary antiseptic (4).this happened mainly due to decreased propensity of collateral damage and minimal bacterial resistance (5).the rst case of nitrofurantoin toxicity was published in new england journal of medicine 1961 , by isreal and diamond identifying nitrofurantoin toxicity in the patient presenting recurrent pneumonia in same segment of lungs by intentional rechallenge by drug (6).nitrofurantoin can induced acute ,subacute and chronic pulmonary reaction .acute reaction causes mild interstitial inammation and eosinophilia .in contrast ,diffuse interstitial pneumonitis is observed in chronic reaction due to nitrofurantoin (7). these reactions may be severe which warrants hospitalisation (8).bronchiolitis obliterans organising pneumonia and chronic eosinophilic pneumonia has been reported with use of nitrofurantoin (9) (10). acute reactions characterised by symptoms within days to weeks similar to community acquired pneumonia such as fever, dyspnoea, cough and inspiratory crackles, hypotension, chest pain and hypoxia (11).chronic reaction is typically slow onset of dyspnoea and dry cough develops over months or years improves subsequently after stopping drug ,although corticosteroids are helpful in severely affected patients (12). histologically, all forms of pulmonary toxicities manifest wide spectrum of pulmonary tissue reactions (13).nitrofurantoin toxicity largely under-recognized and mistaken as community acquired pneumonia while patient being treated for urinary tract infections bacteraemia which may lead to prolong use of drug and pulmonary tissue damage such as irreversible brosis or granulomatous reaction (14). life threatening condition causing haemoptysis following pulmonary haemorrhage and respiratory failure has been reported due to nitrofurantoin toxicity (15).this indicates alternative treatment for patients who carries recurrent urinary tract infections and cystitis, also adding nitrofurantoin in allergy list to prevent its reuse and close monitoring of pulmonary side effects for patients receiving long therapy is warranted . case report a 83 years old independent gentleman, has a background of obstructive sleep apnoea compliant with cpap, presented with exertional dyspnoea following initiation of nitrofurantoin for recurrent urinary tract infections. onset of symptoms was 6 weeks post nitrofurantoin therapy. there were no infective or other systemic symptoms. he is a non-smoker and worked as a boiler maker in a open pit coal mine where he had asbestos exposure. his blood tests were unremarkable except crp was 36 . cxr there is patchy and conuent air space shadowing in both mid and both lower zones likely due to bilateral bronchopneumonia. there are no pleural effusions. there is no pneumothorax. ct chest (qld xray): extensive pulmonary interstitial changes with ground glass opacities has appearance suggesting chronic hypersensitivity pneumonitis rather than uip. thickening interlobular, intralobular septa, severity worse in lower lobes. ?early honeycombing posteriorly in rll. no mass. normal ln. no pleural plaques. a case report – nitrofurantoin toxicity mimicking pneumonia original research paper dr sonali someek basu bpt registrar (fracp), townsville hospital, queensland health, australia toxicology introduction : this case report describes lung injury due to nitrofurantoin use which presents as interstitial lung disease. a 70 yrs old presented with dyspnoea ,fatigue and cough. previously he was given nitrofurantoin for urinary tract infection a couple of weeks ago. chest x-ray has shown patchy and conuent air space shadowing in both mid and both lower zones likely due to bilateral bronchopneumonia. there are no pleural effusions. there is no pneumothorax. knowledge of adverse effect is essential for the early recognition and withdrawal of the drug. nitrofurantoin-induced lung disease has a benign course and respond fully despite radiographic evidence of established lung brosis.symptomatic improvement was observed following steroid course soon after stopping nitrofurantoin. a review information obtained from north american and european pharmacological database identied reports on nitrofurantoin toxicity. we are reporting a case here demonstrating acute toxicity of nitrofurantoin approximately 7-9 days after a short course of nitrofurantoin. abstract keywords : nitrofurantoin toxicity, hypersensitivity reaction, pulmonary toxicity dr pranav kumar* respiratory physician, mackay base hospital, queensland health, australia *corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 30 x gjra global journal for research analysis pft (18.12.17): fev1 2.9 pre, fvc 3.1 pre, fev1/ fvc ratio 94, tlc 5.86, dlco 6.96, kco 1.51. reversibility not tested. 6min walk test on ra (22.12.17): test ceased after 2min and 35seconds (spo2 sustained <85% and patient complained of lightheadedness). applied 4lo2 via n.p post test. spo2 increased to 91% within 1min. o2 decreased to 2lo2 via n.p. spo2 maintained above 93%. returned to rib via attendant propelled w/c *6min walk test on 2l o2/min (22.12.17): test ceased after 4min 30seconds (spo2 sustained <85% and pt c/o lightheadedness). required seated rest. spo2 increased to 90% within 2 mins post test. lightheadedness resolved. on prednisolone 50mg po for 2/52 he was started on prednisone and continued on this for a few weeks. his lung function initially showed fev1 of 2.5 (115% predicted), fevc of 3.10 (93% predicted). his total lung capacity was 5.86 (96% predicted). his corrected diffusion capacity was 1.151 which is 36% of predicted. following steroid introduction his corrected diffusion capacity has improved to 62% of predicted. the last lung function has shown normal fev1 and fvc with some airow limitation. total lung capacity is 7.15 which is 123% of predicted along with corrected diffusion capacity normalising. repeat ct chest: has shown near resolution of symptoms. echo was normal. looking at the whole picture, he had nitrofurantoin induced pulmonary toxicity with ct proven interstitial changes which are predominantly radicular and interstitial pattern along with some distorted parenchymal architecture which is more consistent with the interst i t ial pneumonit is . with nitrofurantoin induced toxicity we see nearly 10 – 30% of patients showed response to corticosteroids usually with a few months of treatment. in this case however complete remission following the use of corticosteroid with both hrct wise and lung function wise. this patient has shown complete conrmed laboratory recovery from severe nitrofurantoin induced interstitial lung disease, pulmonary function parameters have also improved. discussion: nitrofurantoin's chemical name: 1-(5-nitrofurfurylideneamino) hydantoin, is rst line option for uncomplicated cystitis and is a long term suppressive agent prophylaxis in recurrent utis as per australian therapeutic guidelines. macrodantin is bacteriostatic at low concentration and is bactericidal in vitro at higher concentration. it affects bacterial wall synthesis by inhibiting bacterial proteins, dna, rna (16) (17). it is thought to be acute toxicity of nitrofurantoin through hypersensitivity reaction type i or iii, chronic form through oxygen mediated tissue injury either toxic response or cell mediated response (18). lofer's syndrome is associated with nitrofurantoin evident on histology suggestive of peri-vasculitis with eosinophil inltrates, macrophages and proteinaceous oedema uid in alveoli. it is also associated with pulmonary brosis infrequently (19). apart from pulmonary toxicity, nitrofurantoin is associated with hepatic reaction, impaired renal function, metabolic acidosis, hematolytic anaemia, colitis, carcinogenicity (20). pathophysiology behind nitrofurantoin lung toxicity is also documented in details following injury due to highly reactive oxygen species and nitrite radicals. one of the cell's key antioxidant such as nadph get consumed in redox cycling and free radicals forms which causes lipid peroxidation, mitochondrial damage ,apoptosis (21). schematic of the interaction of oxygen radicals and the antioxidant system. (gsh, glutathione; g6pd, glucose-6phosphate dehydrogenase; nadp, nicotinamide-adenine dinucleotide phosphate; nadph, reduced nadp.) (19) clinical features of acute reactions occurs rarely, 1 in 5000 patients after rst exposure .more common in middle age /elderly females with recurrent utis following structural anomalies of genitourinary tract (22). acute pulmonary hypersensitivity reaction to nitrofurantoin presents as cough, dyspnoea and fever often manifests within 3 to 8 days .however, it may appear within few hours to 4 weeks .in subacute or chronic reactions , dyspnoea and cough are most common symptoms generally develops after a month of exposure to drug (23). patient having acute toxicity presents to emergency department appearing unwell, cyanosed due to type ii respiratory distress. these patients are febrile with tachycardia, tachypnoea and hypotension. respiratory examination showed bi-basal crepitation .cxr shows normal lung eld or pulmonary oedema including diffuse parenchymal changes or interstitial alveolar shadowing in lower lobes of lungs in 90% of affected patients volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 31gjra global journal for research analysis and pleural effusion commonly present (23). blood test shows leucocytosis with eosinophilia for weeks which slowly resolves post cessation of nitrofurantoin generally after 6 weeks .esr can be elevated up-to 80 mm/h (23). a variety of positive sexologies including anca, ana, anti-smooth muscle antibody , ra factor have been reported in these patients (24) (25). pulmonary function test shows moderate gas impairment, with no reduction in fev1 or vital capacity. chronic forms shows restrictive pattern with reduced lung volumes (2) (7). hrct shows bilateral ground glass consolidation in acute form and asymmetrical mixed pattern of consolidation and brosis in chronic form (7). imaging ndings and histopathology picture mimics organising pneumonia (9). broncho-alveolar lavage is nonspecic but may be helpful in proving immunological response characterise by presence of lymphocytosis, eosinophilia and neutrophilia (26). lung biopsy not often necessary. when obtained, it shows variation among pathologies suggestive of interstitial inammation, interstitial pneumonia of non-specic pattern, organizing pneumonia or chronic eosinophilic pneumonia (12) (10). re-challenging with nitrofurantoin is not advised due to recurrence of lung toxicity (11). diagnosis of nitrofurantoin pulmonary toxicity is challenging. differential diagnosis includes pulmonary oedema, cryptogenic organizing pneumonia and idiopathic interstitial pneumonia (27). treatment of acute pulmonary toxicity includes cessation of nitrofurantoin which leads to clinical improvement. prognosis of this condition is good when correctly diagnosed. chronic presentation takes weeks to months to recover fully. oral glucocorticoid is not useful routinely. it may be benecial in case of severe respiratory impairment (2) (28). careful initiation of steroid after ruling out infection shows rapid improvement though few cases of severe pulmonary toxicity resolved without steroid (29). follow up needed in certain cases who has persistent symptoms, pulmonary brosis, and persistent blood eosinophilia. conclusion nitrofurantoin has a value in treatment of urinary tract infection. unfortunately, it is associated with adverse effects such as pulmonary toxicity which is often mistaken as infection. references 1. 2018 tgl. etg complete therapeutic guideline australia. 2018th ed. 2018 tgl, editor. victoria 3003, australia : therapeutic guideline australia ; 2018. 2. mendez jl, nadrous hf, hartman te, ryu jh. chronic nitrofurantoin-induced lung disease. mayo clinic proceedings. 2005 october; 80(10). 3. holmberg l, boman. pulmonary reactions to nitrofurantoin. european journal of respiratory disease. 1981 june; 63(3). 4. camus p, fanton a, bonniaud p, camus c, foucher p. interstitial lung disease induced by drugs and radiation. respiration. 2004; 71(4). 5. gupta k, hooton tm, naber kg, wullt , colgan r, loren g. m, et al. international clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women. clinical infectious diseases : an ofcial publication of the infectious diseases society of america. 2011 march; 52(5). 6. israel hl, paul d. recurrent pulmonary inltration and pleural effusion due to nitrofurantoin sensitivity. n engl j med. 1962 may; 266(1024-1026). 7. sovijärvi a, lemola m, stenius b, idänpään-heikkilä j. nitrofurantoininduced acute, subacute and chronic pulmonary reactions. scand j respir dis. 1977; 58(1-41-50). 8. jick ss, jick , walker am, hunter jr. hospitalizations for pulmonary reactions following nitrofurantoin use. chest. 1989 september; 96(3). 9. cameron r, kolbe , wilsher ml, lambie. bronchiolitis obliterans organising pneumonia associated with the use of nitrofurantoin. thorax (bmj). 2000 march; 55(3). 10. martins rr, marchiori , viana sl, lspgj, vlc, lmv. chronic eosinophilic pneumonia secondary to long-term use of nitrofurantoin: high-resolution computed tomography ndings. jornal brasileiro de pneumologia. 2008 march; 34(3). 11. williams e, triller d. recurrent acute nitrofurantoin-induced pulmonary toxicity. pharmacotherapy. 2006 may; 26(5). 12. mendez jl, nadrous hf, hartman te, ryu jh. chronic nitrofurantoin-induced lung disease. mayo clinic proceedings. 2005 october; 80(10). 13. taskinen e, tukiainen p, sovijärvi ara. nitrofurantoin-induced alterations in pulmonary tissue. acta pathologica microbiologica scandinavica section a pathology. 1977 july; 85a(5). 14. sakata kk, larsen bt, boland jm, palen b, muhm jr, helmers ra, et al. nitrofurantoin-induced granulomatous interstitial pneumonia. international journal of surgical pathology. 2013 june; 22(4). 15. averbuch sd, yungbluth p. archives of internal medicine. archives of internal medicine (jama). 1980 february; 140(2). 16. australia m. macrodantin. 2018th ed. australia m, editor. australia : mims australia ; 2018. 17. handbook am. nitrofurantoin. 2018th ed. handbook am, editor. australia : australian medical handbook ; 2018. 18. mwi. nitrofurantoin: potential direct and indirect mechanisms of lung injury. chest. 1983 may; 83(5). 19. dipiro jt, talbert rl, yee gc, matzke gr, wells bg, posey lm. echapter 15drug-induced pulmonary diseases. in dipiro jt, talbert rl, yee gc, matzke gr, wells bg, posey lm, editors. pharmacotherapy: a pathophysiologic approach. new york: mcgraw-hill; 2014. 20. 2018 mo. macrodantin. 2018th ed. 2018 mo, editor. austrlia : mims online 2018 ; 2018. 21. boyd mr, catignani gl, sasame ha, mitchell jr, stiko aw. acute pulmonary injury in rats by nitrofurantoin and modication by vitamin e, dietary fat, and oxygen. ats journal -american review of respiratory disease. 1979 july; 120(1). 22. kabbara wk, kordahi mc. nitrofurantoin-induced pulmonary toxicity: a case report and review of the literature. journal of infection and public health. 2015 july–august; 8(4). 23. chudnofsky cr, otten ej. acute pulmonary toxicity to nitrofurantoin. the journal of emergency medicine. 1989 january–february; 7(1). 24. sa, vdwj, kn, sn, kh. nitrofurantoin-induced immune-mediated lung and liver disease. american journal of medical science. 1999 may; 317(5). 25. hl, bg. pulmonary reactions to nitrofurantoin. 447 cases reported to the swedish adverse drug reaction committee 1966-1976. european journal of respiratory disease. 1981 jun; 62(3). 26. brutine , martin ii. chronic nitrofurantoin reaction associated with tlymphocyte alveolitis. chest. 1986 january; 89(1). 27. camus p , fanton a , bonniaud p , camus c , foucher p. interstitial lung disease induced by drugs and radiation. respiration. 2004 july – august; 71(4). 28. vm, fma, mj, grj, ic, hj. rapid resolution of nitrofurantoin-induced interstitial lung disease. archivos de bronconeumologia. 2009 jul; 45(7). 29. rb. nitrofurantoin-induced interstitial pulmonary brosis. presentation and outcome. the medical journal of australia. 1983 jan; 1(2). volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 32 x gjra global journal for research analysis 71.dr. shubhra bishwas online.cdr introduction: dermatophytoses, the fungal infections caused by three genera of dermatophytes, namely, trichophyton, epidermophyton & microsporum, are very common in summer and monsoon in our country due to hot and humid climate. recent prevalence of dermatophytosis ranges from 36.6% 78.4% in india[1]. itraconazole and terbinane are the preferred drugs for the treatment of dermatophytoses[2]. itraconazole is a synthetic triazole compound which acts by inhibiting fungal cytochrome p450 enzyme resulting into reduced ergosterol synthesis[3]. the selective toxicity of azole drugs results from their greater afnity for fungal than for human cytochrome p450 enzymes[3].usual dose of itraconazole in dermatophytosis of skin is 200mg/day for 1-2 weeks[2]. terbinane is a synthetic allylamine which also acts by interfering with ergosterol biosynthesis, but, by inhibiting fungal enzyme squalene epoxidase[3]. standard dose of terbinane in dermatophytosis of skin is 250mg/day for 1-2 weeks[2]. however, now a days, widespread resistance to conventional doses of these antifungal agents are seen. an expert consensus on the management of dermatophytosis in india suggested that resistant tinea corporis and tinea cruris infections should be treated with higher doses of systemic drugs preferably itraconazole and terbinane for a minimum duration of 4 weeks[4]. therefore, this study was conducted to compare the efcacy of itraconazole and terbinane in higher doses in resistant cases. also, these infections are more common among low socioeconomic population due to poor sanitary conditions, overcrowded population and lack of knowledge about hygiene. again, recalcitrant nature of these infections need longer duration of therapy as well as adherence to the treatment. so the another objective of this study was to nd out the cheaper therapy among the two. materials and methods: this randomized, open, parallel, prospective study was conducted in the department of pharmacology at nalanda medical college & hospital, patna, between april 2019 & september 2019. 200 patients of both genders of resistant dermatophytosis of skin (tinea corporis and tinea cruris) attending opd of the skin & v.d. department of nalanda medical college & hospital, patna in this period, who were willing to participate in the study and gave written and informed consent, were enrolled after fullling the inclusion and exclusion criteria and divided randomly into two groups of 100 each. group i patients received 200mg itraconazole (capsule candiforce-200) twice daily for 4 weeks while group ii patients received 250mg terbinane ( tablet terbinaforce 250mg) twice daily for 4 weeks. ÿ inclusion criteriapatients of both genders aged between 18-55 years with clinical diagnosis of resistant tinea corporis and tinea cruris and conrmed by potassium hydroxide (koh) test. ÿ exclusion criteria 1. age <18 years and >55 years 2. pregnant and lactating women 3. known hypersensitivity to any of the study medications 4. preexisting diabetic, renal, hepatic and cardiac disease patients 5. patient on any other regular medications a baseline liver function test was done at the beginning of the study and again at the end of 2 weeks of therapy. koh test a comparative study of efficacy of itraconazole versus terbinafine and their cost effectiveness in the treatment of resistant dermatophytosis of skin at nalanda medical college, a tertiary care teaching hospital of patna. original research paper dr. shubhra bishwas junior resident, department of pharmacology, nalanda medical college, patna x 1gjra global journal for research analysis pharmacology background dermatophytoses are common fungal infections prevalent in hot and humid climate. itraconazole and terbinane are commonly used antifungal agents for the treatment of dermatophytoses. however, increased resistance is being seen with conventional doses of these drugs. also, these infections are more common among low socio-economic population. therefore, this study has been undertaken to compare the efcacy and cost effectiveness of itraconazole and terbinane in increased dosages in resistant dermatophytoses of skin. objectivesto compare the efcacy of itraconazole and terbinane in increased dosages in resistant dermatophytoses of skin and to select cheaper drug among them. materials and methodsin this open, parallel, prospective, comparative study, 200 patients of tinea cruris and tinea corporis diagnosed clinically and conrmed by potassium hydroxide (koh) test, were randomly and equally divided into two groups. group i patients received itraconazole 200mg twice daily while group ii patients received terbinane 250mg twice daily for 4 weeks. patients were evaluated at the end of 2 and 4 weeks.at the end of 4 weeks koh test was repeated to evaluate mycological cure. resultsat the end of 4 weeks mycological and clinical cure was seen in 92% patients in group i while 75% patients in group ii. mild adverse effects like headache, taste disturbances and gastrointestinal upset were observed in few patients of both groups but none was signicant enough to discontinue therapy. cost of therapy was more with itraconazole than that of terbinane. conclusionhigh dose itraconazole therapy is more effective than high dose terbinane therapy in resistant dermatophytoses. however cost of therapy is more in case of itraconazole. but terbinane has higher failure rates and the duration of treatment may require longer, thereby reducing the cost difference. therefore, itraconazole seems superior to terbinane in the treatment of resistant t.corporis and t. cruris infection in higher doses. abstract keywords : itraconazole, terbinane, resistant dermatophytosis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. (prof.) sanjay kumar* professor and head of the department of pharmacology, nalanda medical college, patna *corresponding author 2 x gjra global journal for research analysis was also repeated at the end of 4th week after completion of therapy. patients were evaluated at the end of 2nd and 4th week for any improvement in clinical symptoms and also for adverse effects. clinical response was divided into cured, improved and not cured types. a cured case was dened as one who had complete absence of symptoms (pruritis, scaling, erythema etc.) as well as mycologically negetive koh test after completion of therapy. not cured was dened as neither remission of symptoms nor mycologically negetive koh test. an improved case was in between the two who had clinically improved symptoms but mycological status was not known. at the end of study, the results were compiled, tabulated, calculated in percentage and statistically analyzed using chi-square tests. results: the demographic prole of patients and diagnosis in both the groups are shown in table-1. table-1 demographic prole and diagnosis in group i and group ii the mean age of group i patients was 35.1±14.2 years and there were 55 males and 45 females. in group ii, mean age was 34.9±13.1 years and there were 54 males and 46 females. most of the patients were diagnosed with both tinea corporis and tinea cruris in both the groups as shown in the table-1. there was no statistically signicant difference in demographic prole and diagnosis in both the groups. fig-1 and fig-2 shows treatment outcomes at the end of 2 weeks and 4 weeks in group i and group ii respectively. at the end of 2 weeks, in group i, there were 60% patients whose symptoms were improved but at the end of 4 weeks, 92% patients were cured. in group ii, 75% patients had improved symptoms at the end of 2 weeks while the number of patients cured at the end of 4 weeks was same i.e. 75%. the result was signicantly better in itraconazole group. fig-1 treatment outcome in group i fig-2 treatment outcome in group ii there were 5 cases of gastric upset, 3 cases of altered taste and 1 case of headache seen among group i patients while in group ii, 6 cases of gastric upset, 2 cases of altered taste, 1 case of headache and 1 case of rash were seen. these adverse effects were mild and did not require discontinuation of therapy. total cost of therapy of group i was rs. 1228.00 while that of group ii was rs. 602.00. discussion: in our study, both itraconazole and terbinane were found effective in the treatment of resistant dermatophytosis of skin but , itraconazole came out as better drug as compared to terbinane in terms of efcacy as well as mycological cure rate. it is similar to other earlier studies done by a. bhatia et al. and nb shakya et al. in patients with t. cruris and t. corporis who also found itraconazole superior to terbinane in cure rate[5][6]. however studies on toenail onychomycosis done by sigurgeirsson b et al. and bala tripura sundari ankani suggests terbinane as more effective than itraconazole [7][8]. both of these drugs have similar pharmocokinetic and safety prole. although cost of therapy is more in case of itraconazole than terbinane but in terms of cure rate, itraconazole is better than terbinane. conclusion: itraconazole has higher cure rates both clinically as well as mycologically than terbinane. although the cost of treatment is lower with terbinane for same duration of therapy, but it has higher failure rates and the duration of treatment may require longer, thereby mitigating the cost difference. therefore, itraconazole seems superior to terbinane in higher doses in the treatment of resistant t.corporis and t. cruris infection. references: 1. naglot a, shrimali dd, nath bk, gogoi hk, veer v, et al. recent trends of dermatophytosis in northeast india and interpretation with published studies. int j curr microbiol app sci. 2015;4(11):111-20. 2. harrison’s principles of internal medicine, 20th ed.p-1546. 3. basic & clinical pharmacology, 14th ed.p-856-860. 4. rajagopalan m, inamadar a, mittal a, et al. expert consensus on the management of dermatophytosis in india (ectoderm india). bmc dermatol. 2018;18(1):6. published 2018 jul 24. doi:10.1186/s12895-018-0073-1 5. shakya nb, jha ms. dangol a, shakya s, shah a. efcacy of itraconazole versus terbinane for the treatment of tinea cruris. med j shree birendra hosp 2012;11:24-6. 6. bhatia a, kanish b, badyal dk, kate p, choudhary s. efcacy of oral terbinane versus itraconazole in treatment of dermatophytic infection of skin – a prospective, randomized comparative study. indian j pharmacol 2019;51:116-9. 7. bala tripura sundari ankani/j pharm. sci. & res. vol. 7(8), 2015, 542-544. 8. sigurgeirsson b, olafsson jh, steinsson jb, paul c, billstein s, evans eg, et al. long-term effectiveness of treatment with terbinane vs. itraconazole in onychomycosis: a 5-year blinded prospective follow-up study. arch dermatol 2002;138:353-7. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra parameters group i group ii age (in years) (mean±sd) 35.1±14.2 34.9±13.1 gender male 55 female 45 male 54 female 46 diagnosis tinea corporis 10 12 tinea cruris 14 13 tinea corporis + tinea cruris 76 75 introduction head and neck cancers are among the 10 most common cancers globally and are the most common cancers in developing countries, especially in south east asia. in india,it accounts for one fourth of male cancers and one tenth of female cancers.oral cancers are most common amongst all head and neck squamous cell carcinoma(hnscc). this mainly attributed to tobacco,areca nut, alcohol, etc.[1] according to cancer statistics of india cancer of oral cavity and lung account for over 25 % of cancer death in male [2]. concurrent chemoradiation,has become the standard treatment option for locally advanced head and neck squamous cell cancer, since several randomized trials reported a signicant survival benet of adding chemotherapy to radiation over radiation alone [36].cisplatin is among the most common agents used in combination with radiotherapy as well as one of the most studied. it has radiosensitizing properties and it's toxicity does not overlap radiotherapy [4].in an attempt to increase to local control in advanced head and neck cancers chemotherapy has been used before or after surgery and has been associated with good clinical response. combined chemotherapy and radiation used simultaneously to get synergistic benet against head and neck cancers has been associated with high level of response in in-operable disease. the mos t common drugs used are c i sp la t in , 5 uorouracil,hydroxyurea and mitomycin [7]. carboplatin has radiosensitizing properties and has lesser renal and gastrointestinal toxicities than cisplatin and is considered an effective option in national comprehensive cancer network (nccn) guidelines for patients unt for cisplatin. phase ii studies of carboplatin based ctrt showed complete response of 65%-70% ,similar to those seen in cisplatin[8]. material methods inclusion criteria biopsy conrmed , locally advanced unresectable , (stage iii and iva) ajcc 8th , oral cavity cancer , kps > 70 % , age > 19 years < 70 years , exclusion criteria patient not willing to give informed consent , age more than 70 years , histopath inconclusive , metastatic tumors study design case control , randomised , prospective carried out at govt. mahatma gandhi memorial medical college and hospital, indore , madhya pradesh , india in the year 2018-2019. total 60 cases were divided into two groups case ( arm 1 ) and control (arm 2) , rst arm received carboplatin ( auc 2 weekly ) as concurrent chemotherapy whereas second arm received cisplatin ( 40 mg per m² weekly ) . both arms were treated with external beam radiotherapy upto 70 gy in 35 fractions . 5 fractions per week , 2 gy per fraction using cone down technique. statistics all statistical calculations were done using spss 20 , p value < .05 was considered signicant toxicity assess ment toxicity criteria were by rtog/eortc. response evaluation complete response (cr) was dened as the complete absence of disease 6 weeks. partial response (pr) was dened as a reduction of disease by at least 50% in the sum of all measurable products of the longest perpendicular diameters of measurable tumor masses for at least 6 weeks, with no growth of other lesions or appearance of new lesions. stable diseases (sd)was dened as reduction in lesion by less than 50%, or increase by less than 25%. progressive disease (pd) was dened as an increase by at least 25% of tumor lesions or appearance of new lesions. observation and results total 60 biopsy proven cases of oral cavity cancer were included in the study. cases were randomly allocated into two groups arm 1 received weekly carboplatin whereas arm 2 received weekly cisplatin . both arms were matched age sex annd stage . out of 30 patients in arm 1 , 24 were males and 6 females . 18 cases were stage 3 , 12 belonged to t4a . n1 nodal stage was seen in 10 patients , 14 patients had n2 staging and 6 patients had n3 stage . buccal mucosa was the most common site observed in our study (n=14) followed by tongue (n=10 ) , lip (n=4) , gbs and alveolus ( n=4 ). concurrent chemo radiotherapy with weekly cisplatin versus weekly carboplatin in locally advanced oral cavity cancers original research paper dr preety jain associate professor dept of radiation oncology m.g.m. medical college indore m. p. , india oncology keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr garima uikey * pg third year dept of radiation oncology m.g.m. medical college indore m. p. , india *corresponding author dr manish verma assistant professor dept of radiation oncology m.g.m. medical college indore m. p. , india dr pranjil mandloi senior resident dept of radiation oncology m.g.m. medical college indore m. p. , india dr vikas pal pg third year dept of radiation oncology m.g.m. medical college indore m. p. , india dr vipin kumar dubey pg second year dept of radiation oncology m.g.m. medical college indore m. p. , india dr jyoti dane pg second year dept of radiation oncology m.g.m. medical college indore m. p. , india 52 x gjra global journal for research analysis arm 2 also comprised of 30 cases , the majority were male (n = 22) and 8 females were included. 13 patients had n1 nodal stage followed by 12 cases having stage n2 and 5 cases n1 stage. buccal mucosa was the most predominant site involved (n = 16) tongue , gbs and alveolus were second most common (6 cases each ) site involved , 2 cases had carcinoma lip. patient characteristics (table 1 ) response in the present study disease assessment after crt complete response in arm 1 were 66.66% and in arm 2 63.33%, partial response were 20% in both the arm.progressive disease were same in both arm 3.33%.stable disease in arm1 and arm 2,10% and 13.33% respectively. table2 toxicity the comparison of both the regimens revealed that carboplat in was assoc ia ted wi th h igher ra te o f haematological toxicity. mucositis grade 3 higher on arm2 whereas grade 4 toxicity more in arm1. grade 3 skin reactions were higher in arm 2. renal toxicity both grade 1 were higher in arm 2. table 3 discussion denitive concurrent chemoradiotherapy is considered standard of care for inoperable locoregionally advanced head and neck squamous cell carcinoma.cisplatin is the most common chemotherapeutic agent used in combination with radiotherapy[ 9 ]. in the present study the arms had almost similar disease response and the p value was not signicant.brainslav et al. in a three arm study compared concurrent ctrt daily lowdose cisplatin 6mg/m2, ctrt carboplatin 25mg/m2 and radical radiotherapy alone in locally advanced head and neck cancers. they found overall similar response rate in both the arm compared to radiotherapy alone arm. non hematological toxicities were similar in all three arm.but haematological toxicities similar in both the ctrt arm but higher than the radiotherapy alone arm [10]. chitapanarux et al. showed that in nasopharyngeal cancer, treatment completion rates were 59% versus 73%, respectively, in cisplatin versus carboplatin arm of concurrent ctrt, showed that carboplatin is better tolerated than cisplatin[ 11].dutta et al.compared carboplatin auc 6 every 3 weeks and cisplatin 100 mg/m 2 every 3 weekly, both given concurrently with radiotherapy, in locally advanced unresectable head and neck cancers excluding nasopharynx and oral cavity cancers. they reported response rates (cr plus partial response) of 76.9% and 63.6% in carboplatin and cisplatin arms, respectively. they reported signicantly higher rates of nausea, vomiting, dermatological toxicity, and mucositis in cisplatin than in carboplatin arm. hematological toxicities were higher in carboplatin than in cisplatin arm [12]. in the present study complete response 66.66% vs 63.33% in arm1 and arm 2 respectively. skin toxicity observed as follows grade3,arm 1 80% and arm 2,86.66%, and grade 4 in arm 1 6.66% and arm2 3.33%. the difference were however statistically insignicant. during rt 76.66% patient had grade 3 mucositis and 23.33% patient had grade 4 mucositis in arm1 while 83.33% patients had grade 3, 13.33% patients had 4 mucositis in arm2. overall incidence of mucositis was higher in arm1 but it couldn't reach signicant level. in the current study 86.66% patients in arm 1 and 73.33% patients in arm 2 had grade 3 haematological toxicities and grade 4 haematological toxicities were 6.66% and 3.33% in arm 1 and arm 2 respectively. hematological toxicities though higher in arm1 , were manageable with hematinics. our results were comparable to other similar studies. in the present study, nephrotoxicity grade 1 was higher in arm 2, ( 60% ) while in arm 2,grade 1 nephro toxicity was (36.66 %.) it was statistically insignicant . conclusion carboplatin can be used as safer alternative as concurrent chemotherapy along with radiation without compromising outcome in locally advanced oral cavity cancer patients. nephrotoxicity was lesser in carboplatin arm while there was an increase in hematological toxicity which was manageable with hematinics however it was not signicant ( p value >0.05 ). carboplatin is a safer alternative to cisplatin in patients whose renal function is compromised and in elderly patients. limitation small sample size and limited follow up are major limitations of the study. conict of interest there was no conict of interest. references 1. imran ali, waseem a. wani and kishwar saleem cancer scenario in india with future perspective. 2. icmr;cancer statistics 2018. 3. brizel dm,albers me,fisher sr,rt al.hyperfractionation irradiation with or without concurrent chemotherapy for locally advanced head and neck cancer. n engl j med 1998;338;1798-804. 4. aldestien dj,liy,adams g2,et al.an intergroup phase iii comparison of standard radiation therapy and two schedules of concurrent chemoradiotherapy in patients with unresectable squamous cell head and neck cancer,jclin. oncol 2003;21:92-8. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra arm 1 ( case) arm 2 (control ) total patients 30 30 male 24 22 female 6 8 stage (t) tumor t3 18 19 t4a 12 11 n ( node) n1 10 13 n2 14 12 n3 6 5 location buccal mucosa 14 16 tongue 8 6 lip 4 2 gbs and alveolus 4 6 response arm 1 ( case) (n= 30) arm 2 (control ) (n= 30) p value cr 20 19 0.79 pr 6 6 1 sd 3 4 0.69 pd 1 1 1 toxicity arm 1 (case) arm 2 (control) p value hematological toxicity 0.16 grade 3 26 22 grade 4 2 1 mucositis 0.78 grade 3 23 25 grade 4 7 4 skin reaction 0.76 grade 3 24 26 grade 4 2 1 renal toxicity 0.65 grade 1 11 18 x 53gjra global journal for research analysis 5. forastier aa, goepfert h, maor m, et al. concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. n engl j med 2003;349:2091-8. 6. denis f,garaud p,bardet e,et al. final results of the 94-01 french head and neck oncology and radiotherapy group randomized trial comparing radiotherapy alone with concomitant radiochemotherapy in advanced stage oropharynx carcinoma. jclinoncol 2004;22:69-76. 7. savita lasrado et al; role of concomitant chemoradiation in locally advanced head and neck cancers. 8. al-saraf m, hussain n.head and neck cancers:present status and future prospect of adjuvant chemotherapy cancer invest 1995;13:41-53. 9. marcu l,van doorn t,olver i, cisplatin and radiotherapy in the treatment of locally advanced head and neck cancer-review of their cooperation acta oncol 2003;42(4);315-325. 10. jeremic b,shibainoto y,stanisavljevic r, milojevic l, milic b,nikolic n. radiation therapy alone or with concurrent low dose daily either cisplatin or carboplatin in locally advanced unresectable squamous cell carcinoma head and neck :a prospective randomized trial :radiotherapy oncol 1997;43:29-37 11. chitapanarux l, lorvidhaya v,kmnerdsupaphon p,sumitsuwan,et al. chemoradiation comparing versus carboplatin in locally advanced nasopharyngeal cancer:randomized non inferiority , open trial. eur j cancer 2007;43;1399-406. 12. dutta s,ghorais,choudhury kb, majumdar a. radical treatment of locally advanced head and neck cancer with concurrent chemoradiation-cisplatin versus carboplatin: a randomized comparative phase iii trial. clin cancer investig j 2013;2:122-7. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 54 x gjra global journal for research analysis introduction moyamoya disease (mmd) is a progressive cerebrovascular disorder characterized by progressive stenosis of the terminal portions of the intracranial internal carotid arteries due to hypertrophy of smooth muscle in the vessel walls [6-7]. reduced blood ow to the brain leads to the growth of collateral vasculature such as branches from small leptomeningeal vessels. imaging of the collateral vasculature was characterized in japan as a “puff of smoke,” or moyamoya in japanese. incidence of mmd is the highest in japan, where there are three cases per 100,000, and in females (2:1 ratio) [8]. mmd is now seen throughout the world with a bimodal age of onset, with children presenting around age 5 and adults presenting around age 40 [8]. the presentation in a child is typically a stroke or a transient ischemic attack, while in adults it is typically a hemorrhage. less commonly, mmd may present with a headache or a seizure. mmd affects bilateral internal carotid arteries, whereas a unilateral presentation of the same underlying pathology is known as moyamoya syndrome and is associated wi th condit ions l ike down syndrome, neurobromatosis type 1, and sickle cell disease. case description a 28-year-old young man presented to the hospital with generalized right side weakness involving right upper and lower limbs which was insidious in onset after the patient got up from the bed and was getting ready for the routine activities. the patient was disoriented and weak. on evaluation,patient did not have any signicant past history and not similar episode in the past. no family history of stroke, seizure, or cancer.patient did not smoke,alcoholic,or drug abuser. on physical examination, the patient was conscious and oriented. his blood pressure was 188/100 mmhg in the left arm. on neurologic examination, the cranial nerves were normal. power was decreased (2/5) and the tone was decreased, supercial reexes were absent and deep tendon reexes were exaggerated in both right upper and lower limbs. the left side neurological examination was normal, and there were no signs of sensory or cerebellar dysfunction.the complete blood cell count showed normocytic anemia with normal leukocyte and platelet counts. coagulation prole and hypercoagulable workup was also normal. specic tests for hypercoagulability disorders inc luded ant icardio l ip in ant ibody, ant i thrombin iii,homocysteine, d-dimer,brinogen, lupus anticoagulant, partial thromboplastin time, protein s, prothrombin time, thrombin time, and antinuclear antibody were normal. other invest igations including a chest radiograph was unremarkable. a magnetic resonance image (mri) of the brain with and without gadolinium contrast revealed early subacute infarcts in left basal ganglia, periventricular white matter, centrum semiovale, and just inferior to left globus pallidus showing restricted diffusion on diffusion-weighted scans. chronic infarcts with gliotic changes were seen in right basal ganglia, periventricular white matter. mr angiography done revealed moderate narrowing of a proximal a1 segment of left anterior cerebral artery also seen with nonvisualization of the left middle cerebral artery and its branches. severe stenosis also seen in right middle cerebral artery and supraclinoid segments of right internal carotid artery with paucity of peripheral branches of right middle cerebral rtery. discussion moyamoya disease is a chronic, progressive occlusion of the circle of willis arteries that leads to the development of characteristic collateral vessels seen on imaging, particularly [9]cerebral angiography . the incidence of mmd is the highest in japan, but has now been reported worldwide.the disease is twice as common in females compared to males. mmd has a bimodal age of presentation. children around 5 years of age present with symptoms of brain ischemia, often triggered by hyperventilation (e.g. transient ischemic attacks, ischemic a case report of moyamoya disease original research paper dr. hiren pandya professor & hod, department of medicine, smt. n.h.l. municipal medical colllege and scl hospital, ahmedabad. x 19gjra global journal for research analysis medicine moyamoya disease is a chronic, progressive occlusion of the circle of willis arteries that leads to the development of characteristic collateral vessels seen on imaging, particularly cerebral angiography. the disease may develop in children and adults, but the clinical features differ. moyamoya disease occurs predominantly in japanese individuals but has been found in all races with varying age distributions and clinical manifestations. as a result, moyamoya disease has been underrecognized as a cause of ischemic and hemorrhagic strokes. [1]moyamoya disease was rst described in japan by takeuchi and shimizu in 1957. although the disease is most common in [2-3]japan, many subsequent cases have been reported elsewhere, including north america and europe. moyamoya disease is deemed a progressive steno-occlusive disease at terminal portions of the bilateral internal carotid [4]arteries with the development of “moyamoya vessels” as collateral channels of circulation. the appearance of these small, multiple vessels at the base of the brain on catheter angiography was originally described by the japanese term moyamoya, [5]which translates to “puff of smoke.” abstract keywords : dr. prasanna patel* rd3 year resident, department of medicine, smt. n.h.l. municipal medical colllege and scl hospital, ahmedabad. *corresponding author dr. kanaiya patel nd2 year resident, department of medicine, smt. n.h.l. municipal medical colllege and scl hospital, ahmedabad. dr. harsh pathak rd3 year resident, department of medicine, smt. n.h.l. municipal medical colllege and scl hospital, ahmedabad. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 20 x gjra global journal for research analysis strokes, neurological deci ts , and al terat ions in consciousness). adults present in their mid-40s with recurrent headache and intracranial hemorrhage, often in the subcortical brain structures such as the basal ganglia. the hemorrhage is likely due to rupture of fragile collateral vessels or the development of cerebral aneurysms from shear stress; headaches may be due to dilated leptomeningeal collateral vessels stimulating nociceptors in the dura. acute management is mainly symptomatic and directed toward reducing elevated intracranial pressure, improving c e r e b r a l b l o o d  o w, a n d c o n t r o l l i n g s e i z u r e s . revascularization procedures are currently performed to increase the perfusion to the hypoxic brain tissue. the literature supports these procedures, and the long-term favorable outcome has been reported in terms of improvement in symptoms and positive angiographic follow-ups in all age [10] groups. hence patient was referred to the higher center for further management. on follow-up, it was found that the patient underwent direct revascularization by supercial temporal artery-mca anastomosis [11] and had no complications in the postoperative period and was discharged. references 1. takeuchi k, shimizu k. hypogenesis of bilateral internal carotid arteries [in japanese]. no to shinkei. 1957;9:37-43. 2. chiu d, shedden p, bratina p, grotta jc. clinical features of moyamoya disease in the united states. stroke. 1998;29:1347-1351. http: // stroke. ahajournals. org /cgi/content/full/29/7/1347. accessed august 27, 2009. 3. bertora p, lovati c, gambaro p, vicenzi a, rosa s, osio m, et al. moyamoya disease in a member of the roma gypsy community [letter] [published online ahead of print february 8, 2008]. eur neurol. 2008:59:274-275. http://content.karger.com/produktedb/produkte.asp?typ=fulltext&le=0001 15643. accessed august 27, 2009. 4. kitamura k, fukui m, oka k. moyamoya disease. in: handbook of clinical neurology. vol2 . amsterdam, the netherlands: elsevier;1989 : 293-306. 5. suzuki j, takaku a. cerebrovascular `moyamoya' disease: disease showing abnormal net-like vessels in base of brain. arch neurol. 1969;20:288-299. 6. miyamoto s, yoshimoto t, hashimoto n, et al.: effects of extracranialintracranial bypass for patients with hemorrhagic moyamoya disease: results of the japan adult moyamoya trial. stroke. 2014, 45:1415-1421. 10.1161/strokeaha.113.004386 7. huang s, guo zn, shi m, yang y, rao m: etiology and pathogenesis of moyamoya disease: an update on disease prevalence. int j stroke. 2017, 12:246-253. 10.1177/1747493017694393 8. scott rm, smith er: moyamoya disease and moyamoya syndrome. n engl j med. 2009, 360:1226-1237. 10.1056/nejmra0804622 9. janda ph, bellew jg, veerappan v: moyamoya disease: case report and literature review. j am osteopath assoc. 2009; 109(10): 547–53. pubmed abstract 10. han dh, kwon ok, byun bj, choi by, choi cw, choi ju, et al. a co-operative study: clinical characteristics of 334 korean patients with moyamoya disease treated at neurosurgical institutes (1976-1994). the korean society for cerebrovascular disease. acta neurochir (wien) 2000;142:1263-73. 11. smith er, scott rm. surgical management of moyamoya syndrome. skull base 2005;15:15-26. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 19.dr. neha chlamela.cdr introduction – in this modern era of globalization people are very busy in their own work and focuses only on his career as a result they do not care about their health to save time they eat instant, packaged food or unhealthy food resulting many peoples are suffering from so many digestive problems like loss of appetite, weak digestion constipation, diarrhea, piles etc. ayurveda, traditional system of indian medicine is very rich about herbal medicine, bilva is very useful& common herbal medicine. the word bilva is derived from 'bil' to split. ya– ska derived this word from bhr. 'to support' or 'to nourish', or from . bhid 'to split' bilva consists of dried stem bark of aegle marmelos corr. (fam. rutaceae), an armed, medium sized tree occurring in the plains and upto 1000 m in the hills as well as cultivated throughout the country, particularly in sacred 1 2groves. bilva has been conserved since ages. more than 15 synonyms of bilva are depicted in ayurvedic texts, like shandilya, shailush, shreephal, maloor, gandhgarbh, 3 kantaki, sadaphala, mahakapittha, granthil etc. bilva (aegle marmelos corr.) belongs to plantae kingdom, geraniales 4order and rutaceae family . vernacular names of bilva are bela or bilva in bangala, bael or baela in marathi, vilvam in tamil, bill or billum in gujarati, bela in oriya, maredu in 5telugu, belin urdu and bengal quince in english . its tree found throughout india its forest found in south india, bihar and bengal it has religious signicance because of this 6it is generally found near temples .bilva is kashaya, tikta rasa, laghu, rukshaguna and katuvipaka, ushanavirya 7drug and has kapha-vatashamak property . literature review – there is an extent description of bilva in our classical text and nighhantus mainly described the properties of various parts of bilva. acharya charaka mentioned bilva in shothahar, arshoghn, aasthapanopaga and anuvasnopaga mahak 8ashaya . in sushrut samhita it is mentioned in vrhut 9panchmoola, varunadi gana and ambasthadi gana . review of “bilva"a marvelous medicine original research paper dr. neha chalmela pg scholar, pg dept. of dravyaguan, govt. dhanwantari ayurveda college ujjain (mp) ayurveda keywords : volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. shiromani mishra* guide & associate professor, pg dept. of dravyaguan, govt. dhanwantari ayurveda college ujjain (mp) *corresponding author uses of different parts of bilva in nighantus bhavaprakash 10nighantu 11shaligram nighantu 12kaiyadeva nighantu 13dhanwantari nighantu bilva patra (leaves) vatahar, shothahar, jwa r ahar, sleshmanisarak, grahi aamshulaghan kapha, vata aam and shoolnashak grahi and rochak vatahar and sangrahi ---bilva pushpa (flowers) benecial in atisar (diarrhea) trusha (thirst), vaman (vomiting) benecial in atisar (diarrhea) trusha (thirst) and vaman (vomiting) benecial in atisar (diarrhoea) trusha (thirst) and vaman (vomiting) ---bilva moola vatanadi sansthan , shamak, madhur, chhar dighan, vatahara ---madhur, laghu, trido sh ahar cure vomiting, dyso urea (mutrakrichha) and shoola tridoshanasak chhardinasak madhur in rasa and laghu in guna bilva taila ---ushna and vata vinashak ushna and uttam vatahar ---bilva phala unripe fruit katu, tikta fruit, kashaya snigdh, ushna, deepan, grahi, vatakapha nashak, protect to intestine ripe fruit – madhur suga n d h i g u r u ( h e a v y ) , vidahi vishtambhi, durj ar doshkar, amulomic durgandhayukta ---unripe fruit – katu, kashaya, tikta rasa, ushana in veerya deepan, pachan, tikshna, laghu, grahi, hridya, vat kaphanashak ripe fruits – madhur anurasa, guru, vidahi, v i s h t a m b h i , d u r j a r, doshkar, diminished, jathragni, rot smelling due to apanvayu vikruti unripe fruit – snighdha in guna, sangrahi deepan, katu tikta, kashaya in rasa, tikshna, vata kapha shamak. ripe fruit – madhur anurasa, guru in guna, vidhahi vishtambhakar, rot smelling due to apan vayu vikruti bilva peshika (dry pulp) ---kapha, vata, aam, shoo lnashak, malarodhak kaphavata shamak, aa m packak, grahi, sho olhar --- x 51gjra global journal for research analysis 14botanical description – a moderate size tree 6.0 – 7.5 m. high, branches armed with straight sharp axillary. 2.5 cm long spine leaves trifoliate, occasionally digitate, five foliate, leaets ovate or ovate lanceolate acuminate, crenate, lateral sessile, terminal long petioled. flowers greenish white, in short axillary panicles, fruits globose grey or yellowish, rind woody. seeds many, oblong, embedded in sacs covered with thick orange coloured sweet pulp. rogaghanta – in ayurvedic textbilva is described to treatatisara, pravahika, agnimandya, grahani, raktatisara, vibandha, visuchika, 14raktarsha, vaman etc. 15chemical constituents – ÿ marmelosin ÿ aegelin ÿ aegelinin ÿ marmin ÿ musilaze ÿ poctine ÿ sugar ÿ volatile oil etc 16parts used – root, leaf, fruits, bark ÿ for churna use unripe fruits ÿ for murabba use underdone fruit ÿ for panak use ripe fruits ÿ for doshmoola kwatha use moola (root) of bilva. 17action & uses – roots – the roots are sweet astringent, bitter and febrifuge, useful in diarrhea, dysentery, dyspepsia, gastralgia, palpitation, seminal weakness, uropathy, vomiting, intermittent fever, swelling & gastric irritability in infants. leaves – are astringent, laxative and expectorant and useful in opthalmia, deafness, diabetes unripe fruits – are bitter, acrid, sour, astringent digestive and stomachic and are useful in diarrhoea, dysentery and stomachalgia. ripe fruits – are astringent sweet, aromatic cooling, febrifuge, laxative and tonic and are good for heart and brain and in dyspepsia. pharmacological activity proved in previous research works – the crude extracts of bilva are reported widely to act as 1 8 1 9antidiabetic analgesic , anti-inammatory and , 20antihyperglycemic and antidyslipidemic, , 21 antidiarrhoeal oral hypoglycaemic anticancer , antiviral , 22 23, 24 25, antifungal radioprotective , cardioprotective 26 27, and antispermatogenic 28 agents. recent studies demonstrate the curative effects of the ethanolic extract of bilva plants against 2,4,6trinitrobenzene sulfonic acid (tnbs) – induced colitis in rats 29through its anti-bacterial and anti-oxidant properties. thus there is extensive data on the use of leaves, bark, roots, fruits and seeds of bilva in ayurveda for prevention and treatment of variety of inammatory diseases. 30religious beliefs – eartiest evidence of religious importance of bael trees are considered an incarnalion of goddess parvati. bael trees can be usually seen near that hindu temples. it is belived that hindu deity lord shiva is fond of bael trees and its leaves and fruits still play a main role in his worship. conclusion – bilva is common easily available and well known drug in community with very high therapeutic values since vedic period the present review of bilva can be benecial to know about properties of various part of bilva mentioned in various nighantus. this article will be useful in giving importance to other therapeutic extension. references – 1. ayurvedic pharmacopoeia of india, govt. of india, ministry of health and family welfare, dept. of ayush, new delhi, part 1, vol. 4, p. 12 2. rawat rbs, uniyal rc (2003). national medicinal plant board committed for overall development of the sector. agro. bios. med. plant, 1: 12-16. 3. dravyaguna vijnana vol ii, prof p.v. sharma, chaukhamba bharti academy reprint 2018. 4. mukherjee pulok, quality control of herbal drugs: an approach to evaluation of botanicals, buisness horizons pharmaceutical publishers, third reprint 2008. 5. ayurvedic pharmacopoeia of india, govt. of india, ministry of health and family welfare, dept. of ayush, new delhi, part 1, vol. 4, p. 12 6. vanoshadhi nigdarshika writer raam sushil singh uttarpradesh hindi sansthan reprint 2008 7. dravyaguna vijnana vol ii, prof p.v. sharma, chaukhamba bharti academy reprint 2018. 8. caraksamhita of agnivesa elaborated by carak and redacted by drdhabala vol – i by acharya vidhyadhar shukla prof. ravi dutt tripathi, chaukhamba sanskrit pratishthan delhi reprint 2011 9. susrutsamhita part i by kaviraja ambikadutta shastri chaukhambha sanskrit sansthan varanasi 2003 10. bhavaprakash nighantu – commentary by dr. k.c. chunekar edited by dr. g.s. pandey reprint 2002 chaukhambha bharti academy. 11. shaligram nighantu bhushnam, khemraj prakashan mumbai. 12. kaiyadeva – nighantu (pathyapathya – vibodhakah) edited and translated by prof. priyavrata sharma & dr. guruprasad sharma, chaukhamba orientalia rst edition 1979. 13. dhanwantari nighantu edited & translated by dr. jaharkhande ojha choukhambasurbharti publication varanasi edition 2004. 14. database or medicinal plants used in ayurveda, volume i, p.c. sharma, m.b. yelne, t.j. dennis, central council for research in ayurveda & siddha. reprinted 2002 15. dravyaguna vijnana vol ii, prof p.v. sharma, chaukhamba bharti academy reprint 2018. 16. bhavaprakash nighantu – commentary by dr. k.c. chunekar edited by dr. g.s. pandey reprint 2002 chaukhambha bharti academy. 17. database or medicinal plants used in ayurveda, volume i, p.c. sharma, m.b. yelne, t.j. dennis, central council for research in ayurveda & siddha. reprinted 2002 18. m.c. sabu, r. kuttanantidiabetic activity of aegle marmelos and its relationship with its antioxidant propertiesindian j physiol pharmacol, 48 (1) (2004), pp. 81-88 19. v. arul, s. miyazaki, r. dhananjayanstudies on the anti-inammatory, antipyretic and analgesic properties of the leaves of aegle marmelos corr j ethnopharmacol, 96 (1–2) (2005), pp. 159-163 20. t. narender, s. shweta, p. tiwari, k. papi reddy, t. khaliq, p. prathipati, etal. antihyperglycemic and antidyslipidemic agent from aegle marmelosbioorg med chem lett, 17 (6) (2007), pp. 1808-1811 21. r. mazumder, s. bhattacharya, a. mazumder, a.k. pattnaik, p.m. tiwary, s. chaudharyantidiarrhoeal evaluation of aegle marmelos (correa) linnroot extractphytother res, 20 (1) (2006), pp. 82-84 22. e.h. karunanayake, j. welihinda, s.r. sirimanne, g. sinnadoraioral hypoglycaemic activity of some medicinal plants of sri lanka j ethnopharmacol, 11 (2) (1984), pp. 223-231 23. b.k. rana, u.p. singh, v. tanejaantifungal activity and kinetics of inhibition by essential oil isolated from leave of aegle marmelos j ethnopharmacol, 57 (1) (1997), pp. 29-34 24. e. lambertini, i. lampronti, l. penolazzi, m.t. khan, a. ather, g. giorgi, et al.expression of estrogen receptor alpha gene in breast cancer cells treated with transcription factor decoy is modulated by bangladeshi natural plant extracts oncol res, 15 (2) (2005), pp. 69-79 25. l. badam, s.s. bedekar, k.b. sonawane, s.p. joshiin vitro antiviral activity of bael (aegle marmeloscorr) upon human coxsackieviruses b1-b6j commun dis, 34 (2) (2002), pp. 88-99 26. g.c. jagetia, p. venkatesh, m.s. baligaevaluation of the radioprotective effect of bael leaf (aegle marmelos) extract in miceint j radiatbiol, 80 (4) (2004), pp. 281-290 27. s.k. haraveya preliminary communication of the action of aegle marmelos (bael) on heartindian j med res, 56 (3) (1968), pp. 327-331 28. a. chauhan, m. agarwal, s. kushwaha, a. mutrejasuppression of fertility in male albino rats following the administration of 50% ethanolic extract of aegle marmelos, contraception, 76 (6) (2007), pp. 474-481 29. r.r. ghatule, m.k. gautam, s. goel, a. singh, v.k. joshi, r.k. goel protective effects of aegle marmelos fruit pulp on 2,4,6-trinitrobenzene sulfonic acidinduced experimental colitis pharmacogn mag, 10 (2014), pp. s147-s152 30. https://em.mwikipedia.org volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 52 x gjra global journal for research analysis introduction: dyspepsia, meaning bad digestion, is a medical condition characterized by chronic or recurrent pain in the upper abdomen, upper abdominal fullness and feeling of fullness earlier than expected when eating. it can be accompanied by bloating, belching, nausea or heartburn. dyspepsia is one of the most common symptoms bringing the patient to the physician according to tally [1]. dyspepsia is fourth ranking symptom presenting for diagnosis in primary care. surveys in western societies have recorded prevalence between twenty one to forty ve percent [2, 3, and 4]. dyspepsia symptoms have been classied as reux or ulcer or dysmotility. in patients with dyspepsia who are investigated, four major causes can be identied for their complaints1. chronic peptic ulcer disease 2. gastroesophageal reux disease (with or without esophagitis) 3. malignancy 4. functional (non ulcer) dyspepsia. non ulcer dyspepsia is dened as chronic or recurrent pain or discomfort centred in the upper abdomen at least for three months where there is no c l in ical , b iochemical , ultrasonography or endoscopic evidence of known organic disease that is likely to explain these symptoms [5]. various investigators have shown that evidence of non ulcer dyspepsia ranges from 7-38% among individuals with all types of dyspepsia. about 40% of all types of dyspepsia occur in patients younger than 25 and 3-7% of all cases occur in patients older than 60. non ulcer dyspepsia has been associated with positive family history of dyspepsia and that of peptic ulcer disease [6]. rome ii diagnostic criteria for functional dyspepsia, based on consensus opinion of an international panel of clinical investigators, [7] are as follows: (1) one or more of (a) post-prandial fullness (b) early satitation. (c) epigastric pain (d) epigastric burning. (2) no evidence of structural disease (including at upper gastrointestinal endoscopy) that is likely to explain the symptoms. (3). no evidence that dyspepsia is exclusively relieved by defecation or associated with onset of a change in stool frequency or stool form (irritable bowel syndrome). non-ulcer dyspepsia is sub-categorised into ulcer-like, dysmotility like and non-specic dyspepsia [8, 9]. ulcer like dyspepsia: three or more of the following are necessary, but upper abdominal pain must be a predominant complaint: 1. pain that is well localised in the epigastrium. 2. pain relieved by food, often (more than 25% of the time). 3. pain relieved by antacids and/or h2 blockers, often.4.pain occurring before meals or when hungry, often.5. pain that at times wakes the prevalence of helicobacter pylori in non-ulcer dyspepsia patients original research paper rayees ahmad bhat assistant professor in dept. of general surgery. al-falah school of medical sciences and research centre (afsmsrc), faridabad, haryana. general surgery background: helicobacter pylori had unquestionably been observed by a number of workers since birchers rst description in 1874. luck jm, seth tn in 1924 documented urease activity in the human stomach. it was thought that this urease activity originated in gastric mucosal cells and was not associated with the presence of bacteria. aims and objective: 1.to know the prevalence of helicobacter pylori in non-ulcer dyspepsia patients and to know the prevalence of helicobacter pylori in different clinical sub-groups of non-ulcer dyspepsia. methods and materials: study was conducted in post-graduate department of surgery in govt. medical college jammu over a period of one year. patients with non-ulcer dyspepsia, who attended the department of surgery either outpatient department or indoor, were subjected to this study. diagnosis of patients was made from the history of patients and upper g.i. endoscopy. overall seventy patients of non ulcer dyspepsia formed the material of the study. . ultrasonography of abdomen was done to rule out any pathology responsible for dyspepsia. result: th rd th the maximum numbers of non ulcer dyspepsia patients were seen in 4 decade of life followed by 3 and 5 decade of th rd thlife. 25.71% of cases were seen in 4 decade of life while 24.29% & 21.42% of cases were seen in 3 & 5 decade of life rdrespectively. the prevalence of h. pylori infection increases with age. among 33 h. pylori positive patients, 7 patients are in 3 th thdecade while 9, 8 and 6 patients are in 4 , 5th & 6 decade respectively. prevalence of h. pylori infection in each age group rd th th thincreases with each decade 41.18%, 50%, 53.33%, 60% cases in 3 , 4 , 5 & 6 decades respectively. conclusion: maximum percentage of non ulcer dyspepsia patients was in third decade. prevalence of h pylori infection increased with age. prevalence of h pylori in males and females was not signicantly different. prevalence of h pylori in lower socio-economic class was signicantly different from middle and upper classes suggesting that poor hygiene and overcrowding are responsible for increased prevalence of h pylori in patients of lower socio economic status. abstract keywords : dyspepsia, helicobacter pylori, gerd, peptic ulcer. dr. dug tariq hassan* assistant surgeon directorate of health services, kashmir *corresponding author dr. liyaqat nazir general surgeon health and medical education dept. j & k. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr shabir ahmad dar general surgeon health and medical education dept. j & k. dr. mohammad zakiuddin professor, dept. of physiology. madhubani medical college, madhubani. 4 x gjra global journal for research analysis patient from sleep. 6. periodic pain with remissions and relapses. dysmotility like dyspepsia: pain is not a dominant symptom; upper abdomen discomfort should be present in all cases. this discomfort should be chronic and characterised by three or more of the following: 1. early satiety 2. postprandial fullness. 3. nausea 4. retching and/or vomiting that are recurrent. 5. bloating in the upper abdomen not accompanied by visible distension. 6. upper abdominal discomfort often aggravated by food. unspecied dyspepsia (non-specic): dyspeptic patients whose symptoms do not full the criteria for ulcer like and dysmotility like dyspepsia. reux type dyspepsia: dyspepsia with predominant feature heart burn. many of these patients may actually have gerd. aims and objective: our study is undertaken with intent to know the prevalence of helicobacter pylori in non ulcer dyspepsia patients through histopathological examination and rapid urease test of biopsy. 1. to know the prevalence of helicobacter pylori in non-ulcer dyspepsia patients. 2. to know the prevalence of helicobacter pylori in different clinical sub-groups of nonulcer dyspepsia. material and methods: this study was conducted in post-graduate department of surgery in govt. medical college jammu over a period of one year. patients with non-ulcer dyspepsia, who attended the department of surgery either outpatient department or indoor, were subjected to this study. diagnosis of patients was made from the history of patients and upper g.i. endoscopy. overall seventy patients of non ulcer dyspepsia formed the material of the study. a detailed history was taken and thorough clinical examination was done according to the performa. patients were subjected to routine investigations. ultrasonography of abdomen was done to rule out any pathology responsible for dyspepsia. inclusion criteria: patients were subjected to upper g.i. endoscopy to rule out any organic cause for dyspepsia like erosions, ulcers, growth etc. patients having normal gastric mucosa or having features of gastritis without erosions were included in the study. endoscopic biopsy was taken from body and antrum of stomach and was studied for helicobacter pylori by histopathological examination of specimen using haematoxylin and eosin and special stains such as giemsa stain. biopsy was also subjected to rapid urease test to check for urease activity of helicobacter pylori. after taking the biopsy from gastric mucosa, specimen was immediately subjected to rapid urease test using rapid urease test kit. this kit contains urea in agar along with phenol red with an acidic hp . biopsy was inoculated into the medium and kept at room temperature. the change in colour from yellow to pink was taken as positive. mostly the colour change occurred within one hour in positive cases. observation: in this study, following observations were made: table – 1: age distribution. fig. : showing age distribution of patients. thmaximum numbers of patients of nud were recorded in the 4 rd thdecade of life followed by 3 and 5 decade of life. there were th rd25.71% of cases in 4 decade, 24.29% in 3 decade and th21.42% in 5 decade. table –2: sex distributions: fig. 2: showing sex distribution of patients 51.43% were males and 48.57% were females thus giving male to female ratio of 1.059. table – 3: distribution according to symptoms into clinical subgroups: the distribution of patients according to their symptoms into three clinical subgroups are as follows: fig. 3-: showing distribution of patients into clinical sub groups so patients in ulcer like subgroup are more compared to non specic subgroup & patients in non specic subgroup are more compared to those in motility disorder like subgroup. table – 4: (nsaid incidence) incidence of drug intake (nsaids and proton pump inhibitors): volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra age no. of patients percentage 0-10 0 0 11-20 3 4.29 21.30 17 24.29 31-40 18 25.71 41-50 15 21.42 51-60 10 14.29 >60 7 10 total 70 100 sex no. of patients percentage males 36 51.43 females 34 48.57 total 70 100 subgroup no. of patients percentage ulcer like 27 38.57 motility disorder like 20 28.57 mixed(non – specic) 23 32.86 total 70 100 nsaids intake no. of patients percentage h/o nsaids intake 12 17.14 no. h/o nsaids intake 58 82.86 total 70 100 x 5gjra global journal for research analysis fig. 4: showing distribution according history of nsaids intake. table – 5: ppi intake incidence. fig. 5: showing distribution according history of ppi intake only 17.14% of patients were using nsaids. while 80% of patients were using proton pump inhibitors. one patient was using benzodiazipines (alprazolam). table – 6: distribution according to endoscopic ndings: fig. 6: showing distribution according to endoscopic ndings. 45.71% of patients were having normal mucosa while 54.29% of patients having gastritis. histopathology and rapid urease test for h. pylori: rapid urease test was done immediately after taking biopsy using rapid urease test kit. results were noted by colour changes. while histopathology examination was done by haematoxylin and eosin and using special stains like giemsa stain. table-7: rapid urease test. fig.7: showing h.pylori +ve and –ve patients. by histopathological examination using special stains, 31 patients were positive for h. pylori and 39 were negative for h. pylori while by rapid urease test 28 patients were positive and 42 were negative. two patients were positive by rapid urease test alone, ve patients were positive by histopathology alone and twenty six patients were positive by both tests. final result was considered positive if either histopathology for h. pylori was positive or rapid urease test was positive or both were positive. overall 33 patients were positive for h. pylori and 37 patients were negative for h. pylori, so percentage of h. pylori positive patients was 47.14%. h. pylori positive patients are more in lower socio-economic class compared to middle socio-economic class and upper socio-economic class. 70.83% patients of lower class are h. pylori positive while 36.36% and 30.77% of middle and upper classes are h. pylori positive respectively. result: the maximum numbers of non ulcer dyspepsia patients were th rd thseen in 4 decade of life followed by 3 and 5 decade of life. th25.71% of cases were seen in 4 decade of life while 24.29% & rd th21.42% of cases were seen in 3 & 5 decade of life respectively. the prevalence of h. pylori infection increases with age. among 33 h. pylori positive patients, 7 patients are in rd th th3 decade while 9, 8 and 6 patients are in 4 , 5th & 6 decade respectively. prevalence of h. pylori infection in each age group increases with each decade 41.18%, 50%, 53.33%, 60% rd th th thcases in 3 , 4 , 5 & 6 decades respectively. discussion: in this study the maximum numbers of non ulcer dyspepsia th rd thpatients were seen in 4 decade of life followed by 3 and 5 thdecade of life. 25.71% of cases were seen in 4 decade of life rd thwhile 24.29% & 21.42% of cases were seen in 3 & 5 decade of life respectively. number of nud patients was relatively less in children and patients with above 60 years of age. these ndings are comparable to ndings of hassan b abdel hafeiz et al in 1999 who found that maximum number of non ulcer rd thdyspepsia cases was seen in 3 , 4th & 5 decades 27.5%, 27.5% & 18.8% respectively. in our study prevalence of h. pylori infection increases with age. among 33 h. pylori rdpositive patients, 7 patients are in 3 decade while 9, 8 and 6 th thpatients are in 4 , 5th & 6 decade respectively. prevalence of h. pylori infection in each age group increases with each rd th th thdecade 41.18%, 50%, 53.33%, 60% cases in 3 , 4 , 5 & 6 decades respectively. these ndings are consistent with ndings of l. thermer et al in 1996 who found that h pylori infection rate in patients increases with age. the prevalence of non ulcer dyspepsia in two sexes was almost similar in our study with slightly increasing prevalence in males compared to females (male = 51.43% and female = 48.57%). results are comparable with the study of hassan b abdel hafeiz et al (1999) where a difference in prevalence of nud among males and females was statistically insignicant. conclusion: non ulcer dyspepsia is a common disorder bringing the patient to opd. maximum percentage of non ulcer dyspepsia patients was in third decade. prevalence of h pylori infection increased with age. prevalence of h pylori in males and females was not signicantly different. prevalence of h pylori in lower socio-economic class was signicantly different from middle and upper classes suggesting that poor hygiene and overcrowding are responsible for increased prevalence of h pylori in patients of lower socio economic status. prevalence of h pylori among smokers and non smokers was not signicantly different. prevalence of h pylori is more in patients with features of gastritis on endoscopy than those with normal mucosa. this suggests that inammatory changes are commonly present in case of h pylori infection. overall prevalence of h pylori was 47.14%. infectivity rate with h pylori was more in ulcer like subgroup compared to other volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra ppi intake no. of patients percentage h/o ppi intake 56 80 no. h/o ppi intake 14 20 total 70 100 endoscopic findings no. of patients percentage features of gastritis 38 54.29 normal 32 45.71 total 70 100 no. of h. pylori +ve/ -ve patients rapid urease test hpe total (including both tests) no. of h. pylori +ve patients 28 31 33 no. of h. pylori –ve patients 42 39 37 total 70 70 70 6 x gjra global journal for research analysis subgroups. so non ulcer dyspeptic patients, where predominant symptom is pain, can be beneted more with h pylori eradication treatment. references: 1. talleyn, non-ulcer dyspepsia: current approaches to diagnosis. american family physician, 1993; 47:6. 2. jones rh, lipleard s. prevalence of symptoms of dyspepsia in the community. british medical journal, 1989; 298: 30-32. 3. locke g. the epidemiology of functional gastrointestinal disorders in north america. gastroenterology clinics of north america, 1996; 25: 1-9. 4. talley n, zinsmester a, scheck c. dyspepsia and dyspepsia subgroups: a population based study. gastroenterology, 1992; 102: 1259-68. 5. talley nj, silverstein md, agréus l et al.aga technical review: evaluation of dyspepsia. gastroenterology 1998; 114: 582-95. 6. mc namara d a, buckley m, o'mortain c a. non-ulcer dyspepsia. gastroenterol. clin. of north america. 2000; 29(4): 807-18. 7. drossman da. functional gastrointestinal disorders and the rome ii process. gut 1995. aga technical review: evaluation of dyspepsia. gastroenterology 1998; 114: 582-95; 45: ii 2-5. 8. talley nj, stanghellini v, heading rc et al. functional gastro duodenal disorders. gut 1999; 45 (suppl 2):1137-42. 9. w h c hu, s k lam, et al .functional dyspepsia: recent advances in pathophysiology hk pract 1998; 20:327-334. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 7gjra global journal for research analysis introduction world-wide, the head and neck cancers are the sixth most common cancer. it is the most common cancer in developing countries. in india it is the most common cancer of males and the fth most common in females. cigarette-smoking and alcohol consumption are the main reasons for hnscc in the western population, whereas the use of smokeless tobacco and areca nut is the most common cause of hnscc in .[1] southeast asia . in india, nearly two-thirds of patients present with advanced stages. the mean age of patients at presentation of head and neck cancers is the fth and early sixth decades in asian populations compared with the seventh and eighth decades in [1-3]the north american population. loco regionally advanced head and neck cancers(lahnc) i.e stage iii & iv comprise > 60% of these tumours for which cure rates have been < 30 %, with notably high morbidity for surgical as well as non surgical treatment and therefore prognosis remained poor in this group of patients and this has [4]remained unchanged over the past 30 yrs. in meta analysis reported in 2000, comparison of local treatment with or without chemotherapy yielded an absolute benet of 4% in overall survival (os) at 2 and 5 yrs. in favour of chemotherapy. when analysing the data for concomitant chemo-radiotherapy, survival benet was 8% at 5 yrs. an update of this analysis focusing on chemo-radiotherapy (with additional 24 trials) show a 4.5% overall survival (os) for all and 6.5% (p value < 0.0001) for patients who received [5]concurrent chemo-radiotherapy. the advent of concurrent chemo radiation has signicantly contributed to the curability of head and neck cancers including the loco regionally advanced stages. radiation with concurrent single agent cisplatin has been established as standard of care in the management of patients with unresectable head and neck cancers. previously 3 weekly cisplatin regimen with concurrent radiotherapy was consid ered to be the standard treatment in patients with unresectable hnscc but it was also seen that it was associ ated with signicant increase in toxicities. therefore, it was thought that splitting this dose as weekly cisplatin might decrease toxicities maintaining the dose intensity and also avoids the problem of inadequate inpatient beds and delay in administration of chemotherapy. in this background, this prospective, institutional study was undertaken to compare the two different chemotherapy schedules given concurrently with radiotherapy. materials and methods: this prospective study was conducted on 50 histologically proven squamous cell carcinoma lahnc(ajcc stage iii and iv)inoperable patients coming to this hospital between age of 18 to 55 years who were previously untreated .all patients were randomized into two arms of 25 patients each. in arm a patients received inj cisplatin 30mg/m2 weekly on day 1,8,15,22,29,36 given concurrently along with standard rad iotherapy and in arm b patients will receive inj. cisplatin 100mg/m2 on a three weekly basis on days 1,22 given concurrently along with standard radiotherapy. patients received radiotherapy to dose of 70 gray(gy) over 35 fractions(#) over 7 weeks with 5#/week @ 2gy/# .the theratron 780c tele-cobalt machine was used for radiotherapy of the patients after convention planning by radiation oncologist for assessment of toxicity all patients were monitored weekly during the course of ccrt for assessing the early toxicity of therapy. response assessment: for assessment of response recist v1.01 was used. com plete response (cr) was dened as the complete abs ence of disease 6 weeks. partial response (pr) was dened as a reduction of disease by at least 50% in the sum of all measurable products of the longest perpendicular diameters of measurable tumor masses for at least 6 weeks,with no evaluation of toxicity and compliance of cisplatin given weekly vs three weekly concurrently with radiotherapy in head and neck cancer original research paper dr. manish verma department of radiation oncology, government cancer hospital, mgm medical college, indore-452001 x 55gjra global journal for research analysis oncology background: concurrent chemoradiotherapy with cisplatin is widely accepted modality of treatment for head and neck cancer. aim: to compare three weekly cisplatin and weekly cisplatin given concurrently along with external beam radiotherapy in locally advanced head and neck cancers(lahnc) for toxicity and response. materials and methods: 50 patients of lahnc were taken for this prospective study. in arm a 25 patients received 6 cycles of weekly cisplatin 30mg/m2along with radiotherapy and in arm b 2 cycles of cisplatin 100mg/m2 given 3 weekly along with radiotherapy. treatment response was seen at the end of treatment as per recist v1.01 criteria. all chemotherapy toxicities were graded as per common toxicity criteria v4.0 and all radiation toxicities were graded as per rtog toxicity criteria. student unpaired t test was used for statistical analysis. observations and results: in our study no signicant difference was seen in terms of all measured toxicities but hematological toxicities were higher in group b. regarding acute mucositis and dermatitis, most of them were grade 1 and 2 and were taken care of on outpatient care basis. with regards to response to treatment in our study cr was seen in 56% of patients in group a and 54.5% of patients in group b while 3 (12%) patients had stable disease and 6 (24%) patients had partial response in group a while 1 (4.55%) patient in group b had stable disease and 7 (31.82%) patients had partial response with no signicant difference between both groups. conclusion: weekly cisplatin chemotherapy can provide good alternative to 3 weekly cisplatin chemotherapy with lesser toxicity. abstract keywords : head and neck cancer, radiotherapy, concurrent chemotherapy volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. ayush naik* department of radiation oncology, government cancer hospital, mgm medical college, indore-452001 *corresponding author 56 x gjra global journal for research analysis growth of other lesions or appearance of new lesions. stable diseases (sd)was dened as reduction in lesion by less than 50%, or increase by less than 25%. progressive disease(pd) was dened as an increase by at least 25% of tumor lesions or appearance of new lesions. evaluation of toxicity toxicities were evaluated by history, physical examination and laboratory tests. the grading system was based on the radiation therapy oncology group (rtog) acute radiation morbidity scoring criteria.and ctcae v.4. statistical analysis for statistical analysis student unpaired t test was applied and p value was calculated between two arms.the statistics was calculated using mini tab version 17.0. observations and results: according to staging in group a, stage iii patients were 8 (32%), with stage iv a were 15 (60%) and with stage iv b were 2(8%). in group b, stage iii patients were 7 (28%), stage iv a patients were 15 (60%) and stage iv b were 3 (12%). table 1 shows the site wise distribution of patients in both the arms. table 1: distribution of patients according to site of disease. toxicity evaluation: details given table 2 showing different toxicities observed response evaluation: complete response was achieved in 14 (56%) patients in group a and 12 (54.55%) patients in group b, while progressive disease was seen in 2 (8%) patients in group a and 2 (9.09%) patients in group b. in group a, 3 (12%) patients had stable disease and 6 (24%) patients had partial response while 1 (4.55%) patient in group b had stable disease and 7 (31.82%) patients had partial response with no signicant difference between both groups. discussion: historically cisplatin 100 mg/m2 once in every 3 weeks along with radiotherapy was recommended as standard regimen for adjuvant treatment in hnscc. however it was seen that schedules that deliver cisplatin in smaller doses on a more frequent basis may be preferable to high dose bolus administration as more frequent administration could provide radio sensitizing chemotherapy and small individual doses of cisplatin may lead to less chemotherapy induced morbidity without compromising efcacy. in our study the baseline characteristics of patients were similar and no signicant difference was seen between group a and group b with respect to age, sex, performance status, grade and stage. according to ajcc staging in our study majority of patients had stage iva disease, constituting 60% in both groups which [6]was similar to what was seen in study by ahmed el-azony in which 45% of patients had stage iva disease in both groups. with regards to response to treatment in our study cr was seen in 56% of patients in group a and 54.5% of patients in group b while 3 (12%) patients had stable disease and 6 (24%) patients had partial response in group a while 1 (4.55%) patient in group b had stable disease and 7 (31.82%) patients had partial response with no signicant difference between [6]both groups. in similar study by ahmed elazony, cr was achieved in 10 (50%) in 3 weekly group and 9 (45%) patients in weekly group, while pr was achieved in 7(35%) patients in both groups. 3 (15%) patients in group a had no response of whom 2 patients had sd and 1 patient had pd while 4 (20%) patients in group b had no response of whom 3 (15%) had sd and 1 (5%) patient had pd. similar to our study no statistically signicant difference was seen in both arms and comparison between two modalities resulted in statistically similar response rates and adverse event prole. in our study no signicant difference was seen in terms of all measured toxicities but hematological toxicities were higher in group b. regarding acute mucositis and dermatitis, most of them were grade 1 and 2 and were taken care of on outpatient care basis. no signicant difference was seen between acute toxicities in two groups. no grade iv toxicities were seen in [7]either groups..uygun et al, showed that grade 3-4 toxic events were 53.3% in 3 weekly and 40% in weekly cisplatin and no statistical difference was seen similar to our study. ,[8]similiarly in a study by kose et al showed no difference in ,[9]terms of grade 3-4 mucositis.geeta et al showed that 3 weekly was less toxic as compared to weekly cisplatin. less grade iii toxicity of skin and mucous membrane was seen in 3 weekly (40% vs 33%) which was probably attributed to delivery of chemotherapy in divided doses. in our study there was no signicant difference regarding hematologic toxicity, nephrotoxicity and vomiting between both groups due to proper hydration and other symptomatic care measures taken along with regular weekly check [7] up.ugyun et al, reported similar vomiting in both groups. grade 3-4 nephrotoxicity was 16.6% in 3 weekly and 5% in weekly cisplatin group. difference being statistically insignicant. in 3 weekly group neutropenia was mildly [10] higher. .in study by ho et al, no signicant difference was seen between two groups with regard to grade iii neutropenia, there was similar renal toxicity in both groups and no grade 3volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra site weekly group 3 weekly group no. % no. % larynx 6 24.0 5 20.0 oral cavity 13 52.0 10 40.0 pharynx 6 24.00 10 40.0 total 25 100.0 25 100.0 toxicity weekly group 3 weekly group p value no. % no. % anemia grade i 8 32.0 8 36.36 0.75 grade ii 8 32.0 9 40.91 0.526 grade iii 4 16.0 4 18.18 0.84 leucopenia grade i 7 28.0 8 36.36 0.54 grade ii 8 32.00 7 31.82 0.989 grade iii 2 8.00 3 13.64 0.53 renal toxicity grade i 12 48.00 10 45.45 0.86 grade ii 6 24.00 5 22.73 0.92 grade iii 2 8.00 2 9.09 0.89 vomiting grade i 5 20.00 10 45.45 0.056 grade ii 12 48.00 9 40.91 0.62 grade iii 3 12.00 1 4.55 0.34 dermatitis grade i 14 56.00 13 59.09 0.83 grade ii 10 40.00 9 40.91 0.94 grade iii 1 4.00 0 0.00 0.30 mucositis 0 0.00 0 0.00 grade i 14 56.00 10 45.45 0.46 grade ii 9 36.00 10 45.45 0.51 grade iii 2 8.00 2 9.09 0.89 4 renal toxicity was seen. ,[9]geeta et al reported higher grade iii hematological toxicity in weekly group. grade iii anaemia was 12.5% in weekly and 4% in 3 weekly group. grade iii neutropenia was also higher in weekly group. grade i thrombocytopenia was 8% in 3 weekly and 6% in weekly group. in our study, in group a, 8 (32%) patients had grade i, 8 (32%) patients had grade ii and 4 (16%) patients had grade iii anemia. in group b, 8 (36.36%) patients had grade i, 9 (40.91) patients had grade ii and 4 (18.18) patients had grade iii anemia with no signicant statistical difference and regarding thrombocytopenia, in group a, 4 (16%) patients had grade i, 5 (20%) patients had grade ii, 3 (12%) patients had grade iii thrombocytopenia. in group b, 4 (18.18%) patients had grade i, 2 (9.09%) patients had grade ii, 4 (18.18%) patients had grade iii thrombocytopenia. no signicant statistical difference was seen between both groups in terms of anemia and thrombocytopenia and both were taken care of with blood transfusions wherever needed. no grade iv anemia or thrombocytopenia was seen. in our study, in group a, 22 out of 25 patients completed treatment without any breaks whereas in group b, out of 22 patients 20 patients completed treatment without any breaks and due to severe dermatitis and mucositis along with [11],hematological toxicity. jemal a in his study showed that signicant number of patients could not receive the third cisplatin dose of 100 mg/m2. in our study in group b, 3 patients did not complete full course of treatment and therefore were excluded from the study. compliance is another signicant problem with the standard cisplatin 100mg/m2 concurrent chemo-radiotherapy regimen.in our study in which the compliance was 100% in group a and 88% in group b which was similar to the study done previously by eortc and rtog conclusions in our study comparison of both regimens given concurrently with radiotherapy showed statistically similar response rates and adverse event prole. in terms of tumor response and toxicity both the regimens had equal results due to more potent medications available to manage them. however better compliance was seen in weekly cisplatin group as compared to 3 weekly due to toxicities. thus use weekly cisplatin can be used nowadays due to less tolerability of 3 weekly regimen in some settings because of which less patients achieve cumulative dose beyond 200 mg/m2, lowering chemotherapy dose intensity . references: 1. agarwal ak, sethi a, sareen d, dhingra s. treatment delay in oral and oropharyngeal cancer in our population: the role of socio-economic factors and health-seeking behaviour. indian j otolaryngol head neck surg. 2011;63:145–50. 2. patel ua, lynn-macrae a, rosen f, holloway n, kern r. advanced stage of head and neck cancer at a tertiary-care county hospital. laryngoscope. 2006;116:1473–7 3. chhetri dk, rawnsley jd, calcaterra tc. carcinoma of the buccal mucosa. otolaryngol head neck surg. 2000;123:566–71. 4. diaz em, holsinger ffc, zuniga er, roberts db, sorensen dm. squamous cell carcinoma of the buccal mucosa: one institution’s experience with 119 previously untreated patients. head neck.2003;25:267–73. 5. pignon jp, le maitre a, maillard e, bourhis j, mach-nc collaborative group. meta-analysis of chemotherapy in head and neck cancer (mach-nc): an update on 93 randomised trials and 17,346 patients radiotherapy and oncology 2009; 92(1): 4-14. 6. aahmed el-azony, abbas m. sarhan, waleed e. hamouda ,mohammed a. mazrouh z.u.m.j. vol. 18;n.5;september ;2012. 7. uygun k , bilici a , karagol h, et al.: the comparision of weekly and three weekly cisplatin chemotherapy concurrent with radiotherapy in patients with previously untreated inoperable non-metastatic squamous cell carcinoma of the head and neck. cancer chemother pharmacol 2009, 64:601-605. 8. kose f, besen a, sumbul t, et al.: weekly cisplatin versus standard three weekly cisplatin in concurrent chemoradiotherapy of head and neck cancer:the baskent university experience. asian pacic j cancer prev 2011;12,1185-1188. 9. geeta sn, padmanabhan tk, samuel j et al: comparision of acute toxicities of two chemotherapy schedules for head and neck cancers. jcrt 2006; 2(3):100-104. 10. ho kf, swindell r, brammer cv. dose intensity comparision between weekly and 3weekly cisplatin delievered concurrently with radical radiotherapy for head and neck cancer: a retrospective comparision from new cross hospital, wolverhampton, uk. acta oncol 2008;47:1513-8. 11. jemal a, seigel r, xu j, ward e. 2010 cancer statistics. ca cancer j clin; 60:277-300. x 57gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction induction of labor (iol) is a common procedure in obstetrics which implies stimulation of contractions before the spontaneous onset of labor. the indications for iol were postterm pregnancy, oligohydramnios , gestational hypertension , chronic hypertension , gestational diabetes mellitus , intrauterine fetal growth restriction and also fetal (1)death . this procedure is important for both safety of mother and baby. there are mechanical and pharmacological techniques for iol. mechanical techniques include transcervical catheter, extra amniotic saline infusion, and hygroscopic cervical dilators. common pharmacological techniques include oxytocin and prostaglandins (pg) such as misoprostol, a synthet ic pg e1 analogue, can be administered intravaginally, orally and sublingually, it is widely used to (2)terminate pregnancy in the rst and second trimesters . reported iol prevalence varies between countries and over (3)time . for example, in saudi arabia it was 16% in 2012; in the united states it was approximately 20 % of all births. the united states rate increased from 9.5% in 1990 to 22.8% in (4, 5)2007 and 23.3% in 2012 . the successful rate of iol and (6-9)associated factors also varied in different reports . this information is necessary for patient's management and counseling. therefore, the objectives of this study are to determine the prevalence and associated factors of successful iol, and the maternal and perinatal outcomes in our center. materials and methods this study is a descriptive study in the department of obstetrics and gynecology, udonthani hospital, udonthani, thailand. it was conducted after the human research ethical committee of udonthani hospital approved the protocol. patients' medical records who underwent iol in udonthani hospital from october 2017 to june 2019 were reviewed. the inclusion criteria were; singleton pregnant woman who received iol during the study period. the indications for iol were late term pregnancy (gestational age 41 weeks), post term pregnancy (gestational age > 42 weeks), oligohyd ramnios, preeclampsia, chronic hypertension, gestational diabetes mellitus and overt diabetes mellitus, prelabor rupture of membrane, intrauterine fetal growth restriction, chorioamnionitis, fetal anomaly and death fetus in utero. the contraindications of iol were; previous cesarean delivery or myomectomy, multifetal pregnancy, active genital herpes, estimate fetal weight ≥ 4000 grams. an exclusion criterion was incomplete medical record. the sample size was calculated using a formula for a descriptive study, with an estimated prevalence for a (10)successful iol 0.65 with 0.06 acceptable error , a 0.05 chance of making a type 1 error. the result was 242 women were needed for the study. the statistical analysis was performed using stata program version 13. continuous variables are presented by the mean + standard deviation. categorical variables are presented by number and percentage. binary regression analysis was performed to evaluate the difference of variable. multivariable logistic regression analysis was applied to evaluate the factors associated with successful iol. results were presented as adjusted odds ratio with 95% condence interval. a p-value <0.05 was considered statistically signicant. data collection included patients' baseline characteristics, factors associated with successful induction of labor in udonthani hospital original research paper chutinan chantarakhantee* m.d., department of obstetrics and gynecology, udonthani hospital, udonthani, thailand. *corresponding author x 55gjra global journal for research analysis obstetrics and gynecology background: the prevalence of induction of labor varies between countries. the successful rate of iol and associated factors also varied in different reports. objective: to determine the prevalence and associated factors for successful induction of labor (iol). materials and methods: medical records of patients who underwent iol in udonthani hospital from october 2017 to june 2019 were reviewed. results: there were 242 patients who underwent iol and had completed data. the prevalence of iol was 3.7% (242/6469) of total deliveries. a successful iol was achieved in 126 (52.1%) patients (95% ci 45.6-58.5). multiparity had a 3.5 times (95% ci 1.76-6.97,p<0.01) higher success rate than nulliparity., preterm pregnancy increased successful iol of 3.9 times (95% ci 1.4810.49, p<0.01). conclusion: successful iol was achieved in about half of the iol cases. multiparity and preterm pregnancy were associated with higher iol success rate. abstract keywords : induction of labor, success rate, factors, bishop score srisuda songthamwat m.d., department of obstetrics and gynecology, udonthani hospital, udonthani, thailand. ueamporn summart ph.d. faculty of health sciences, udon thani rajabhat university, udonthani, thailand metha songthamwat m.d.,ph.d., department of obstetrics and gynecology, udonthani hospital, udonthani, thailand. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 56 x gjra global journal for research analysis cervical condition and, obstetrics and neonatal outcomes. successful iol was dened as vaginal delivery could be achieved. the prevalence and associated factors for successful iol were analyzed. results there were 242 patients who underwent iol and had complete patient data during the study period. the prevalence of iol in udonthani hospital was 3.7% (242/6,469) of total deliveries. baseline characteristics of the pregnant women and obstetric outcomes are presented in table 1. the mean age was 26.7± 7.2 years. the mean gestational age was 38.4 ± 3.3 weeks. mean body mass index at term was 29.1 ± 5.4. the mean bishop score was 5.2 ± 2.2. the most common indication for iol was late term in 83 women (34.3%). the most common method of iol was oxytocin in 129 (53.3%) patients. the mean time for iol was 20.8+20.0 hours. successful iol was achieved in 126 (52.1%) patients (95% ci 45.6-58.5). comparison of possible associated factors between successful and non-successful iol groups found advanced maternal age group (age > 35) and preeclamptic patients had a lower iol success rate. while multiparity, preterm pregnancy had a higher iol success rate. there were no signicant difference found with body mass index, initial cervical dilatation and effacement, cervical consistency and position, fetal head station and membrane status, induction methods between two groups which shown in table 2. maternal and neonatal outcomes are presented in table3. the neonatal birthweight was higher in the non-successful iol group. the meconium strained amniotic uid was found to be higher in the cesarean (non-successful iol) group, however the birth asphyxia was lower in this group than the vaginal delivery (successful iol) group. there were no difference found in other maternal and neonatal complications in both groups. discussion this study demonstrated that the iol prevalence rate in our institute is 3.7%. this rate is less than other reports, such as in (3)usa which approximately 20% of deliveries , 16% in saudi (11) (12)arabia , 12.1% in asia and 4.4% in africa . induction of labor rate was higher rate in higher income countries and the elective induction of labor (without indication) is more common. the recent randomized controlled study and metaanalysis reported that elective induction in low risk pregnant women with gestational age more than 39 weeks has the better composite neonatal outcome than expectant (13, 14)management . successful iol was achieved in only half of the patients in this study. this rate is lower than previously reported studies which (6-9)the successful iol rate was approximately 70-80% . this (15)study's rate is closest to osmundson s, et al study at 56.9 % . the low iol success rate might be caused by the various and subjective criteria of failed iol, the unsuitable adjustment of oxytocin dosage, and the discontinuation of iol in the nighttime, which increase the failure rate of iol in our center. associated factors for successful iol in this study were multiparity and preterm pregnancy. while multiparty is (6-8)similar to previous studies , preterm pregnancy is different from other studies which had higher iol success rate in term (6-8)pregnancy . maternal body mass index was similar between groups which is also different from previous studies. those studies reported higher successful iol in lower body (6-8)mass index or taller women . cervical status from bishop score is not a successful factor in this study which is different (6, 16, 17)from some previous studies , however this result is similar to a systemic review by kolkman dg, et al which reported that the bishop score is a poor predictor for the iol outcome and (18)should not be used for iol decision making . the most common indication for iol in this study was late term pregnancy, which is similar to al-shaikh gk, et al and (11, 19)dällenbach p,et al studies . the most common method of iol was oxytocin which is similar to data in africa from vogel (12)jp, et al study . the prevalence, indication and, method of iol with a high rate of cesarean delivery in our center reects too low of use of iol. this arose from the fear of its complication especially with misoprostol, although the world health (20)organization and the american college of obstetricians (21)and gynecologists recommend misoprostol as being safe and effective for iol. the only two interventions to delivery before the onset of labor are cesarean delivery and iol, therefore the careful selection of iol can reduce unnecessary (22)cesarean delivery which cause many complications . this study's limitation is the information was retrospective from a single tertiary care center. a larger prospective multicenter study is needed to indicate the effect on the general population. conclusion successful iol was achieved in about half of the iol cases. multiparity and preterm pregnancy were associated with higher successful iol rate. acknowledgements we gratefully acknowledge dr. narong tadadech director of udonthani hospital for permission and grant support. thanks for udonthani hospital staff who participated in this trial. potential conflicts of interest the authors declare no conict of interest. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra characteristics total vaginal delivery cesarean delivery p valueβ total, n (%) 126 (52.1) 116 (48.0) maternal age (years), n(%) 20-34 <20 >35 mean ± sd 163 40 39 26.7 ± 7.2 91 (55.8) 19 (47.5) 16 (41.0) 26.1 + 6.9 72 (44.2) 21 (52.5) 23 (59.0) 27.5 + 7.6 0.20 0.14 parity, n (%) nullipara multipara 136 106 60 (44.1) 66 (62.3) 76 (55.8) 40 (37.7) <0.01* gestational age (weeks),n(%) < 37 ≥37 mean ± sd 37 205 38.4 ± 3.3 27 (73.0) 99 (48.3) 38.0 + 4.0 10 (27.0) 106 (51.7) 39.0 + 2.1 <0.01* 0.02* iol:induction of labor, sd: standard deviation, cpd: cephalo pelvic disproportion. table 1: comparison of maternal characteristics in succe ssful iol and non-successful iol group. x 57gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra body mass index 2(kg/m ), mean+sd 29.1(±sd 5.4) 28.8 (±sd 5.5) 29.5 (±sd 5.2) 0.26 bishop score, n(%) <5 ≥5 mean + sd 85 157 5.2 ± 2.2 38 (44.7) 88 (56.1) 5.3+2.2 47 (55.3) 69 (44.0) 5.1+2.1 0.09 0.35 cervical dilatation (cm), n(%) <2 ≥2 191 51 95 (49.7) 31 (60.8) 96 (50.3) 20 (39.2) 0.16 effacement, n(%) ≤50 >50 211 31 108 (51.2) 18 (58.1) 103 (48.8) 13 (42.0) 0.47 consistency, n(%) firm medium soft 21 70 150 11 (52.4) 32 (45.7) 82 (64.7) 10 (47.6) 38 (54.3) 68 (45.3) 0.48 station, n(%) -3 -2 -1 0 20 74 126 22 12 (60.0) 36 (48.7) 65 (51.6) 13 (59.1) 8 (40.0) 38 (51.4) 61 (48.4) 9 (40.9) 0.73 membrane, n(%) intact ruptured 202 40 109 (54.0) 17 (42.5) 93 (46.0) 23 (57.5) 0.19 position, n(%) posterior middle anterior 78 139 25 37 (47.4) 75 (54.0) 14 (56.0) 41 (52.6) 64 (46.0) 11 (44.0) 0.60 indication for induction, n(%) late term pre-eclampsia prom other 83 37 43 79 46 (36.5) 11 (8.7) 20 (15.9) 49 (38.9) 37 (31.9) 26 (22.4) 23 (19.8) 30 (25.9) 0.01* mode of induction, n(%) misoprostol oxytocin misoprostol + oxytocin other 55 129 55 3 33 (26.2) 61 (48.4) 31 (24.6) 1 (0.8) 22 (19.0) 68 (58.6) 24 (20.7) 2 (1.7) 0.33 route of delivery, n(%) normal delivery cesarean section vacuum extraction breech assisting 117 (48.4) 116 (48.0) 6 (2.5) 3 (1.2) 117 0 6 3 0 116 0 0 indication of c/s, n(%) failed induction fetal distress cpd chorioamnionitis 63 (54.3) 33 (28.5) 19 (16.4) 1 (0.7) 63 33 19 1 β -p value was calculated by linear regression analysis for continuous outcome and by binary regression for binary outcome. *statistically signicant difference (p value <0.05) table 2: univariate and multiple logistic regression analysis of possible associated factors for successful iol. characteristics vaginal delivery cesarean delivery or (95%ci) adjusted or (95% ci) p-valve� maternal age (years) 20-34 <20 ≥35 91 19 16 72 21 23 1 0.72(0.36-1.43) 0.55(0.27-1.12) 1 1.01 (0.44-2.30) 0.40 (0.17-0.94) 0.99 0.02* parity nullipara multipara 60 66 76 40 1 2.09(1.24-3.51) 3.50 (1.76-6.97) <0.01* gestational age (wks) ≥37 <37 99 27 106 10 1 2.89(1.33-6.27) 3.94 (1.48-10.49) <0.01* volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra references 1. cunningham f, leveno k , bloom s, dashe j, hoffman b, casey b, spong cy. williams obstetrics. 25 ed.new york:mcgraw-hill 2018. 2. hofmeyr gj. induction of labour with misoprostol. curr opin obstet gynecol 2001;13:577–81. 3. martin ja, hamilton be, ventura sj, osterman mj, mathews tj. births: nal data for 2011. natl vital stat rep 2013;62:1-69, 72. 4. martin ja, hamilton be, sutton pd, ventura sj, mathews tj, kirmeyer s, et al. births: nal data for 2007. natl vital stat rep 2010;58:1-85. 5. osterman mj, martin ja. recent declines in induction of labor by gestational age. nchs data brief 2014;1-8. 6. crane jm. factors predicting labor induction success: a critical analysis. clin obstet gynecol 2006;49:573-84. 7. gibson ks, waters tp. measures of success: prediction of successful labor induction. semin perinatol 2015;39:475-82. 8. pevzner l, rayburn wf, rumney p, wing da. factors predicting successful labor induction with dinoprostone and misoprostol vaginal inserts. obstet gynecol 2009;114:261-7. 9. tolcher mc, holbert mr, weaver al, mcgree me, olson je, el-nashar sa, et al. predicting cesarean delivery after induction of labor among nulliparous women at term. obstet gynecol 2015;126:1059-68. 10. wayne w. biostatistics: a foundation of analysis in the health sciences. 6 ed. john wiley&sons, inc.; 1995. 11. al-shaikh gk , wahabi ha , fayed aa, esmaeil sa, al-malki ga . factors 58 x gjra global journal for research analysis bmi mean (kg/m2), mean+sd 28.77 (sd± 5.46) 29.54 (± sd 5.22) 0.97(0.93-1.02) 0.98 (0.92-1.03) 0.41 bishop score <6 ≥6 59 67 63 53 1 1.35(0.81-2.24) na na cervical dilatation(cm) <2 ≥2 95 31 96 20 1 1.57(0.85-2.94) 1.59 (0.72-3.50) 0.25 effacement ≤50 >50 108 18 103 13 1 1.32(0.62-2.83) 1.56(0.58-4.23) 0.38 consistency firm medium soft 11 32 82 10 38 68 1 0.77(0.29-2.03) 1.09(0.44-2.74) 0.69(0.20-2.44) 1.17(0.34-4.11) 0.80 station -3 -2 -1 0 12 36 65 13 8 38 61 9 1 0.63(0.23-1.72) 0.96(0.28-3.31) 0.71(0.27-1.86) 0.54(0.16-1.82) 0.68(0.13-3.55) 0.52(0.15-1.77) 0.32 0.65 0.29 membrane intact ruptured 109 17 93 23 1 0.63(0.32-1.25) 0.56(0.22-1.44) 0.23 position posterior middle anterior 37 75 14 41 64 11 1 1.30(0.75-2.26) 1.41(0.57-3.49) 1.80(0.91-3.56) 1.28(0.42-3.88) 0.09 0.66 indication for induction late term pre-eclampsia pre labor rupture of membrane others 46 11 20 49 37 26 23 30 1 0.34(0.15-0.78) 0.70(0.33-1.46) 1.31(0.70-2.46) 1 0.26 (0.09-0.73) 0.79 (0.28-2.24) 1.34 (0.63-2.84) 0.01* 0.66 0.45 mode of induction misoprostol oxytocin misoprostol+oxytocin others 33 61 31 1 22 68 24 2 1 0.60(0.32-1.13) 0.86(0.40-1.83) 0.33(0.02-3.90) 1 0.68 (0.29-1.57) 1.08 (0.46-2.58) 0.34 (0.02-4.95) 0.36 0.86 0.43 iol: induction of labor, or: odd ratio, ci: condence interval. iol: induction of labor, sd: standard deviation, af: amniotic uid, nicu: neonatal intensive care unit. β -p value was calculated by linear regression analysis for continuous outcome and by binary regression for binary outcome. *statistically signicant difference (p value <0.05) β -p value was calculated by multiple logistic regression analysis. *statistically signicant difference (p value <0.05) table 3. comparison of obstetrics and neonatal outcomes in successful and non-successful iol groups. characteristics vaginal delivery, n(%) cesarean delivery, n(%) p valueβ route of delivery 126 (52.1) 116 (48.0) complication uterine atony postpartum hemorrhage 15 (11.9) 9 (7.1) 18 (15.5) 0 (0.0) 0.41 na birth weight (gm) 4000+ 2500-4000 <2500 mean birthweight + sd (gm) 2 (2.0) 94 (74.6) 30 (23.8) 2778.7 + 807.5 4 (3.5) 90 (77.6) 22 (19.0) 2992.3 + 546.5 0.46 0.02* apgar score<7 at 1 min 23 (18.3) 2 (1.7) < 0.01* apgar score<7 at 5 min 23 (18.3) 0 (0.0) na meconium strained af 14 (11.1) 20 (17.4) <0.01* nicu admission 1 (0.8) 4 (3.5) 0.14 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra associated with successful induction of labor. saudi med j 2012;33:298-303. 12. vogel jp, souza jp, gulmezoglu am. patterns and outcomes of induction of labour in africa and asia: a secondary analysis of the who global survey on maternal and neonatal health. plos one 2013;8:e65612. 13. grobman wa, rice mm, reddy um, tita atn, silver rm, mallett g, et al. labor induction versus expectant management in low-risk nulliparous women. n engl j med 2018;379:513-23. 14. grobman wa, caughey ab. elective induction of labor at 39 weeks compared with expectant management: a meta-analysis of cohort studies. am j obstet gynecol 2019;221:304-10. 15. osmundson s, ou-yang rj, grobman wa. elective induction compared with expectant management in nulliparous women with an unfavorable cervix. obstet gynecol 2011;117:583-7. 16. vrouenraets fp, roumen fj, dehing cj, van den akker es, aarts mj, scheve ej. bishop score and risk of cesarean delivery after induction of labor in nulliparous women. obstet gynecol 2005;105:690-7. 17. teixeira c, lunet n, rodrigues t, barros h. the bishop score as a determinant of labour induction success: a systematic review and meta-analysis. arch gynecol obstet 2012;286:739-53. 18. kolkman dg, verhoeven cj, brinkhorst sj, van der post ja, pajkrt e, opmeer bc, et al. the bishop score as a predictor of labor induction success: a systematic review. am j perinatol 2013;30:625-30. 19. dallenbach p, boulvain m, viardot c, irion o. oral misoprostol or vaginal dinoprostone for labor induction: a randomized controlled trial. am j obstet gynecol 2003;188:162-7. 20. world health organization who recommendations for induction of labour. geneva 2011. 21. obstetrics acopb--. acog practice bulletin no. 107: induction of labor. obstet gynecol 2009;114:386-97. 22. world health organization. who recommendations: non-clinical interventions to reduce unnecessary caesarean sections; 2018. x 59gjra global journal for research analysis introduction nickel occurs in small amount in soil and it is a micro nutrient for plant growth and development. at very low concentration it express some effect on germination of seeds. deciency of nickel causes toxic effect in plant due to high concentration of urea. nickel is main component of urease . urease regulates metabolism of nitrogen containing compounds and this process play essential role during seed germination .metronidazole is a heterocyclic drug and used mainly as antibacterial and antifungal agent, possess ability to form complex with metals .many metronidazole complexes of cu,zn,pt,ni cd,co,fe are known having antimicrobial activity ,anti fungal activity and antiviral activity. urea is nitrogen containing fertilizes and provide nitrogen to plants. having adverse effect of high urea concentration on germination of seed ,in present study complex of urea and metronidazole with nickel is examined for germination of t.auestivum and brassica nigra seeds .it was assumed that in complex form urea is not freely available in effective amount to affect the germination of seed. in seed germination seed absorbs water by micropyle and seed swells ,the swelling of embryonic tissue ruptures the seed coat and allow to grow plumule and radical to emerge. the main function of water to activate enzymes which is necessary for hydrolysis of stored food materials .except water the other requirements are temperature ,light, presence of oxygen . the growth and development of plant are acquired by active cell division and differentiation in certain localized region of plant. the urea and its derivatives have also ability to co ordinate with metal ion many complexes of derivative of urea with many metals are known having antibacterial activity. nickel chloride also have some anti bacterial activity. experimental material and methodssynthesis of complexall the chemicals were analytical grade purchased from merck and s. d . ne and used as supplied. in 250 ml r.b. ask 20 ml of .02 m ethanolic solution of nickel chloride is prepared and it mixed with equimolar solutions of urea and metronidazole in ethanol (20mlof each). reuxed the content for 3 hours and then cooled ,ltered, washed and dried . recrystallized it by methanol. (ii) antibacterial studies-antibcterial study were done by disc diffusion method on selected bacterial strains e.coli. ,k. pneumonia ,rizobium, s.aureus. (iii) study of seed germinationbrassica nigra and t. auestivum seeds were selected for petri dish method rstly seeds were sterilized in mercuric chloride and ethanol. the 25,50,75,100,125 µm solution of metronidazole , urea and complex were prepaered.100 healthy seeds of each species of same size were soaked in each solutions of different concentration for three hours using distilled water as control. the seeds then transferred into petri dishes with cotton beeds containing specic solutions. dishes were incubated at240c for 24 hours in dark and then transferred in light conditions for two days and again in dark for two days .then percentage germination was calculated. %germination = no. of seeds germinated /total no. of seeds ×100 result and discssion characterization of complex colour dirty green molar conductance – 21.74 ohm-1cm2 melting point202-205 oc magnetic moment 2.32 b.m. molecular formula-c7n5h18o7cl2ni thermal analysisthe complex starts decomposing at 80oc corresponds to three moles of hydrated water and after 206oc anhydrous complex decomposed. i.r. spectral data of complexstudy of antimicrobial activity of mixed ligand ni(ii) complex and it's effect on germination of some selected seeds original research paper shailendra yadav chemistry research laboratory,deptt.of chemistry, basic science,a.k.s.u., satna ,m.p. 485001 x 53gjra global journal for research analysis chemistry in the present study mixed ligand complex of ni(ii) with urea and metronidazole was synthesized and characterized by elemental analysis, i.r. and n.m.r. spectral data. study of antibacterial activity of this complex is done on e.coli. ,k. pneumonia ,rizobium, s.aureus and seeds selected were brassica nigra and t. auestivum. it was found that antibacterial activity of this synthesized complex was lesser than metronidazole but more than urea .complex showed positive effect on germination of t. auestivum seed at low concentration but at high concentration the result was negative. in case of brassica nigra seeds. it did not show positive effect at any concentration range. abstract keywords : mixed ligand complex, antibacterial activity, metronidazole volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra percentage of elements %c %n %h %o %cl %ni s 20.30 (20.31) 16.91 (16.91) 4.35 (4.36) 27.06 (27.05) 17.15 (17.16) 14.01 (14.03) frequency region metronidazole urea [ni(met)2(urea)2]cl2.3h 20 hydrogen region 3780.3s 37.07 b 3436s 3337b 3784 s 3700b 3430 b double bond region 1615b 1570s 1710 s 1680 b 1660s ,b 1680s 1625 s single bond region 1300 s 1238w 1129 1074 1464 1150s 1500w 1459s 1370s 998 789 717b 1083s 1140s 927b 740 696m h1n.m.r. spectral data of complex chemical shift in ppm(tms) 7.72(1h,s) 5.03(1h,s) 5.6(2h,s) 5.5(2h,s) 4.4(2h,t) 3.9(2h,t) 2.0(3h,s) 54 x gjra global journal for research analysis on the basis of elemental analysis proposed molecular formulaof dirty dreen complex is c7n5h18o7cl2ni.from thet.g.a i.r. spectral data bands appeared at 3400 -3784 cm-1 is due to c-h,n-h,o-h str.(hydrogen region).the bands appeared in double bon region are due to c=c,n=o,c=o str.and in region below 1500 cm-1 single bond str.appeared with bending vibration mood .the bands at 740 cm-1,696cm1 i s v i s i b l e i n c o m p l e x a r e d u e t o c o o r d i n a t e bond.h1n.m.r.spectra of complex gave peak 7.72 s for 1h of o-h group peak at 5.5 for n-h group and at 2.0 3h s is of ch3 proton . antibacterial activity istested on e.coli ,k. pneumonia ,rizobium ,s.aureus and from table it is clear that complex have less antibacterialactivity than metronidazole for every species. complex was effective forgermination oft . auestivum seeds but will not give any positive effect on seeds of brassica nigra. conclusion from the above discussin complex[ni(met)2(urea)2]cl2.3h20 showed lesser antibacterial than metronidazole , but higher than urea. on t . auestivum seed it expressed positive effect while on brassica nigra seeds it did not give positive effect. references 1campolat.e; kaya,m5; gur,s;(2004) synthesis,chacterisation of some co(iii)complexes with vic-dioxime ligands and their antimicrobial properties .turk.j.chem.28,235-242. 2obaleye,ja;lawal,a. synthesis, characterization and antifungal studies of some m e t r o n i d a z o l e c o m p l e x e s . j . a p p l .. sci. environ. manage. d e c e m b e r , 2007, vol.11 (4)15-18. 3j.p.verma,v.singh ,j.yadav effect of copper sulphate on seed germination,peroxidase activity of mung bean i.j. of botany.2011 vol.7,issue 2 page200-204. 4n.h. bhausar,b.d. mistry and k.r.desai,asian j. chem.,11,65(1999). 5m.r.maurya,co.ord.chem.rev.,237,163(2003). 6a.k.usha and s.chandra,synth.react.inorg.chem.met.-org.2,1565(1992). 7p.parimal,n.kamalaksha,inorg.chem.,26,1586((1987). 8j.l. bellamy, infrared spectra of complex molecules.,vol. i,3rd ed.,chaman and hall. 9b.s.garg and l. kapur, inorg. chem. acta .173,223(1990). volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra bacterial strain zone of inhibition(in mm) e.coli k. pneumonia rizobium s.aureus [ni(met)2(urea)2]cl2 urea metronidazole 11 14 18 21 7 12 17 23 6 9 15 19 11 14 16 22 0 4 7 11 5 8 10 12 3 5 9 10 2 6 8 13 18 22 24 27 15 18 23 26 17 22 25 27 20 23 25 28 concentration inmicro litre 20 40 80 100 20 40 80 100 20 40 80 100 antibacterial activityeffect on seeds germinationt. auestivum % germination concentration (urea)in µm 50 75 100 150 concentration(nickel ion) µm 50 75 100 150 concentration (complex) µm 50 75 100 150 % germination 17 21 19 14 11 13 10 o8 14 17 12 10 brassica nigra % germination 08 11 06 03 10 07 06 05 06 09 07 05 introduction globally, preterm birth is signicant maternal and neonatal problems that is a leading cause of neonatal death and disability. the incidence of premature birth is estimated about 15 million annually and has increased in all countries .(sharvit et al., 2017) this condition causes many problems to the survival neonates such as vision, respiratory, neurological and developmental problems (nirunsittirat et al., 2016; society for maternal-fetal medicine . electronic address, mcintosh, feltovich, berghella, & manuck, 2016). the diagnosis and management of this condition are still problematic such as the diagnostic criteria, tocolytics use. cervical length (cl) is an indicator to diagnose preterm labor in developed countries (sotiriadis, papatheodorou, kavvadias, & makrydimas, 2010; tsoi, akmal, rane, otigbah, & nicolaides, 2003; tsoi, fuchs, rane, geerts, & nicolaides, 2005). the american college of obstetricians and gynecologists (acog) recommended the use of cl for the diagnosis and treatment of preterm labor. the short cl < 3 cm is an indication for further investigation by perform fetal bronectin and cl < 2cm is an indication for preterm labor treatment (american college of & gynecologists' committee on practice, 2016). however, many centers in low-resource countries cannot provide cl measurement from many reasons such as lack of trained personnel or lack of equipment. in many hospitals, ultrasound machine is available without vaginal probe. therefore, this study was conducted to determine the diagnostic performance in using abdominal convex ultrasonic probe for tps-cl compare with tvs-cl, in case of tvs-cl is not available. material and method this diagnostic test study was conducted in a tertiary care regional hospital from december 2018 through may 2019. this study protocol was approved by the ethical research committee of udonthani hospital (no.40/2561). the inclusion criteria were: 1) women with singleton live preterm (ga 25-36 weeks) pregnancies, 2) who had painful and regular uterine contraction of at least one time in every 10 minutes persisting for more than 30 minutes (chawanpaiboon, pimol, & sirisomboon, 2011) 3). the exclusion criteria were cervix dilated more than 3 cm, placenta previa, abnormal vaginal bleeding, preterm premature rupture of membranes, dead fetus in utero, fetal anomaly, uncertain gestational age, history of previous cervical or uterine surgery, the clear image of tps-cl or tvs-cl cannot be obtained or unwilling to participate in the study. the eligible participants were counseled and invited to participate in this study. a written informed consent was obtained after the explanation of study methods to the participants. then, all participants were examined by digital vaginal examination, by experienced nurses who have worked in the labor room for at least 5 years, to rule out advance labor (cervical dilatation > 3 cm). first, cl was measured transperineally, then transvaginally by trained obstetricians or residents, using a ge voluson p6 ultrasound machine with a 3.5-5 mhz convex probe and 7-10 mhz transvaginal probe. the patient was examined with an empty bladder. the cl was obtained by measuring from external to internal os in a longitudinal axis. three measurements were taken and the shortest values was taken as the nal cl in both measurements. transperineal measurement was done by apply a convex ultrasonic probe, which was covered by a sterile plastic bag, at anterior perineum and between labia majora (raungron gmorakot et al., 2004). the ultrasonic probe was moved until clear image found. cut off value for short cl diagnosis was < 30 mm (american college of & gynecologists' committee on practice, 2016; ness, visintine, ricci, & berghella, 2007). all diagnostic performance of transperineal sonographic cervical length measurement for diagnosis of preterm labor: a diagnostic test study original research paper jirada promnimit m.d. department of obstetrics and gynecology, udonthani hospital, udonthani, thailand. obstetrics & gynecology objective: to evaluate the diagnostic performance of transperineal sonographic cervical length measurement (tps-cl) compare with transvaginal measurement (tvs-cl). materials and methods: the participants were 107 suspected preterm labor women whom cervical dilatation was < 3 cm. tps-cl and tvs-cl were measured. the short cervical length (cl) was diagnosed when cl < 3 cm. the diagnostic performance of tps-cl was evaluated. results: short cl (cl < 3cm) was found in 52.3% by tvs-cl and 51.4% by tps-cl. tps-cl had high correlation with tvs-cl (r = 0.77). the sensitivity, specicity, positive and negative predictive value, and accuracy of tps-cl were 78.6% (95%ci 65.688.4), 78.4% (95%ci 64.7-88.7), 80.0% (95%ci 67.089.6), 76.9%% (95%ci 63.2-87.5), 78.5 % (95%ci 69.5-85.9), respectively. conclusion: tps-cl had high correlation with tvs-cl. in case of tvs-cl is unavailable, tps-cl can be used for preterm labor diagnosis. abstract keywords : cervical length, suspected preterm labor, transperineal ultrasound, transvaginal ultrasound srisuda songthamwat m.d. department of obstetrics and gynecology, udonthani hospital, udonthani, thailand. ueamporn summart ph.d. faculty of health sciences, udon thani rajabhat university, udonthani, thailand. metha songthamwat m.d., ph.d. department of obstetrics and gynecology, udonthani hospital, udonthani, thailand. *corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 60 x gjra global journal for research analysis staff and residents, who participated in this study, were trained and assessed for standardization of cl measurement in a 1-day course. then, the participants were managed according to the hospital protocol and the royal thai college of obstetricians and gynecologists (rtcog) guideline (the royal thai college of the obstetricians and gynaecologists, 2015). statistical analysis the sample size was calculated using the formula for diagnostic test study. the estimated sensitivity of tps-cl was 80 % with 0.08 acceptable error and 5% signicance were used. the calculated sample size was 97, then a 10% dropout rate was added. the total sample size was 107 (khiewyoo, 2014; sanoonrat, srisantiroj, & yanaranop, 2017). this study protocol was approved by the research ethics committee of udonthani hospital (number no.40/2561). the written informed consent was obtained from all participants before enrolling to this study. the participants' characteristics are presented in term of frequency and percentage for categorical data. mean, standard deviation and range were used for continuous data. tvs-cl < 2 cm was used as the gold standard diagnosis of short cl. diagnostic performance of tps-cl was assessed including sensitivity, specicity, positive and negative predictive value and accuracy. statistical analysis was performed using stata program version13. p-value <0.05 was considered statistically signicant. results there were 116 participants with suspected threatened preterm labor were examined by tps-cl and tvs-cl and 9 participants were excluded due to unable to obtain the clear image of tps-cl. the clear image of tps-cl and tvs-cl can be measured in 107 (92.2%) and 100.0% of participants, respectively. their mean age was 25.6 (±sd 7.0) years and 47 (43.9%) women were primigravida. mean gestational age was 33.2 (±sd 2.5) weeks. baseline characteristics are presented in table1. table 1. basic characteristic of study group. the mean tvs-cl was 3.0 cm (±sd 0.92) and mean tps-cl was 3.0 cm (+sd 0.94). the figure 1 show the correlation of tps-cl and tvs-cl. signicant correlation of tps-cl and tvs-cl was demonstrated ( r = 0.77) abbreviation: cl ; cervical length figure 1: the correlation of transperineal and transvaginal cervical length measurement the prevalence of short cl (tvs-cl < 3 cm) was 52.3% (95%ci: 42.5-62.1), range of cl was 0.4-5.3 cm. tps-cl found short cl in 51.4%. the sensitivity, specicity, positive and negative predictive value and accuracy were 78.6% (95%ci 65.6-88.4), 78.4% (95%ci 64.7-88.7), 80.0% (95%ci 67.089.6), 76.9%% (95%ci 63.2-87.5), 3.6 (95%ci 2.1-6.3), 0.27 (95%ci 0.16-0.46), 78.5 % (95%ci 69.5-85.9), respectively. (table 2). table 2.: diagnostic performance of transperineal sonog raphic measurement for short cervical length (< 3 cm) compare with standard transvaginal measurement. abbreviation: tvs: transvaginal sonography, tps: transper ineal sonography, cl: cervical length, ci: condence interval discussion preterm labor is sometime difcult to differentiate from false labor pain or braxton-hicks contraction, especially in case of minimal cervical dilatation. cl measurement has been recommended by many obstetric guidelines as a part of preterm labor diagnosis and management in developed countries (american college of & gynecologists' committee on practice, 2016; lockwood c, 2018; national institute for health and care excellence, 2018). however, in low and middle-income countries, an ultrasound machine with transvaginal probe and trained personnel are still unavailable in many hospitals. in some hospitals, ultrasound with convex probe is available but transvaginal probe is not. data from this study demonstrated that cl measurement by tps-cl had a high correlation with tvs-cl and can be used with high sensitivity and specicity when compared with tvscl. therefore, tps-cl can be used in the situation that volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra characteristics total (n=107) (%) maternal age (years), n(%) mean ±sd < 20 20 – 34 ≥ 35 25.6+7.0 26 69 12 24.3% 64.5% 11.2% gestational age at admission (weeks), n(%) mean ±sd < 34 weeks >34 weeks 33.2 + 2.5 46 61 43.0% 57.0% primigravida, n (%) 47 43.9% body mass index (kg/m2) mean(±sd) < 18.5 18.5 – 22.9 23 – 24.9 25 – 29.9 >30 25.4 (+4.1) 4 27 21 40 15 3.7% 25.2% 19.6% 37.4% 14.0% previous preterm birth, n(%) 8 7.5% previous term birth, n(%) 42 39.3% initial dilatation of cervix (cm) closed dilate ≥ 1 cm 63 44 58.9% 41.1% bishop score mean (±sd) < 6 ≥ 6 3.8 (+2.5) 80 27 74.8% 25.2% tvs-cl tps_cl short cl (< 3cm) cl > 3 cm short cl(< 3cm) 44 11 cl > 3 cm 12 40 diagnostic performance percent 95%ci prevalence of short cl 52.3 42.5-62.1 sensitivity 78.6 65.6-88.4 specicity 78.4 64.7-88.7 positive predictive value 80.0 67.089.6 negative predictive value 76.9 63.2-87.5 positive likelihood ratio 3.6 2.1-6.3 negative likelihood ratio 0.27 0.16-0.46 accuracy 78.5 69.5-85.9 x 61gjra global journal for research analysis vaginal ultrasonic probe is unavailable for evaluating the cervical condition of suspected preterm labor patients. data from this study is compatible with raungrongmorakot k, et al study (raungrongmorakot et al., 2004) which found signicant correlation between tps-cl and tvs-cl ( r = 0.73), meijer-hoogeveen m, et al study which found strong correlation with r = 0.85, larscheid p ,et al study which found high correlation with lin'rho =0.922. however, this is the rst study that reports the diagnostic performance of tps-cl in the diagnosis of short cl for preterm labor management. in this study, the denition of short cl was < 3 cm in accordance with acog guideline and ness a, et al study (american college of & gynecologists' committee on practice, 2016; ness et al., 2007). however, different cut-off lengths of cl were used in other recommendations. national collaborating centre for women's and children's health (nice) guideline (sarri , davies, gholi tabar, norman, & guideline development, 2015), tsoi e, et al (tsoi et al., 2003) and alrevic z, et al (alrevic, allen-coward, molina, vinuesa, & nicolaides, 2007) study recommends that if cl is > 1.5 cm, the diagnosis of preterm birth is unlikely. palacio m, et al study (palacio et al., 2007) reported cut-off length of 25 mm in gestational age less than 32 weeks and 15 mm in 32 weeks or later. therefore, the diagnostic performance of tps-cl will be different if others cut-off lengths are used. there are some limitations with this study; rst the standardization of observer was done by a workshop, however the inter and intra-observer reliability of tps-cl and tvs-cl were not measured, therefore reliability problem can be occurred. second, the tps-cl and tvs-cl were done by same operator which can have a measurement bias. the further study should be done to compare the outcome of preterm management between using tps-cl and tvs-cl in the suspected preterm labor cases. conclusion: tps-cl had high correlation with tvs-cl and high sensitivity and specicity when compared with tvs-cl. in case of tvscl is unavailable, tps-cl can be used for diagnosis of short cl in preterm labor diagnosis. acknowledgements we gratefully acknowledge dr.narong thadadech, director of udonthani hospital for permission and grant support. thanks for udonthani hospital staff and all participants who participated in this trial. disclosure statement no author has any potential conict of interest. funding this study was supported by udonthani hospital. the study protocol was approved by the udonthani research ethics committee: no.40/2561 references 1. alrevic, z., allen-coward, h., molina, f., vinuesa, c. p., & nicolaides, k. (2007). targeted therapy for threatened preterm labor based on sonographic measurement of the cervical length: a randomized controlled trial. ultrasound obstet gynecol, 29(1), 47-50. doi: 10.1002/uog.3908 2. american college of, o., & gynecologists' committee on practice, b.-o. (2016). practice bulletin no. 171: management of preterm labor. obstet gynecol, 128(4), e155-164. doi: 10.1097/aog.0000000000001711 3. chawanpaiboon, s., pimol, k., & sirisomboon, r. (2011). comparison of success rate of nifedipine, progesterone, and bed rest for inhibiting uterine contraction in threatened preterm labor. journal of obstetrics and gynaecology research, 37(7), 787-791. 4. khiewyoo, j. (2014). statistics for diagnostic teast. in j. khiewyoo (ed.), statistical mrthods for health measurement (1 ed., pp. 57-77). khon kaen. 5. lockwood c. (2018). diagnosis of preterm labor. in: uptodate. retrieved may 29, 2018, from https://www.uptodate.com/contents/diagnosis-of-pretermlabor 6. national institute for health and care excellence. (2018). preterm labour and birth. retrieved may 29, 2018, from https://www.nice.org.uk/guidance/ng25 /chapter/recommendations#diagnosing-preterm-labour-for-women-withintact-membranes 7. ness, a., visintine, j., ricci, e., & berghella, v. (2007). does knowledge of cervical length and fetal bronectin affect management of women with threatened preterm labor? a randomized trial. am j obstet gynecol, 197(4), 426 e421-427. doi: 10.1016/j.ajog.2007.07.017 8. nirunsittirat, a., pitiphat, w., mckinney, c. m., derouen, t. a., chansamak, n., angwaravong, o., . . . pimpak, t. (2016). adverse birth outcomes and childhood caries: a cohort study. community dent oral epidemiol, 44(3), 239247. doi: 10.1111/cdoe.12211 9. palacio, m., sanin-blair, j., sanchez, m., crispi, f., gomez, o., carreras, e., . . . gratacos, e. (2007). the use of a variable cut-off value of cervical length in women admitted for preterm labor before and after 32 weeks. ultrasound obstet gynecol, 29(4), 421-426. doi: 10.1002/uog.3950 10. raungrongmorakot, k., tanmoun, n., ruangvutilert, p., boriboonhirunsarn, d., tontisirin, p., & butsansee, w. (2004). correlation of uterine cervical length measurement from transabdominal, transperineal and transvaginal ultrasonography. j med assoc thai, 87(3), 326-332. 11. sanoonrat, p., srisantiroj, n., & yanaranop, m. (2017). spot urine albumin to creatinine ratio versus urine protein to creatinine ratio for the diagnosis of proteinuria in pregnancy. thai j obstet gynaecol, 25(4), 249-258. 12. sarri, g., davies, m., gholitabar, m., norman, j. e., & guideline development, g. (2015). preterm labour: summary of nice guidance. bmj, 351, h6283. doi: 10.1136/bmj.h6283 13. sharvit, m., weiss, r., ganor paz, y., tzadikevitch geffen, k., danielli miller, n., & biron-shental, t. (2017). vaginal examination vs. cervical length which is superior in predicting preterm birth? j perinat med, 45(8), 977-983. doi: 10.1515/jpm-2016-0273 14. society for maternal-fetal medicine . electronic address, p. s. o., mcintosh, j., feltovich, h., berghella, v., & manuck, t. (2016). the role of routine cervical length screening in selected highand low-risk women for preterm birth prevention. am j obstet gynecol, 215(3), b2-7. doi: 10.1016/j.ajog.2016.04.027 15. sotiriadis, a., papatheodorou, s., kavvadias, a., & makrydimas, g. (2010). transvaginal cervical length measurement for prediction of preterm birth in women with threatened preterm labor: a meta-analysis. ultrasound obstet gynecol, 35(1), 54-64. doi: 10.1002/uog.7457 16. the royal thai college of the obstetricians and gynaecologists. (2015). clinical practice guideline ob014: the management of preterm labour and premature rupture of membranes (pp. 15-42). 17. tsoi, e., akmal, s., rane, s., otigbah, c., & nicolaides, k. h. (2003). ultrasound assessment of cervical length in threatened preterm labor. ultrasound obstet gynecol, 21(6), 552-555. doi: 10.1002/uog.131 18. tsoi, e., fuchs, i. b., rane, s., geerts, l., & nicolaides, k. h. (2005). sonographic measurement of cervical length in threatened preterm labor in singleton pregnancies with intact membranes. ultrasound obstet gynecol, 25(4), 353-356. doi: 10.1002/uog.1809 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 62 x gjra global journal for research analysis introduction there is no doubt in saying that social accounting is the measurement and reporting information concerning the impact of entity and its activities on society. also, social responsibility reporting has become an integral part of good management in india as well as in foreign countries. majority of the companies are making efforts to earn the loyalty of customers through community development schemes, good corporate governance and by engaging stake holders within and outside the company. therefore, it is mandatory that managements at all level understand the scope and content of social responsibility so that they can make value added contributions towards building the reputation and brand image of the company. the acceptance of this wonderful concept of social responsibility gets reected in the information and disclosure that the company makes available for the benet of the various constituents like share holders, community workers, creditors, etc. every company apart from being able to justify itself on the test of economic viability, will have to pass the test of social responsible entity which includes rural development, environmental protection including conversation of resources, control of population, provision of clean drinking water, etc. meaning and scope of the study ÿ it can be said rightly that social accounting is the application of double entry book keeping to socioeconomic analysis. the national association of accountants dened that it is the identication, measurement, monitoring and reporting of social and economic effects of an institution on society. this gave a rise to the possibility that this responsibility could be discharged through method of social responsibility accounting and further this debate focused on the nature of csr (corporate social responsibility). ÿ in order to facilitate corporate accountability, there are ve possible areas in which corporate social objectives can be implemented. ÿ to determine whether the individual rm's strategies and practices are consistent with widely shared social principles. ÿ to identify and measure the net social contribution of individual rms internally and externally which affect different segments of the society. ÿ to decide the goals, programs and performances and use of contribution available. ÿ the scope of social accounting includes net income contribution, human resource contribution, public contribution, environmental contribution, product and services contribution. challenges in social reporting following challenges are faced when the rm is attempting to report its social activities in the framework of current nancial reporting methodology: ÿ how should the social contribution be measured? ÿ how should the social contributions be identied? ÿ how should the social contributions be related to the conventional nancial information expressed in corporate nancial reports? ÿ how should the social contributions be described in signicant manner so that informed judgments may be made about these contributions? objective of the study ÿ our study primarily aims to evaluate the divergent social responsibility reporting practices in indian rms from both sectors by analyzing the scope and a type of social responsibility reporting in indian companies. ÿ secondly, the study was carried out by closely analyzing annual reports of 25 randomly selected and studying their nancial reports. ÿ our study aims to bring out the latest social accounting and reporting practices of indian rms. important disclosure regarding indian firms the most signicant items receiving the most attention recently in our country are as under: ÿ efforts to save energy are receiving the most attention recently, although reporting of energy receiving conversation is statutory. as per the board of directors rules 1988, u/s217 (e) of the companies act 1956, information regarding environment, population and control techniques adopted also needs to be disclosed. ÿ as per the consumer's protection act, it is essential for the companies to offer quality products and services. the particulars of employees are required to be furnished pursuant to section 217(2a) of the company's act 1956 read with the companies rules 1975. ÿ maintenance of adequate foreign exchange has become social obligation of a business enterprise today. hence they have to disclose this information pertaining to the next foreign exchange earned by the enterprise. five main principles of social accounting ÿ multi perspective the different views of people and groups that are important to the organization should be taken into consideration as far as the social accounting and reporting practices of the company are concerned. ÿ comprehensive an organization should prepare the report in detail which is inclusive of all activities related to various stake holders of the company. a study on social responsibility accounting and social responsibility reporting in indian context original research paper asha brahmakshatriya teaching assistant, k.s. school of business management, gujarat university, ahmedabad. x 21gjra global journal for research analysis management we can dene the word social responsibility as the means to help the society in every manner. today the word social accounting attracts the attention of many industrialists because of industrial growth and economic prosperity of the nation. an organization has to be accountable to the public at a large in order to function effectively and survive in longer run. “value added statement and sustainability reports” are given by many indian companies in their annual reports in place of social reporting. similarly, we can say that social accounting is a method by which a rm seeks to place a value on the impact on society of its operations. abstract keywords : human resource contribution, public contribution, environmental contribution, net income contribution, foreign exchange, multi perspective volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 22 x gjra global journal for research analysis ÿ disclosed disclosure is not mandatory but still corporate sector should take all possible steps to make all the disclosures timely. the rm needs to be very transparent with regard to its social cost and benets contributed to the society. ÿ regular reporting social accounting and responsibility reporting should become a continuous process of an organization. it should be conducted on an ongoing basis at regular intervals. ÿ comparative the report should able to compare its activities with other similar companies to understand it comparative position and should also help to compare its own activities over a period of time. process of social accounting and auditing the following are the three stages involved in social accounting: ÿ planning in the rst stage of social accounting, the organization claries its mission, objective and activities as well as its values. this stage also involves identication of stake holders and their interest in the organization. ÿ accounting in this phase an organization decides the scope or focus on social accounts. moreover, it includes the areas it should cover in social accounting and then the organization sets up the ways of collecting relevant information over a period of time. ÿ reporting and audit the information that was collected and analyzed in step 2 is brought together in a single document, which serves as a draft of social accounts. people from outside the organization referred to as social audit panel review this document to check that the report has been properly gathered and interpreted. conclusion and suggestions ÿ the social accounts give both the information, qualitative as well as quantitative to highlight the performance of the company. ÿ social accounts audited by an independent social audit panel have more credibility. ÿ the information which is audited can be used powerfully to demonstrate not only what the organization has done, but also how it intends to improve. ÿ there are no standard norms available for measuring, reporting and evaluating the social performance of a corporate enterprise. there is need to develop one comprehensive model of social accounting which in turn will help in bringing uniformity in reporting. ÿ reporting of the social activities of the rm should always be in the form of social report separately enclosed with the annual report that should take some steps and should be made compulsory. references 1. www.cci.com/mediaroom/speechespresentation/2001nov-csr-lic.htm 2. www.irft.org 3. www.enterpriseimpact.org 4. www.neweconomics.org 5. www.interchangensw.com 6. corporate social reporting, management accounting, march page no. 36-40. 7. annual reports of respective companies epstein m, elias h 1975, dimensions of social reporting. 8. sachar committee, 1978 “social responsibility of companies” chapter xii, sachar committee july 20-22. 9. sengupta p.r., 1988 “population disclosure in india” 10. porwal l.s. & sharma n, 1991 “social responsibility disclosure by indian companies” the chartered accountant, feb page no. 630-635. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: nearly (27 to 30%) twenty seven to thirty percent of all pregnant women in their rst trimester complain of bleeding. in these women who present with bleeding per vagina, during their rst trimester several diagnostic possibilities can be considered. by mere clinical examination & also history, denitive diagnosis is usually impossible. the three major causes of bleeding in rst trimester are abortion, ectopic pregnancy & molar pregnancy. usg helps in assessing the type of abortion. early diagnosis & better management including post evacuation follow up of molar & ectopic pregnancy. materials & methods: the main sources of data for this study were 50 cases of pregnant women who presented with bleeding per vaginum during the rst trimester between may 2018 to june 2019 in the department of obstetrics & gynaecology at shri vasant rao naik govt medical college, yavatmal,m.s. all patients referred to the dept of radio diagnosis with clinically suspected rst trimester bleeding were evaluated with clinical history, clinical examination & ultrasonography as per st&ard proforma.this study was approved by the ethical committee of the institution.relevant images were recorded. inclusion criteria: all patients with clinically suspected rst trimester bleeding (< 12 completed weeks) exclusion criteria: all non-obstetrical causes of vaginal bleeding. all patients with more than 12 completed weeks of gestation. observation & results: table 1: showing ndings of usg examination on usg examination, 28 cases (56%) out of 50 showed gestational sac out of which 18 cases were of threatened abortion. out of 21 cases in which fetal node was visualized, 18 cases showed fetal cardiac activity. 2 cases with absent fetal cardiac activity were diagnosed as inevitable abortion & 1 case as missed abortion. of the 3 cases which demonstrated less liquor, 2 cases were inevitable abortion & 1 case was threatened abortion. yolk sac was detected in 12 cases. all were diagnosed as threatened abortion. placenta was visualized in 6 cases & all were of more than 11 weeks gestation. we have divided our study group into 3 main categories for the purpose of statistical correlation. the 3 groups are: viable intrauterine pregnancies role of usg in evaluation of first trmester bleeding pervaginum in a rural tertiary care hospital in maharashtra, india: a prospective observational study original research paper dr. rohidas chavan professor & head, department of obstetrics & gynaecology, shri vasantrao naik govt medical college, yavatmal obstetrics & gynaecology background: vaginal bleeding in the rst trimester of pregnancy is a common obstetric problem.the common causes of bleeding during rst trimester include various types of abortions, ectopic pregnancy & molar pregnancy. clinical history & pelvic examination are inadequate in assessing the cause & prognosis. objective of this study is to evaluate the role of usg in the evaluation of patients with rst trimester bleeding & to prognosticate & predict the status of abnormal pregnancies. methods: the study was carried out on 50 pregnant women who presented with bleeding per vaginum in rst trimester of pregnancy visiting obstetrics & gynaecology department . the patients were included on the basis of clinically suspected rst trimester bleeding (< 12 completed weeks). all non-obstetrical causes of vaginal bleeding & those with more than 12 completed weeks of gestation were excluded from the study. all patients referred to the dept of radio diagnosis with clinically suspected rst trimester bleeding were evaluated with clinical history, clinical examination & ultrasonography. results: of the fty cases of rst trimester bleeding, 26 cases were diagnosed as threatened abortion clinically, out of which only 12 cases were conrmed. usg examination conrmed 12 cases of clinically suspected threatened abortions & aids in correctly diagnosing 8 cases which were missed on clinical examination. 12 cases out of 18 threatened abortions continue to term gestation with a successful outcome of 66%. all cases of threatened abortion (n=18), incomplete abortion (n=10), missed abortion (n=4), ectopic (n=4), inevitable abortion (n=4), blighted ovum (n=2), & hm (n=2), were correctly diagnosed on usg. 48 out of 50 cases were correctly diagnosed on usg compared to 18 out of 50 cases on clinical diagnosis with a disparity of 64%. 4 out of 5 proved ectopic pregnancies were correctly diagnosed both on usg & clinical examination. conclusion: usg is a non-invasive, non-ionizing, without any proved harmful effects on the developing fetus & easily available method of investigation to assess the patients with rst trimester bleeding which is highly accurate in diagnosing the actual causes of bleeding & guides the clinician in choosing the appropriate line of management & prevents mismanagement of the cases. in the present study, 48 out of 50 cases were correctly diagnosed on usg compared to 18 out of 50 cases on clinical diagnosis with a disparity of 64%. abstract keywords : first trimester bleeding, usg examination, clinical examination volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. sushma gore* associate professor, department of obstetrics & gynaecology, shri vasantrao naik govt medical college, yavatmal *corresponding author dr. arshiya syed post graduate student usg examination number (n=50) % 1.g sac 28 56.0 2.foetal pole 21 42.0 3.cardiac activity 18 36.0 4.yolk sac 12 24.0 5.subchorionic bleed 7 14.0 6.placenta 6 12.0 7.less liquor 3 6.0 18 x gjra global journal for research analysis nonviable intrauterine pregnancy ectopic pregnancy/gestation the groups were formed on the basis of the subsequent line of management in the particular cases. all cases of viable intrauterine pregnancies were to be followed up without intervention; while other cases were managed as appropriate based on the usg ndings. table 2: correlation of usg diagnosis with final diagnosis an evaluation in present study, 18 cases of viable intrauterine pregnancies were correctly diagnosed on usg with zero false positive & zero false negativity with sensitivity, specicity, ppv, npv & accuracy of 100% each. 80% of ectopic pregnancies were correctly diagnosed with a specicity & ppv of 100 % whereas 1 case was missed on sonography with a sensitivity of 80% & npv of 97.83% with an accuracy of 98%. of the nonviable pregnancies diagnose on usg were conf irmed with a sensitivity & npv of 100% whereas 1 case of false positive complete abortion was made on usg with a specicity of 95.65%, ppv of 96.43% & accuracy of 98%. usg diagnosis proved to be very accurate on statistical evaluation with a very signicant p value of <0.001. table 3: correlation of clinical diagnosis with usg diagn osisan evaluation sen. sensitivity; sp: specicity, ppv: positive predictive value; npv: negative predictive value & accuracy in present study, when compared to the usg diagnosis, clinical diagnosis has true positive of 15, false positive of 11 & true negative of 21 in diagnosing viable pregnancies that constitutes threatened abortion . clinical diagnosis has high false negative & true negative in diagnosing non viable intrauterine pregnancies. our study has a sensitivity of 83.3, ppv of 57.7 & accuracy of 72% in diagnosing viable pregnancies with a very signicant p value (< 0.001). clinical diagnosis of ectopic pregnancy has good specicity (97.93%), npv (97.83%) & accuracy (96%) with p value < 0.001 which is very signicant. clinical diagnosis has got very poor statistical correlation when compared to usg diagnosis in evaluating non viable intrauterine pregnancies with a sensitivity of 57.14 %, npv of 60% & accuracy 68.0 % which shows a p value of 0.052. this data shows that usg diagnosis is considerably more accurate than clinical diagnosis. table 4: treatment out of 50 cases of in our study, 30cases were managed conservatively. all threatened cases were managed with bed rest either in the hospital on in the home. all 4 cases of inevitable abortion were spontaneously aborted on expectant management. 1 out of the 4 missed abortions & 2 out of the 5 ectopic pregnancies were managed conservatively. all cases of complete abortion were treated with bed rest. 3 cases out of 5 of ectopic pregnancy were treated by laparotomy. all incomplete abortions & anembryonic gestation were surgically evacuated. 2 cases of h mole were treated by d&c. discussion: bleeding per vaginum in the rst trimester is 1 of the most common obstetric problems. by mere clinical history & examination denitive diagnosis is usually impossible. the causes of bleeding are many & cover a spectrum of conditions ranging from a viable pregnancy to non-viable pregnancy. ultrasonography has opened new dimensions in early pregnancy bleeding so that specic treatment, medical or surgical, can be immediately instituted. accurate diagnosis of nature of the pregnancy (viable or non-viable) can avoid unnecessary hormonal treatment & prolonged hospit aliz ation. it also indicates the need for a dilatation & curettage by diagnosing retained products of conception in the uterine cavity. ultrasonographic examination provides good index for evacuation in cases of abortion. curettage is necessary if residual contents are seen but not when the uterus though bulky appears empty. conclusion : vaginal bleeding in the rst trimester of pregnancy is a common obstetric problem & is a cause of anxiety & worry both to the patients & the obstetrician. clinical history & pelvic examination are inadequate in assessing the cause & the prognosis.usg is a noninvasive, non-ionizing & easily available method of investigation to assess the patients with rst trimester bleeding which is highly accurate in diagnosing the actual causes of bleeding & guides the clinician in choosing the appropriate line of management & prevents mismanagement of the cases. usg can assess some ndings which are helpful in predicting the prognosis of the pregnancy. references: 1. cunningham fg, editor. williams’s obstetrics 21 edition. new york; mcgrawhill; 2001. p-866. 2. nyberg da, filly. ra, duart e, filho dl, laing fc, et al abnormal pregnancy: early diagnosis by us & serum chorionic gonadotropin levels. radiology 1986; 158: 393-6 3. j.w.s baron rayleigh, “on the theory of sounds, philos. trans” 1971, 161, 77 118. 4. curie. j.p., curie. (1880) développement par pression de l’é’lectricite polaire dans les cristaux hémièdres à faces inclinées. c.r. acad. sci. (paris) 91:294. 5. langévin, m.p. (1928) lés ondes ultrasonores. rev gen elect 23:626 6. dussik, k.t., dussik, f. & wyt, l. (1947) auf dem wege zur hyperphonographie des gehirnes. wien. med. wochenschr. 97:425-429 7. wild, j.j. & reid, j.m. (1957) current developments in ultrasonic equipments of medical diagnosis. ire trans. ultrason. engng. 5:44-56. 8. howry, d.h. & bliss, w.r. (1952) ultrasonic visualization of soft tissue structures of the body. j. lab. clin. med. 40:579-592. 9. donald, i. (1962) clinical applications of ultrasonic techniques in obstetrical & gynaecological diagnosis. br. j. obstet. gynaecol. 69:1036. 10. kossoff, g., carpenter, d., robinson, d., & garrett, w.j. (1975) a new multi transducer water coupling echoscope. pro 2nd eurp congr on ultrasonics in medicine. kazner, e., muller, h.r. & de vlieger, m., eds., munich. abstract no. 11. david a. nyberg, faye c. laing, roy a. filly, margaret un-simmons, r. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra parameters sen. sp ppv npv accuracy p value viable intrauterine pregnancy 100.00 100.00 100.00 100.00 100.00 <0.001** ectopic pregnancy 80.00 100.00 1000.00 97.83 98.00 <0.001** nonviable intrauterine pregnancy 100.00 95.65 96.43 100.00 98.00 <0.001** parameters sen. sp ppv npv accuracy p value viable intrauterine pregnancy 83.33 65.63 57.69 87.50 72.00 <0.001** ectopic pregnancy 75.00 97.93 75.00 97.83 96.00 <0.001** nonviable intrauterine pregnancy 57.14 81.82 80.00 60.0 68.00 0.052+ treatment number (n=50) % conservative 30 60 laparatomy 3 6.0 d & c 17 34.0 x 19gjra global journal for research analysis brooke jeffrey. ultrasonographic differentiation of the gestational sac of early intrauterine pregnancy from pseudo-gestational sac of ectopic pregnancy. radiology; 1983. 146:755-759. 12. keith g. bernard peter l. cooperberg. sonographic differentiation between blighted ovum & early viable pregnancy. ajr march 1985. 144:597-602 13. rajan r, rajan v; ultrasonography in first trimester bleeding. j obstet gynecol india; 1987. 37:457-461 14. david a nyberg, roy a filly, faye c. laing. threatened abortion: sonographic distinction of normal & abnormal gestation sacs. radiology; 1986. 158:397-400. 15. jaideep malhotra, k saxena & n malhotra. usg evaluation of rst trimester bleeding per vaginum: j obstetrics & gynecology of india, 1987. 37:341343 volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 20 x gjra global journal for research analysis introduction: hydatid disease, also known as echinococcosis is human infection caused by echinococcus granulosus. hydatid disease most commonly involves liver (60%) and lungs (20%) but it can involve any organ. cardiac echinococcosis (ce) incidence is reported to be less than 2 percent of total 1, 2incidence of echinococcosis . presence of ce in pediatric patient is even rare. we are presenting case of 11-year-old female child presenting with multiple cardiac echinococcosis that resolved completely after surgical treatment. case report: an 11-year old female presented with complaints of highgrade fever and difculty in breathing for 1-day. physical examination revealed tachycardia, tachypnea with respiratory distress and low blood pressure (bp). pallor was present along with hepatosplenomegaly. complete blood count revealed microcytic hypochromic anemia with marked eosinophilia. cardiac enzymes and biochemical analysis were within normal range. postero-anterior chest radiograph showed normal pulmonary appearance however there was abnormal convexity along right border of heart. lateral view chest radiograph revealed a re t ros ternal mass . electrocardiography (ecg) ndings were unremarkable. a transthoracic echocardiogram revealed mass in the right atrium. contrast enhanced computerized tomography scan (cect) revealed a well-dened cystic lesion in the anterosuperior mediastinum showing daughter cysts within. the cyst was causing compression of superior vena cava and right atrium with extension within svc lumen. it was also causing compression of right ventricle. there was another small cyst in lumen of right atrium along with a tiny cyst in the wall of left ventricle. abdominal ultrasonography did not reveal any lesion in liver or other viscera. after initial stabilization patient was planned for surgery with provisional diagnosis of cardiac hydatid cyst. cyst uid was aspirated and total cystectomy was performed. histologic examination conrmed the diagnosis of hydatid cyst. postoperative period was uneventful. tablet albendazole was commenced at a dose of 15 mg/kg/day post operatively for 8-weeks. patient was asymptomatic at 6-month follow up and repeat cect chest revealed no residual lesion. image (a) showing abnormal convexity along right heart border. image (b) showing retrosternal mass in x-ray lateral view. image (c) coronal section ct chest and (d)axial section ct angiography showing mediastinal and intracardiac cystic lesion. discussion: cardiac involvement in hydatid disease is very rare. most of the reports in the recent literature concern adult patients. an 3epidemiologic study from benghazi showed that only 11.7% of patients were less than 10 years old. low incidence in pediatric age group can be attributed to long incubation period and very slow growing nature of hydatid cyst. growth of hydatid cyst is reported to be less than 1 centimeter per year. ce is usually asymptomatic until the cyst has grown to large dimension. clinical presentation of ce depends upon number, size, site and complications of cyst. ce most commonly involves left ventricular myocardium, which is twothree times more commonly involved than right ventricle. it rarely involves interventricular septum, atrium and 4-8pericardial cavity. rupture of intracavitary cyst can lead to pulmonary embolization. intracardiac cyst may lead to valve destruction. involvement of pericardium may lead to pericarditis and pericardial effusion. compression by cardiac cyst may lead to cardiac tamponade and cardiogenic shock. chest radiography, echocardiography, computerized tomography (ct) and magnetic resonance imaging (mri) aids in diagnosis. presence of viable cyst in heart is an 9indication for surgery. post operatively albendazole may help in prevention of recurrence. a high index of suspicion should always be kept. medical management alone is not effective in case of cardiac hydatid cyst and surgery should always be performed even in case of asymptomatic viable ce. further studies are required to prove efcacy of post-operative antihelminthics in prevention of recurrence. references: 1. perez-gomez f, duran h, tamames s, perrote jl, blanes a. cardiac echinococcosis: clinical picture and complications. br heart j. 1973;35(12):1326-31. �� 2. polat p, kantarci m, alper f, suma s, koruyucu mb, okur a. hydatid disease from head to toe. radiographics. 2003;23(2):475-94. a peculiar case of multiple cardiac echinococcosis in a juvenile patient original research paper dr. arpit mittal senior resident, department of pediatrics, pt. b.d. sharma pgims, rohtak. x 1gjra global journal for research analysis paediatrics cardiac hydatid cyst is a rare presentation of hydatid disease. presence of cardiac hydatid cyst in pediatric age group is even rare due to long incubation period and slow growing nature of cyst. we discuss an 11-year–old female child with multiple cardiac cysts presenting with cardiogenic shock that was diagnosed with the aid of echocardiography and computerized tomography of chest. patient remains asymptomatic after surgical treatment followed by oral albendazole therapy. abstract keywords : cardiac hydatid cyst, childhood, echinococcosis, surgery. dr. parul gupta* senior resident, department of radiation oncology, pt. b.d.sharma pgims, rohtak. *corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 2 x gjra global journal for research analysis 3. dar fk, taguri s. epidemiology and epizootiology of hydatidosis in the libyan jamahiria, and recommendations for a program of surveillance and control of the disease. garyounis med j. 1979;2:11–5. 4. maroto lc, carrascal y, lõpez mj, forteza a, pérez a, zavanella c. hydatid cyst of the interventricular septum in a 3.5-year-old child. ann orac surg. 1998;66(6):2110–11. 5. di bello r, menedez h. intracardiac rupture of hydatid cyst of the heart. a study based on three personal observations and 101 cases in the world litera ture. circulation. 1963;27:366–74. 6. vassiliki malamou-mitsi, lina pappa, theodore vougiouklakis, dimitrios peschos, �nikolaos kazakos, george grekas, et al., sudden death due to an unrecognized cardiac hydatid cyst, forensic sci. 47 (5) (2002) 1–3. 7. macedo aj, magalhães mp, tavares nj, bento l, sampayo f, lima m. cardiac hydatid cyst in a child. pediatr cardiol. 1997 may-jun;18(3):226-8. 8. fiengo l, bucci f, giannotti d, patrizi g, redler a, kucukaksu ds. giant cardiac hydatid cyst in children: case report and review of the literature. clin med insights case rep. 2014;7:111–16. 9. kaplan m, demirtas m, cimen s, ozler a. cardiac hydatid cysts with intracavitary expansion. ann thorac surg. 2001 may;71(5):1587-90. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: the term prameha is derived from “pra” which means watering, “meha” means sechane i.e. frequently passage of urine. it means passing of vikrut mutra in excessive quantity .(prabhut mutra) this disease is dened according to ayurveda as excessive urination (prabhut mutrata) and turbidity (avila mutrata). upadrava (complication) is one which occurs in the course of some other disease, although it may result from the main disease. the morbid process occurring during a disease may be a minor or major ailment. updrava means which manifest after the genesis of the main disease. this episode has been superimposed, altering symptoms and modifying its course as a result disease may become difcult for management. sushruta mention word aupasargika as a synonym to updrava. it also means that updrava manifest upon another disease and also due to same factors which are responsible for the manifestation of the main disease. updrava comes under paratantra vyadhi, means one which depends on the pradhan vyadhi for this reason it is also called as apradhana. updrava don't have its own existence, it means beginning from the nidana to chikitsa it depends on pradhana vyadhi. methodology: this is literary type of study. literary study of prameha upadrava thoroughly including ayurveda samhita and all sorts of relevant research papers published in various journals from pub-med, dhara were studied. prameha updrava: acharya charaka has explained the prameha updrava. upadrava develops in all doshic types of prameha are as follows1. kaphaja upadrava: ÿ avipaka ÿ daurbalya ÿ arochak ÿ chardi ÿ aalasya ÿ pratishay ÿ mansopachaya ÿ makshikopsarpan ÿ kaphapraseka ÿ lolata ÿ pinasa ÿ klama 2. pittaja updrava: ÿ trushna ÿ atisara ÿ daha ÿ putimansapidaka ÿ jwara ÿ alaji ÿ vidradhi. ÿ bastimehantoda ÿ amlak ÿ panduroga ÿ mushkavdaran ÿ murccha 3. vataja upadrava: ÿ udavarta ÿ kampa ÿ hridgraha ÿ shoola ÿ nidranasha ÿ kasa ÿ shwasa ÿ shosha ÿ baddhapurishata discussion: a] kaphaja upadrava 1. chardi: ama is the main causative factor for prameha. it causes amlata and vidaha to the annarasa. srotorodha in prameha causes vataprakopa. this prakupita vata carries amla and vidhahi annarasa out of stomach manifesting in chardi. 2. arochaka: is a condition where even after aahara-iccha the patient experiences tastelessness for food which is already in mouth as described by the sentence “mukhapraveshena asvadu avbodhaha.” it is disorder of taste perception in spite of normal appetite. arochaka is due to pichhila and guru guna of kapha and also vitiation of pitta dosha. 3. daurbalya: in prameha there is dhatusara vahana in the form of kleda through mutra. ojokshaya and srotorodha due to medasanchiti causes daurbalya. comprehensive study of prameha updrava-a review original research paper vd. monali l. bagde* b. a. m. s., m. d., ph. d (sch), asst. prof. (rognidan), m.a. darade ayurved college *corresponding author x 39gjra global journal for research analysis ayurveda background: the term prameha is derived from “pra” which means prakarshen mehati i.e. watering. “meha” means sechane i.e. frequently passage of urine. it means passing of vikruta mutra in excessive quantity (prabhut mutrata). this varies in different types of prameha. updrava (complication) arises after the appearance of the disease & is thus distinguished from the symptoms which arise with the disease. objective: to study the concept of prameha updrava. discussion: description of prameha updrava with its type was done. conclusion: prameha on chronicity give rise to these complications-trushna (thrust), atisara (diarrhea), jwara (fever), daha (burning sensation), daurbalya(debility), arochaka (anorexia), putimansa (boils due to sloughing of muscle). abstract keywords : prameha, updrava, complications volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra vd. sonali l. bagde b. a. m. s., m. d., ph. d (sch), asst. prof.(kriyasharir), m.a. darade ayurved college 40 x gjra global journal for research analysis 4. mansopchaya: is due to vitiation of mamsa which is main dushya in prameha. it is described by word “mamsa sanghata” 5. makshikopsarpan: this condition is result of tanu madhurya and subsequent madhura bhava of sweda. it is attraction of ies towards patient body. this condition here should be considered as a symptom indicating asadhya avastha, which is likely to be preceded or succeeded by murchadi updrava. 6. aalasya: this one among the kapha nanatmaja vikara. aalasya is due to manda guna of kapha. it is dened as person feels lethargic even though he performs work. 7. pratishyay: this is due to kapha, vata dosha, ojokshaya and pranavahasrotodushti. 8.lolata: a conditions where there is an abnormal desire to have all rasa described as “sarvaraseshu loluptvam” due to vata vrrudhi as a result of dhatu kshaya. 9. pinas: this is due to kapha, vata dosha, and ojokshaya , pranavaha srotodushti. 10. kaphapraseka: means excess lalasrava. it is due to bahu-dravatva of kapha. 11. klama: dhatwagnimandya and ojonasha. b] pittaja updrava: 1. daha: daha is a pittaja nanatmja vikaraand described as sarvanga dahamiva. it develops in conditions of pitta dosha obstruction by vitiated vata dosha in madhumeha. daha is mainly seen especially in hasta-pada tala. 2. trushna: it is due to vitiation of vata-pitta dosha. vitiated vata-pitta causes drying out of rasa & udakdhatu. it is dened as even after repeated intake of water the person doesn't get satisfaction and desires to drink water. 3. amlak: it is result of agnimandya caused by improper karma of pachak pitta. 4. panduroga: this is pitta pradhan vyadhi where due to dhatwagnimandya there is rakta dhatu poshak sarabhaga kshapana leading to panduroga. 5. mushkavdaran: it is result of kandu or kushta affecting mushka or vranashopha as a result of rakta pitta dushti causing avadarana. 6. jwara: jwara is mainly due to pitta pradhanya among tridoshas. in pittaja prameha there is involvement of rasa and rakta dhatu. in prameha there is dhatukshaya which further leads to ojonasha; due to this there will be decreased vyadhishamatva (immunity) leads to jwara. 7. vidradhi: due to vitiation of pitta, rakta mamsa and meda with increased dravatva of shleshma causes shotha resulting in pooya nirmti. increased vitiation of pitta ultimately leads to pooya vruddhi. 8. putimansa: the vitiated pitta, meda, mamsa and rakta get combined with bahudrava shleshma results in development of pidikas, which causes shotha resulting in pooya vrrudhi. if not treated, the pooya attains abhyantara prapti and utsanga, resulting in asadhyata. the development of pidikas described as limited only to the lower limbs as the rasayanis there are durbala. clinically also, the incidence of diabetic ulcers occurring in the lower limb is maximum. the pidikas are the most important upadrava of madhumeha if it is untreated it leads to asadhyatva of the disease. 9. atisara: it is mentioned both in samanya and vishesha classication of updrava. due to increase vata in pakwashaya and pitta vitiation leads to agnimandya causing 53atisara. 10. murcha: this is mainly due to rakta pitta dushti. c] vataja updrava: 1. udavarta: baddha purishtva and vatavrrudhi causes udavarta. 2. hridgraha: a condition where person experiences as if his heart is being pulled out. it is due to kapha-pitta avarana and vitiation of vata. this is symptom of hridroga that is clinically evident as updrava of madhumeha. 3.baddhapurishata: it is due to vatavrrudhi. 4. nidra: is caused as a result of kapha dushti and tamo dosha in madhumeha. 5. shwasa: is a result of pranavaha srotodushti by vriddha (elevated) kapha and vata. also due to doshaja marmabhighat like hridya, this is pranvahasrotomoola. 6. bastimehantoda: it is due to vatavrudhi. 7. kasa: this updrava is a result of pranavaha srotodushti by vriddha kapha and vata. kasa results as a consequence of altered motion of apana-prana vayu with increased motion of udan vayu . 8. shaithilya: the dhatu kshaya leads to anibida samyogata (loss of compactness) leading to daurbalya. 9. shoola: it is dened as ruja (pain) caused by vata when the disease proceeds to involve gambhira dhatu like majja. 10. kampa: is due to dhatukshaya and vatavrrudhi. it is called as ativepanam. 11. shosha: occurs due to dhatu kshaya. conclusion: prameha on chronicity give rise to these complicationstrushna (thrust), atisara (diarrhea), jwara (fever), daha (burning sensation), daurbalya(debility), arochaka (anorexia), putimansa (boils due to sloughing of muscle). references: 1) agnivesh.elaborated by charak & dridhbala with ayurveda dipika commentary by chakrapanidatta & edited by yadavjee trikamjee acharya. (2011) charaksamhita, chaukabha prakashan, varanasi. 2) apte v.s. (1992) the practical sanskrit english dictionary, motilal banarasidas publisher pvt limited, delhi. 3) dalhana yadavji trikamji acharya. (1994) sushruta samhita with nimbandha sangraha, chaukhambha surbharti prakashan, varanasi. 4) mishra b. (2003) bhavaprakasha, chaukhambha sanskrit sansthan, varanasi. 5) monier m. – williams. (1992) a dictionary english and sanskrit, motilal banarasidas publisher pvt limited, delhi. 6) shastri lakshmi pati. (2005) yogaratnakara, chaukhambha sanskrit sansthan, varanasi. 7) vagabhata. (2002) ashtang sangraha, kaviraj atridev gupt krushnadas akadami, varanasi. 8) vagabhata with arun dattas sarvang sundar & hemadri’s ayurved rasayan pandit hari sadashiv shastri. (1997) ashtang hrudayam, chaukhambha surbharti prakashan, varanasi. 9) vartaka sh. g. (1962) dosha dhatu mala vigyana, r. a. podar, mumbai. 10) vijayrakshit and shrikant datta. (2006) madhava nidana with madhukosh tika, yadunandan upadhyaya chaukhambha prakashan, varanasi. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: fractures of the distal tibia have been a challenging situation. stable fractures with minimal shortening can be treated conservatively, but requires prolonged immobilisation. it has also been associated with malunion, shortening of affected 1, 2limb, restriction of range of motion and early osteoarthritis. external xation can be a useful option in open fractures with soft tissue injury, but can lead to pin-track infections, septic 3 arthritis, mal-alignment and delayed union. soft-tissue management has been seen to play a vital role in the 4management alongside the bony reconstruction . internal xation usually failed due to infection, inadequate skin coverage and avascular necrosis of the skin leading to 5sloughing. in a study of 84 patients by ruedi and allgower , that established the open reduction and internal xation with screws and plate as the standard, the authors with a nine year follow up reported 74% good functional results. the principles of treatment included 1. re-establishment of the bular length 2. re-construction of the lower articular surface of tibia 3. placement of metaphyseal bone graft; and 4. stabilization of the medial aspect of tibia using a plate 6in a series of 26 patients, kellam and waddell divided them into 2 groups based on fracture pattern. type a fractures with twisting injuries with little comminution, whereas type b fractures were more severe injuries, with a crush component. better results were obtained in type a fractures (84%) than b (53%). crucial factors besides fracture type were the length of 7immobilization and quality of reduction. bourne et al , in a retrospective clinical review of 42 patients treated with open reduction and internal xation demonstrated the importance of using a logical classication system in describing the outcome of fractures of the distal tibia. the results of this study have clearly demonstrated that types i and ii (ruedi and allgower) are amenable to open reduction and stable internal xation with an 80% success rate. the type iii fractures present a much more difcult problem; a satisfactory outcome was present only in 6 of the 19 patients (32%) in this study. 9dillin and slabaugh , in a series reported disastrous results when inadequate and unstable xation was used to treat the functional outcome of distal tibia fractures treated with locking compression plates using mippo technique original research paper amit yadav senior resident, h.b.t. medical college and dr. r.n. cooper hospital, mumbai; address: room no.407,rmo quarters,dr.r.n. cooper hospital,vile parle(west),mumbai, maharashtra400056 x 9gjra global journal for research analysis orthopaedics volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra ali saify post-graduation student, h.b.t. medical college and dr. r.n. cooper hospital, mumbai.;address: m31,khatiwala tank,angan apt.,at no203,indore,madhya pradesh-452014 dr. ganesh yeotiwad* assistant professor, h.b.t. medical college and dr. r.n.cooper hospital, mumbai;address:at no.301,aadhikari niwas,cooper hospital campus,vile parle(west),mumbai, maharashtra-400056 * corresponding author sagar g. daliya post-graduation student, h.b.t. medical college and dr. r.n. cooper hospital, mumbai;address: room no.202, rmo quarters,dr.r.n. cooper hospital,vile parle(west),mumbai, maharashtra-400056 pagadala manikanta babu post-graduation student, h.b.t. medical college and dr. r.n. cooper hospital, mumbai.;address: room no.202, rmo quarters,dr.r.n. cooper hospital,vile parle(west),mumbai, maharashtra-400056 background: the limited soft tissue, subcutaneous location of large portion of tibia and precarious blood supply renders the treatment of distal tibial fracture very challenging. conventional osteosynthesis is not suitable because distal tibia is subcutaneous bone with poor vascularity. closed reduction and mippo with locking compression plate (lcp) has emerged as an alternative treatment option because it respects biology of distal tibia, maintains fracture haematoma and provides biomechanically stable construct, early mobilization, less complications and relatively higher rates of union. methods: 30 patients with distal tibia fracture with or without intra articular extension were treated with closed reduction and mippo with locking compression plate (lcp) closed reduction and. the patients were prospectively followed up for the duration of 12 months. results: there were 30 patients in the study including 22males and 8 females in the age group of 23 to 62 years (average 42years). the mean follow up period of our patients varied ranging from 6 months to 12 months. all fractures united at an average of 16 weeks (range12 to 20 weeks). in our study rate of supercial infection was 16.7% (5 patients), and ankle stiffness 6.7% (2 patients) .there were no cases of deep infection, delayed union, malunion or non union. conclusion: mippo with lcp is a reliable and effective method of treatment for the distal tibia fractures with or without intra articular extension, preserving most of the osseous vascularity and fracture haematoma and thus providing for a more biological repair. the use of indirect reduction technique and small incision is technically demanding as it is effective, minimally invasive, safe, optimises the operation time, reduces the incidence of infection, allows restoration of limb alignment and provides good clinical and radiological results with low complications and high union rates. abstract keywords : distal tibia fracture, mippo, functional outcome, lcp 10 x gjra global journal for research analysis distal tibia fractures. they had 36% rate of skin sloughing and a 55% infection rate16. follow up evaluations of 34 distal tibia 10fractures by helfet et al , showed that results of operative treatment are dependent on the severity of the initial injury, the 12quality and stability of the reduction. hazarika et al , in a series of 20 patient of distal tibia fracture treated using locking compression plates through mippo technique. this provided 1387.5% of good to excellent results. ozakaya et al , in a retrospective review of 22 patients with distal third tibia fractures were treated with titanium locking compression plates using minimally invasive technique good biological xation of distal tibia. a total of 81% of good to excellent outcome was assessed using american orthopaedic foot and 13ankle society score . locking plates (lps) have the biomechanical properties of internal and external xators, with superior holding power because of xed angular stability through the head of locking screws, independent of friction 14t . with the increasing prevalence of high energy injuries and the accompanying soft tissue damage, more recent treatment protocols have focused on maintaining a healthy soft tissue envelope while reducing the articular surface by indirect means using minimally invasive techniques. minimally invasive percutaneous osteosynthesis aims at minimal periosteal dissections and disruption of hematoma, stable xation and early mobilization, decreased postoperative complications and higher rates of union. more importantly it helps preserve the fragile soft tissue envelop 19,20and avoids stripping of the precious periosteum. methods: the present study was conducted in the inpatient and outpatient department of orthopaedic surgery, h.b.t. medical college & dr. r. n. cooper municipal general hospital, mumbai during the period of september 2017 to september 2019. we involved 30 patients of distal tibia fractures, after satisfying the inclusion and exclusion criteria. ethical committee clearance was obtained prior to the study patients were given information sheet and details of the study were explained. after obtaining written informed consent, patients were enrolled into study. inclusion criteria were age more than 18 years, both males and females with distal tibia fractures both intra-articular and extra-articular. exclusion criteria included patients less than 18 years of age, patients unt for surgery, gustilo anderson type-iii open fractures. plain radiographs were taken, antero-posterior view and lateral view of full length tibia and bula along with ankle mortise view of the affected side was obtained. the fractures were classied using ao/ota classication system. the patient was posted for surgery, once anaesthesia tness was obtained. the surgical procedure of xation with lcp using mippo technique was carried out on a fracture table with image intensier. tourniquet was applied routinely. in patients with distal bula fracture, it was xed rst by open reduction using 3.5mm reconstruction plate/distal bula pre-contoured locking plate. patients were followed up and evaluated in detail post operatively both clinically and radiologically at 1 week, 4 week, 2 months, 4 months, 6 months,9 months and 1 year. at every follow up clinical examination was done to assess status of the surgical wound, pain, swelling, tenderness, range of motion, stability of the fracture and clinical union results: there were 30 patients in the study including 22males and 8 females in the age group of 23 to 62 years with mean age of 42 years(table 1). table 1: age group distribution. the fractures were classied according to ao–ota classication in to various types. out of 30 cases, 6(20%) were type a1, 12(40%) type a2, 11(36.6%) type a3 and 1(3.3%)type b1. 23(76.7%) of patients sustained injury following road trafc accidents and 7(23.3%) patients sustained injury due to fall. 26 (86.6%) cases were closed fractures and 4 (13.3%) cases were open fractures. classication of the 4 cases of open fractures was done based on gustillo anderson classication of open fractures, 3(75%) were type 1 compound, 1(25%) were type 2 compound. 23(76.7%) of patients sustained injury following road trafc accidents and 7(23.3%) patients sustained injury due to fall. follow-up period of our patients varied ranging from 6 months to 24 months. the mean time to union was 16 weeks, (range– 12 weeks to 20 weeks). out of 30 cases, 23(76.7%) had no complications, 2(6.7%) developed ankle stiffness, 5(16.7%) developed supercial skin infection(table 2). table 2: post op complications. five supercial wound infections were treated with oral antibiotics and regular dressing. all patients were kept nil weight bearing till radiological signs of union was seen. functional outcome was evaluated as per clinical scoring by teeny and wiss criteria. 8(26.7%) had excellent outcome, 17(56.7%) good outcome, 3(10%) fair outcome and 2(6.7%) had poor outcome(table 3). table 3: functional outcome. in our study there was a statistical signicance between age and functional outcome with cases in age group 23 to 30 years having more excellent outcome compared to patients more than 50 years.(table 4) table 4 : association between age and functional outcome in our study there was a statistical signicance between post operative complication and time of union, with longer duration of union in cases with complication like infection as shown in the graph. the study showed statistical signicance between gender and time of union with early union rates in male volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra age group frequency percent 23 to 30 years 5 16.7 31 to 40 years 12 40.0 41 to 50 years 6 20.0 51 to 60 years 5 16.7 more than 60 years 2 6.7 total 30 100.0 post op complications frequency percent absent 23 76.7 ankle stiffness 2 6.7 supercial skin infection 5 16.7 total 30 100.0 functional outcome frequency percent excellent 8 26.7 fair 3 10.0 good 17 56.7 poor 2 6.7 total 30 100.0 functional outcome total excellent fair good poor age group 23 to 30 years count 4 0 1 0 5 % 50.0% 0.0% 5.9% 0.0% 16.7% 31 to 40 years count 1 0 10 1 12 % 12.5% 0.0% 58.8% 50.0% 40.0% 41 to 50 years count 2 2 2 0 6 % 25.0% 66.7% 11.8% 0.0% 20.0% 51 to 60 years count 1 0 3 1 5 % 12.5% 0.0% 17.6% 50.0% 16.7% more than 60 years count 0 1 1 0 2 % 0.0% 33.3% 5.9% 0.0% 6.7% total count 8 3 17 2 30 % 100.0% 100.0% 100.0% 100.0% 100.0% patients compared to female patients. also functional outcome was better in male patients. no statistical signicance was found between mode of injury and time of union. discussion: fractures of distal tibia are among the most difcult fractures to treat effectively. the status of the soft tissues, the degree of comminution sustained at the time of injury affect the long term clinical results. treatment of these fractures with conventional plates by open reduction techniques, intra medullary nailing resulted in high rates of complication. with the development of technique of mippo with lcp which preserve extraosseous blood supply, respect osteogeinic fracture haematoma, biologically friendly and stable xation method is available for distal tibial fracture. 15cory collinge et al observed 100% high energy fractures in his study. however, our present study correlates with the study 18conducted by neeraj mahajan who attributed 65% of such injuries to be high energy injuries. in our study, 20% were type 43a1 fractures, 40% type a2, 36.6% type a3 and 3.3% type b1 22which was comparable to study by supe ac . the average surgical time was 53 minutes. it is comparable with the 17average of 97.9minutes taken by j.j. guo et al in their study. the average time for fracture union in various studies conducted using various methods was 16-28 weeks. in study 19by gi et al showed in their study that average time for union was 20 weeks. our study had an average time of fracture union of 16 weeks which is comparable to study by muzaffar n 21et al. in which it was 16.8 weeks. conclusion: mippo with lcp is a reliable and effective method of treatment for the distal tibia fractures with or without intra articular extension, preserving most of the osseous vascularity and fracture hematoma and thus providing for a more biological repair. the use of indirect reduction technique and small incision is technically demanding as it is effective, minimally invasive, safe, optimises the operation time, reduces the incidence of infection, allows restoration of limb alignment and provides good clinical and radiological results with low complications and high union rates. references: 1. othman m, strzelczyk p. results of conservative treatment of “pilon” fractures. ortop traumatol rehabil. 2003;5:787–94. 2. digby jm, holloway gm, webb jk. a study of function after tibial cast bracing. injury. 1983;14:432–9. 3. anglen jo. early outcome of hybrid external fixation for fracture of the distal tibia. j orthop trauma. 1999;13:92–7. 4. mcferran ma, smith sw, boulas hj, schwartz hs. complicationsencountered in the treatment of pilon fractures. j orthop trauma. 1992;6:195–200. 5. ruedi tp, allgower m. the operative treatment of intra articular fractures of the lower end of tibia. clin orthop 1979; 138: 105-110. 6. kellam j, waddell jp. fractures of the distal tibial metaphysic with intra-articular extension the distal tibial explosion fracture. j trauma 1979; 19: 593-601. 7. bourne r, rorabeck c, macnab j. intra-articular fractures of the distal tibia: the pilon fracture. j trauma 1983; 23: 591-596. 8. ovadia dn, beals rk. fractures of the tibial plafond. j bone joint surg am. 1986; 68:543-551. 9. dillin l, slabaugh p. delayed wound healing, infection, and non union following open reduction and internal fixation of tibial plafond fractures. j trauma 1986; 26: 1116-1119. 10. helfet dl, koval k, pappas j, sanders rw, dipasquale t. intra articular "pilon" fracture of the tibia. clin orthop 1994; 298: 221-228. 11. im gi, tae sk. distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation. j trauma. 2005 nov; 59(5):1219-23; discussion 1223. 12. hazarika s, chakravarthy j, cooper j. minimally invasive locking plate osteosynthesis for fractures of the distal tibia – injury.2006 sep;37(9):877-87.epub 2006 aug 8. 13. ozakaya u, parmaksizoglu as, gul m, sokuou s, kabukcuoglu y. minimally invasive treatment of distal tibial fractures with locking and non locking plates. foot ankle int .2009 dec; 30(12):1161-7 14. cory collinge, md, mark kuper , do, kirk larson , rnfa, and robert protzman, md. minimally invasive plating of high-energy metaphyseal distal tibial fractures. j orthop trauma 2007; 21:355-361. 15. andrew grose, michael. j. garden. open reduction and internal fixation of tibial pilon fractures using a lateral approach. j. orhop trauma 2007; 21:530-537. 16. andrew grose, michael. j. garden. open reduction and internal fixation of tibial pilon fractures using a lateral approach. j. orhop trauma 2007; 21:530-537. 17. guo jj, tang n, yang hl, tang ts. a prospective, randomized trial comparing closed inramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. j bone joint surg br.2010 jul; 92(7): 984-8 18. neeraj mahajan, minimally invasive techniques in distal tibia fractures, j k science, vol. 10 no. 2, april-june 2008 19. d.j redfern, s.u syed, s.j.m davies, fractures of the distal tibia: minimally invasive plate osteosynthesis, injury, volume 35, issue 6, june 2004, pages 615-620 20. int orthop. 2004 jun;28(3):159-62. epub 2004 feb 14.percutaneous plating of distal tibial fractures.-maffulli n, toms ad, mcmurtie a, oliva f. 21. muzaffar n, bhat r, yasin m. complications of minimally invasive percutaneous plating for distal tibial fractures. trauma monthly. 2016;21(3):e22131. doi:10.5812/traumamon.22131. 22. supe ac, kinge kv, badole cm, wandile kn, patond kr. minimally invasive percutaneous plate osteosynthesis in distal tibial fracture: a series of 32 cases. international journal of orthopaedics. 2016;2(1):06-9. x 11gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra increasing number of women in the corporate world in a country like india, due to technological, social and legal changes the boundaries demarcating the male and female domains have blurred. the advancement of industrialization and increased education among women have opened up new opportunities or rather, forced organizations to accept that women too have an important role to play in the country's development. in the past few decades, there has been a rapid increase in the number or women entering the workforce in diverse elds and at various hierarchical levels. now, women have entered not only into several gainful jobs of different kinds but have also come out to take up jobs and positions in those elds which were traditionally the exclusive preserve of men. minority status in the managerial cadres combined with the social prejudices against working women in general pose limitations on them in performing their relatively new roles effectively. thus women face many problems and difculties while working on higher level jobs as managers. the current article focuses on women executives working in a dynamic environment coping with a broad spectrum of challenges and problems. an attempt is being made to focus on the possible efforts of employers to hone managerial talent and tap into the latent professional skills of women executives by creating a positive work environment. unique place of women managers there is no doubt that due to growing ambitions and changes in our societal norms, young women of tomorrow will be dedicated professionals in their chosen elds. thus this growing breed is going to form a substantial percentage / chunk of the next generation of managers. there is no doubt that qualied women desirous of climbing the corporate ladder are increasing in number. since management is a science, it does not recognize gender. professionally qualied women or women managers are an important and crucial work group that has enormous potential for contribution to the growth of any organization. in fact in tomorrow's society, women will have an added advantage: management conscience, the need for competent managers in a fast moving and competitive world and pressures from government will all provide a special edge for women with the will and competence to succeed. the woman manager must show her ability to cope with the four r's – role, risks, relationships, and results. so the trick is to get women to put their natural organizing ability to work in management, since the rewards are substantial in hard cash and in job satisfaction. in the coming years, employers will begin to view women employees as not being inferior to males, but rather acknowledging them as different (not necessarily infer ior) and wi l l u t i l ize their unique brand of professionalism to the fullest. women will value their hard won equal rights to professional education, as never before. top management today cannot afford to overlook the signicance of an ever-increasing numbers of women joining organizations at levels previously forbidden for them-however tacitly. role models corporate india is gradually showcasing female managers who have been successful in attaining desired positions in their professions. this select coterie of professionals would have certain characteristics and personality traits, which distinguish them from other women. it is fascinating to study the specic qualities of these managers that have enabled them to gain a foothold in today's male dominated organizations. there are denite distinctive qualities that propel any person forward on the path to success. these qualities need to be identied, so that in the coming years, the new generation of young women could emulate these desirable traits. looking up to some ideal gure gives the greatest inspiration and encouragement. there is an urgent need to reiterate the facets of personality of the women executives who have been successful in attaining chosen milestones in their careers. these facets and qualities can be cultivated by aspiring women managers of today and tomorrow. by learning about the hurdles and barriers that their predecessors had to cross, these young women can arm themselves better and prepare to take on the challenges of a management career. this focus of this article is relevant in today's world, because it attempts to understand those women who are successful executives. (it is they who can share a wealth of information about their experiences, personal attributes). it is through their experiences that we can glean information about the organizational structure, culture, process and interpersonal relations, etc. thus, we can determine how far, various initiatives by employers to create a positive work environment for women managers –an imperative original research paper dr. navneet baveja professor, mba department, iimt college of engineering management in this era of globalization and the race to surge ahead and win, organizations have to tap every resource they can identify. women are a valuable human resource in today's competitive organizational arena. with an increasing number of female students pursuing professional/higher education, the number of women in managerial positions in organizations is bound to be higher than before. in such an emerging situation, focus on women executives of india, becomes that much more relevant, both from the career woman's and our national planners point of view. this article will contribute in highlighting the importance of women breaking through the 'glass ceiling' and reaching top managerial levels. there is a serious hindrance to women managers in career advancement that leads to an innate frustration and affects work drastically. this article attempts to study the problems and constraints faced by them. it is vital that these situations and possible alleviating factors be studied. this article attempts to draw the attention of equal opportunity employers and the government. women managers are a small select category of professionals and an exploratory insight into the possible unique initiatives extended proactively by corporate india is quite fascinating. abstract keywords : dr. richa sharma* associate professor, mba department, iimt college of engineering *corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 122 x gjra global journal for research analysis organizations have internal environments which are devoid of gender biases. problems unique to women a multi dimensional model of occupational stress is presented in a research study by davidson and cooper, which comprised of isolated variables in four arenas-work arena, social arena, individual arena and behavioral or stress 3manifestation arena . there is a vital need to provide food for thought in two areasto bring about a change in attitudes regarding career breaks and exible working hours. women, however well qualied and successful in their chosen professions, still have to share an unequal portion of the housework and family responsibilities. often, due to these reasons they are forced to opt out of work for certain periods of time. this reinforces preconceived notions on the part of employers about the non-dependability of women, through no fault of the women. this is bound to be a stressful period for any employee, when she wonders whether her employment will continue after the break or not. career breaks could be due to the responsibilities of childcare, sickness due to ill-health / disability or old age of any family member. stress has a cost for individuals in terms of health, well-being and job dissatisfaction, as well as for organizations in terms of absenteeism and turnover, which in turn may impact upon the 1 quality of patient care. besides this, in our country the family as a social unit and women's role as a wife, a mother and a housewife has its own signicance. a woman working outside is still considered, consciously or unconsciously as doing something unnatural and unwomanly and society does not encourage the extra interests that interfere in the comforts of the family. reconciliation between commitment to the career and family responsibilities give rise to many problems and difculties. kala rani (1976) explains that any combination of work and home that requires a woman to opt out completely for paid work is highly inconsistent with success in many high status occupations. the performance of traditional responsibilities from women at home puts an almost intolerable strain on those women who take up professional employment even 4when their children are at school . the two roles, those of a successful career woman and a good housewife are very taxing because each is a full time job. naturally there are many occasions when one has to be neglected in the interest of the other and this gives rise to a sense of guilt and inadequacy. the career woman occupying a position of responsibility is torn between two loyalties, loyalty to achieve success in her career and thus hold her head high among men and loyalty to her family, particularly, to her children. thus her dilemma becomes really excruciating and she begins to feel as if there is no way out of it. no wonder, this gives rise to tension that adversely affects her dual roles. in any society, but especially in indian society it is the woman who is expected to give up/take leave from her job in case of any household contingency. the husband's profession is given precedence. since these facts are obvious and perhaps immutable, ways should be found to make these career breaks, a part of normal working patterns. since problems do arise in every home and women are usually the ones to handle them, there needs to be some rethinking about career breaks/exible working hours on the part of employers. the stigma attached to unscheduled stoppage in work will be lessened if career breaks/leave are legitimized and made a part of the system. in some cases, a break in career might not be needed if there is a provision for exible working hours. thus, a drastic change in attitudes is needed to alleviate the problems faced by women executives due to unscheduled career breaks. this article hopes to facilitate a move towards that stage by bringing to light the special qualities of women executives that can enable them to juggle housework/ household responsibilities & the challenges of a management career. dissatised workers are more likely to provide substandard services, the physical and mental status, and the social performance of these workers can be affected signicantly by 2the level of their job satisfaction . in case of dual career couples, it has been seen that generally the husband's job is given precedence in terms of whether to relocate or not in case of transfers. in such cases, it is the woman's career that suffers. she moves along with her husband & the chances are that she might have to settle for some lower designation/ non-progressive organization. hence her career suffers a denite setback & career progression is not continued at a normal pace. companies need to build up policies / programmes regarding the wife's occupation: ÿ employment in same company ÿ help in scouting in the new area proactive initiatives 1. the role of central and local government as developers of women managers is important. promoting good employment practices, especially equal opportunities (eo) policies could have the following elements: a. issuing of an eo policy statement and written code of practice; b. monitoring procedures to 'audit' the occupancy prole of all levels. c. advertising job vacancies internally and externally and using standardised procedures to eliminate bias in recruitment and selection. d. ensuring all staff have access to training, staff development and promotion; e. providing exibility in working hours and conditions so that staff with dependents and caring responsibilities are not disadvantaged; f. monitoring and evaluating policy periodically to measure its effectiveness. it is reiterated that equal opportunity policy should involve a series of strategies to change the composition of the workforce and is much more than the legal requirement not to discriminate. 2. women need to take a period of leave from work when they have a child, even if this break is extremely short. this break creates problems for the employers (providing cover for the job, uncertainty about the woman's return, etc.) and also for the individual (concern about how she will be viewed, the practical problems of childcare, uncertainty as to future job opportunities on return, etc.) employers should undertake initiatives in the area of managing the career break, enhancing maternity leave and designing longer career break and retainer schemes. even when the career break is statutory maternity leave or shorter, women need to be able to discuss the issues arising with someone at work frankly and without fear of prejudicing their career. women having their rst child also need a good deal of information about their statutory rights, their employer's policies, options for childcare and so on. a second range of initiatives could be in relation to maternity leave whereby rather longer periods of maternity leave or higher rates of pay than the statutory requirements could be facilitated. employers could require that additional maternity pay be repaid if the woman does not return for a minimum period of employment. a third type of career break initiatives could volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 123gjra global journal for research analysis involve women (and occasionally men) to take longer unpaid periods of leave from work (commonly of 1-5 years duration). these schemes could either offer previous employees 'preferential reinstatement' or offer the guarantee of re-employment to certain categories of women. preferential reinstatement policies may be an effective means of retaining women with valuable skills and potential. 3. existing policy initiatives in india have been primarily concerned with career breaks and maternity leave provisions. such initiatives effectively address a short term problem of childcare for infants by permitting mothers to stay at home for a few years. however, these schemes do nothing to provide childcare for the 'below ve's' for those women who choose not to take a longer break. nor do they address at all the issue of childcare for children of school age. even for women who can afford the considerable costs of private childcare for pre-school children, nding stable high quality provision can be a continued source of anxiety. individual employers, the public sector and some consortia of employers should look at the advantages of setting up crèches and workplace nurseries. tax concessions on these ventures may encourage employers. 4. another main thrust of initiatives could be concerned with offering more exible working arrangements for women with family responsibilities. the main exible working arrangements that are suggested are part-time working job-sharing/job-splitting and working from home. homeworking would not seem to be applicable to managerial work, although it is an important option for some kinds of professional work. it could allow individuals to continue their career and this, in itself, may be important for women who go on to build a managerial career out of their professional work experience. also, paternity leave, needs to be given wider acceptance both by employers and their managers themselves, instead of remaining just a concept on paper. this article attempts to draw the attention of equal opportunity employers and the government. the women executives themselves need to know the kind of environment in which their counterparts, in various categories of organizations, are functioning. this could be a springboard for action on the part of the women themselves to alleviate their lot. it could also initiate joint effort among individual executives or even among voluntary associations to solve some common problems of professional women managers. this article also has implications for practicing women managers in as much as that they recognize, that any constraints they face in their work lives or factors affecting their sense of job satisfaction might be faced by other women across various organizations. this could instill more condence and assertiveness in them by reducing their sense of isolation. references 1. price, j. l. and mueller, c. w. professional (1981), turnover: the case for nurses. york, new medical and scientic books. 2. mcneely rl. (1988), age and job satisfaction in human service employment, gerontologist, 2,163-168. 3. davidson m.j., cooper c.l. (1987) “ occupational stress in female managers: a comparative study “. journal of management studies, 21,2. (185-205). 4. rani, kala “role conict in women”. chetna, new delhi. (1976). volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 124 x gjra global journal for research analysis introduction: schizophrenia is really one of the most perplexing but disabling of all brain diseases, with its severity and persistency of psychotic manifestations accompanied by means of variable cognitive dysfunction and profound psychosocial impairment. the onset of disease, at least of the psychotic manifestations, happens two in late adolescence/ early adulthood. symptomatology is regularly undetectable in early life, are at their worst at some stage in child-bearing years, and often improve, to a degree, with aging. people with psychosis, go through notably for the duration of existence and medical requirement globally continues to be very high.[1] in 1959, a period when tobacco use was at its highest level, abraham published “cardiovascular disease in psychotics,” which showed an increased prevalence of atherosclerotic and hypertensive cvd in hospitalized patients with schizophrenia. he rejected the popular view of the time that “the protective life of people with schizophrenia seems to guard them from early onset of degenerative diseases of the heart.” by the late 1970s, accumulating mortality data from psychiatric patients showed a consistent pattern of increased mortality rates relative to the general population. however, despite such reports there were only a few controlled studies in that period that aimed to understand the causes and contributions to this excess mortality.[2] cvd is also the leading cause of mortality in individuals with schizophrenia, who are even more likely to experience premature cardiovascular mortality than individuals in the general population. the prevalence of cvd in people with schizophrenia is approximately twoto threefold increased, particularly in younger individuals. in a retrospective cohort study conducted by curkendall and colleagues, 3,022 individuals with schizophrenia were compared to a general population cohort. the overall prevalence of cvd was increased in the patients with schizophrenia (10.6 vs. 8.7 percent), as was with the incidence of ventricular arrhythmia (odds ratio [or] = 2.3; 95 percent condence interval [ci], 1.2 to 4.3), stroke (or = 1.5; 95 percent ci, 1.2 to 2.0), diabetes (or = 1.8; 95 percent ci, 1.2 to 2.6), and heart failure (or = 1.6; 95 percent ci, 1.2 to 2.0). cardiovascular mortality in schizophrenia has also been evaluated in large populationbased samples using long periods of observation. patients with schizophrenia were evaluated for mortality risk over a period of 19 years in a swedish registry study, analyzed by osby and colleagues. between 1976 and 1991, death rates due to cvd increased 4.7-fold in men and 2.7-fold in women.[2] correll et al. reported a 10-year chd risk of 6.5% for inpatients with schizophrenia (n = 111). they also reported that 23.4% of patients with schizophrenia had a chd risk more than equal to 10%.[4] in the clinical antipsychotic trials of intervention effectiveness study, it was observed that patients with schizophrenia had signicantly higher 10-year risk of chd than the general population (9.4% vs. 6.3% in males and 7% vs. 4.2% in females).[5] these ndings were replicated in a later study too.[3] other studies reported 10-year chd risk of 6 . 5 7 . 2 % a n d c m r t o b e 0 . 9 % i n p a t i e n t w i t h schizophrenia[4,6] with high/very high risk of chd (≥10%) in 22-23% patients with schizophrenia[4,6] and high cmr risk (≥5%) in 6.5-8% patients with schizophrenia. materials and methods: the study was approved by the ethics review committee of the institute .the patient was incompetent on account of the severity of illness to provide informed consent, then informed consent from the lar of the patient was taken. the study was conducted by including patients above age 20years at the opd of department of psychiatry mgm medical college indore. the participants were screened for the following predened inclusion and exclusion criteria. patients were diagnosed for schizophrenia according to the international classication of diseases classication of mental and behavioral disorders clinical descriptions and diagnostic criteria for research 10th revision[18] were invited to participate in the study. sociodemographic and clinical details of all subjects were recorded in structured formats. the study design was the cross sectional study in which study sample was the 100 patients. who were divided into two groups1) 50 chronic schizophrenic patients whose illness is more than 2 years and who are taking the treatment for the illness. 2) 50 chronic schizophrenic patients whose illness is more than 2 years and who are not taking the treatment for the illness. the study was conducted at department of psychiatry mgmmc indore for one year from date of ethics committee approval. to study the cardiovascular risk factors in patients with chronic schizophrenia who are receiving treatment and not receiving treatment original research paper krishna kumar carpenter m.d. redsident, m.g.m. medical college indore psychiatry to assess the cardiovascular risk in chronic schizophrenia(duration >2 yrs) patients with objective: and without treatment. materials and methods: 100 opd patients (aged 20 or above,both male or female), who were diagnosed with chronic schizophrenia(duration >2yrs) with and without treatment according to the international classication of diseases classication of mental and behavioral disorders diagnostic criteria for research 10th revision. those patients were evaluated for the coronary heart disease (chd) risk as per framingham (10 year all chd events) function/risk equation. results: intermediate cardiovascular risk was found in 2% without treatment patients and 5.73% in with treatment patients. compared to females, males had higher framingham score (4.08± 4.51 vs. 1.07± 0.26, likelihood ratio= 622.19, p value < 0.05 in with treatment patients and 1.63± 1.67 vs. 1.11± 0.48,likelihood ratio= 6.444, p value > 0.05 in without treatment patients) conclusion: patients of schizophrenia have a high prevalence of cardiovascular risk factors. hence, there is a need to screen the patient of schizophrenia for the cardiovascular risk and manage it as early as possible. abstract keywords : cardiovascular risk, mortality, schizophrenia volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra ujwal sardesai* m.d. associate professor, m.g.m. medical college indore *corresponding author ram ghulam razdan m.d. professor, m.g.m. medical college indore 38 x gjra global journal for research analysis assessments: by using standard mercury manometer systolic and diastolic blood pressure was measured. fasting venous blood sample was collected under aseptic condition to estimate cholesterol, triglycerides (tga) and high-density lipoprotein (hdl). analysis of cardiovascular risk with the fra mi ngham/atp iii criteria the framingham/atp iii criteria had been used to estimate chd risk in the usa. data from 11,611 patients from a very large study, the nhanes iii, have been used. [275] high risk used to be most many times found in patients with advanced age, and used to be more frequent in men than women. high risk patients are once in a while emerge as unknown with clinical features of cardiac failure scoring. framingham risk score for women age: 20–34 years: minus 7 points. 35–39 years: minus three points. 40–44 years: zero points. 45–49 years: three points. 50–54 years: 6 points. 55–59 years: 8 points. 60–64 years: 10 points. 65–69 years: 12 points. 70–74 years: 14 points. 75–79 years: sixteen points. total cholesterol, mg/dl: age 20–39 years: under 160: zero points. 160-199: four points. 200-239: eight points. 240-279: eleven points. 280 or higher: thirteen points. age 40–49 years: under 160: zero points. 160-199: 3 points. 200-239: 6 points. 240-279: 8 points. 280 or higher: 10 points. age 50–59 years: under 160: zero points. 160-199: 2 points. 200-239: four points. 240-279: 5 points. 280 or higher: 7 points. age 60–69 years: under 160: zero points. 160-199: 1 point. 200-239: 2 points. 240279: 3 points. 280 or higher: four points. age 70–79 years: under 160: zero points. 160-199: 1 point. 200-239: 1 point. 240279: 2 points. 280 or higher: 2 points. if cigarette smoker: age 20–39 years: 9 points. age 40–49 years: 7 points. age 50–59 years: four points. age 60–69 years: 2 points. age 70–79 years: 1 point. all non smokers: zero points. hdl cholesterol, mg/dl: 60 or higher: minus 1 point. 5059: 0 points. 40-49: 1 point. under 40: 2 points. systolic blood pressure, mm hg: untreated: under 120: zero points. 120-129: 1 point. 130-139: 2 points. 140-159: three points. one hundred sixty or higher: four points. treated: under 120: zero points. 120-129: 3 points. 130-139: four points. 140-159: 5 points. a hundred and sixty or higher: 6 points. 10year risk in %: points total: under 9 points: <1%. 9-12 points: 1%. 13-14 points: 2%. 15 points: 3%. sixteen points: 4%. 17 points: 5%. 18 points: 6%. 19 points: 8%. 20 points: 11%. 21=14%, 22=17%, 23=22%, 24=27%, &gt;25= over 30% framingham risk score for men age: 20–34 years: minus 9 points. 35–39 years: minus 4 points. 40–44 years: zero points. 45–49 years: three points. 50–54 years: 6 points. 55–59 years: eight points. 60–64 years: 10 points. 65–69 years: 11 points. 70–74 years: 12 points. 75–79 years: thirteen points. total cholesterol, mg/dl: age 20–39 years: under 160: zero points. 160-199: four points. 200-239: 7 points. 240-279: 9 points. 280 or higher: eleven points. age 40–49 years: under 160: zero points. 160-199: three points. 200-239: 5 points. 240279: 6 points. 280 or higher: eight points. age 50–59 years: under 160: zero points. 160-199: 2 points. 200-239: 3 points. 240-279: four points. 280 or higher: 5 points. age 60–69 years: under 160: zero points. 160-199: 1 point. 200-239: 1 point. 240279: 2 points. 280 or higher: three points. age 70–79 years: under 160: zero points. 160-199: zero points. 200-239: 0 points. 240-279: 1 point. 280 or higher: 1 point. if cigarette smoker: age 20–39 years: eight points. age 40–49 years: 5 points. age 50–59 years: 3 points. age 60–69 years: 1 point. age 70–79 years: 1 point. all non smokers: zero points. hdl cholesterol, mg/dl: 60 or higher: minus 1 point. 50-59: 0 points. 40-49: 1 point. under 40: 2 points. systolic blood pressure, mm hg: untreated: under 120: zero points. 120-129: 0 points. 130-139: 1 point. 140-159: 1 point. 160 or higher: 2 points. treated: under 120: zero points. 120-129: 1 point. 130-139: 2 points. 140-159: 2 points. 160 or higher: 3 points. 10-year risk in %: points total: 0 point: <1%. 1-4 points: 1%. 5-6 points: 2%. 7 points: 3%. 8 points: 4%. 9 points: 5%. 10 points: 6%. 11 points: 8%. 12 points: 10%. 13 points: 12%. 14 points: 16%. 15 points: 20%. sixteen points: 25%. 17 factors or more: over 30%.[7] statistical analysis the spss version 14.0 for windows (chicago, illinois, usa) was used for analysis. frequencies with percentages were calculated for nominal and ordinal variables and mean, and standard deviation were calculated for continuous variables. chi-square test and t-test were used for comparisons. for variables with a skewed distribution, nonparametric tests like mann–whitney u-test, test for proportion and fisher exact test were used for comparison. results: during the study period of 1 year (2018 to 2019), 100 patients were assessed on the opd basis. 50 of them were without treatment and 50 of them were with treatment chronic schizophrenia patients. all of them/their caregivers provided informed consent to participate in the study. sociodemographic and clinical profile of the sample average age of without treatment schizophrenic patients was 32.16 yrs and with treatment schizophrenic patients was 39.17 yrs.mean age of onset was 26.53 yrs in without treatment schizophrenic patients and 25.70yrs in with treatment schizophrenic patients. mean duration of illness was 6.21 yrs in without treatment schizophrenic patients and 13.74 yrs with treatment schizophrenic patients.male patients were 33 and female patients were 17 in both with and without treatment. majority of the patienuts were hindu. most of the patients were from low socioeconomic status (74% in without treatment and 76% in with treatment patients).most of the patients wer unemployed ( 84% in without treatment and 78% in with treatment patients. most of the patients were urban (67.5% in with treatment and 56% in without treatment patients) intermediate cardiovascular risk was found in 2% without treatment patients and 5.73% in with treatment patients. compared to females, males had higher framingham score (4.08± 4.51 vs. 1.07± 0.26, likelihood ratio= 622.19, p value < 0.05 in with treatment patients and 1.63± 1.67 vs. 1.11± 0.48,likelihood ratio= 6.444, p value > 0.05 in with treatment patients). there is no statistically signicant difference in the systolic and diastolic blood pressure of with treatment and without treatment schizophrenic patients. there is no statistically signicant difference in the blood parameters( hdl,tg and serum cholesterol) of with treatment and without treatment schizophrenic patients. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 39gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra comparison of socio demographic prole between with treatment schizophrenic patients and without treatment schizophrenic patients variables without treatment schizophrenia patients with treatment schizophrenia patients age m:f 32.16 1.9 : 1 (m= 33,f=17) 39.47 1.9 : 1 (m= 33,f=17) marital status in %: married unmarried divorced widowed separated 38% ( n=19) 48%( n=24) 4%( n=2) 0%( n=0) 10%( n=5) 35.3%( n=18) 28.7%( n=14) 17.5%( n=9) 4.7%( n=2) 13.9%( n=7) religion in %: hindu muslim 90%( n=45) 10% ( n=5) 91.4%( n=46) 8.6% ( n=4) education in %: illiterate thprimary(5 ) thmiddle(8 ) high school inter/diploma graduate post graduate professional 14%( n=7) 20%( n=10) 26%( n=13) 10%( n=5) 18%( n=9) 8% ( n=4) 4%(n=2) 17.6%( n=9) 10.9%( n=5) 23.5%( n=12) 25.8%( n=13) 12.5%( n=6) 7.7% ( n=4) 2%(n=1) socioeconomic – low middle high 74%( n=37) 24%( n=12) 2% ( n=1) 76%( n=38) 22%( n=11) 2% ( n=1) occupationemployed unemployed 16%( n=8) 84% ( n=42) 22%( n=11) 78% ( n=49) family type nuclear extended/ joint. 58%( n=29) 42% ( n=21) 41.9%( n=21) 58.1% ( n=29) locality urban rural 56%( n=28) 44% ( n=22) 67.5%( n=34) 32.5% ( n=16) age of onset in years.(mean) 26.53 25.70 total duration of illness in years.(mean) 6.21 13.74 cardio vascular risk ( intermediate risk ) 2%( n=1) 5.73%( n=3) cardio vascular risk ( low risk ) 98%(n=49) 94.24% ( n=47) smoking 24%( n=12) 24.01%( n=12) tobacco chewing 30%( n=15) 40%( n=20) tests for proportion for “with treatment schizophrenic patient” tests for proportion for “without treatment schizophrenic patient” comparison of parameters of physical examination between with treatment and without treatment schizophrenic patients comparison of blood parameters between with treatment and without treatment schizophrenic patients correlations n mean ± sd in males mean ± sd in females pearson value p value likelihood ratio exact sig sex percentage cvd risk 50 4.08±4.51 1.07± 0.26 464.21 0.00 622.19 -correlations n mean ± sd in males mean ±sd in females pearson value p value likelihood ratio exact sig sex percentage cvd risk 50 1.63± 1.67 1.11± 0.48 4.248 0.373 6.444 --variables patients without treatment (mean±sd) patients with treatment (mean±sd) correlation sig ( 2 tailed) sbp (mm hg) 124.80±18.89 124.12±15.26 0.07 0.842 dbp(mm hg) 79.06± 13.49 77.57± 11.64 0.16 0.536 variables patients without treatment (mean±sd) patients with treatment (mean±sd) correlation sig ( 2 tailed) triglyceride (mg/dl) 124.14±67.34 135.65±72.43 0.25 0.362 cholesterol (mg/dl) 170.25±41.55 179.78±37.65 -0.01 0.254 hdl (mg/dl) 44.93±13.28 45.06±12.66 -0.05 0.963 40 x gjra global journal for research analysis discussion: findings with respect to coronary heart disease risk (framingham score) for patients with schizophrenia in the present study is similar to sandeep grover et al study however it is less than that reported from the west (6.5-11.3%).[8,9,10] the major reason for this difference could be a lower age and lower prevalence rate of smoking in sandeep grover's study compared to those evaluated in studies from the west,[9,11] in which the mean age of the study groups was 40.7 years[9,11] and the percentage of smokers varied from 53.7[9] to 58.[11] this ndings also suggest that age is an important variable which inuences the framingham risk score.[12] this suggests that possibly with age and treatment the coronary heart disease risk increases in patients with schizophrenia. studies from different ethnic groups and that from india have reported prevalence rate of metabolic syndrome to be 9-68% in patients with schizophrenia.[10] in our study cardiovascular risk was higher in male patients than female patients in with treatment schizophrenia patients, which was statistically signicant and metabolic syndrome was present more in female patients than male patients in with treatment schizophrenia patients, which was also statistically signicant. but cardiovascular risk was higher in male patients than female patients in without treatment schizophrenia patients. as per denial bressington et al exposure to endogenous oestrogens during the fertile period of life delays the manifestation of atherosclerotic disease in women. before menopause the coronary heart disease event rate in women is low and predominantly attributed to smoking.3 women with an early menopause (<40 years) have a two-year lower life expectancy compared with women with a normal or late menopause. [13,14,15] conclusion: on the basis of available literature and results of index study , which substantiate the earlier ndings, it can be concluded that: cardiovascular risk causes signicant morb idity and mortality in schizophrenic patients .there is no signicant difference in the physical and blood parameters of with treatment and without treatment schizophrenia patients. age , duration of the treatment, duration of illness, smoking and severity of illness affect cardiovascular risk and metabolic syndrome in schizophrenia patients. male patients had more risk for cardiovascular disease than female patients. limitations and future directions: the limitations of the present study are cross-sectional design, inclusion of out patients only, which had lack of healthy control group. we also did not assess the effect of lifestyle factors, physical activity, dietary factors and family history of diabetes, all of which can confound the prevalence of cardiovascular risk in schizophrenia patients. the study was also constrained by the lack of validation of the cardio vascular risk scores used for 10year risk projection in the indian population (the framingham risk score is based on data from white people, whereas score was developed for european populations). in future studies with the longitudinal design should try to overcome the limitations of this study. only selecting patients visited in out patient care, involved a selection bias, as the sample was not representative of the entire population. however, examining this sub-population could be interesting for the development of preventive strategies that are focused on primary care. the study was conducted at a single center and was conned to out patients with chronic disease. it may not, therefore, reect the true cardiovascular risk of all patients with schizophrenia in community. references: 1. carlsson a, lindquist l. effect of chlorpromazine or haloperidol on formation of 3methoxytyramine and normetanephrine in mouse brain. acta pharmacologica ettoxicologica. 1963;20:140–145. clementz ba, sweeney ja, hamm jp, et al. identication of distinct psychosis biotypes using brain-based biomarkers. am j psychiatry. 2016;173:373–384. hyman se. revolution stalled. sci transl med. 2012;4(155):155cm11. 2. brown s, kim m, mitchell c, inskip h. twenty-ve year mortality of a community cohort with schizophrenia. br j psychiatry. 2010;196(2):116–121. *charlson fj, baxter aj, dua t, degenhardt l, whiteford ha, vos t. excess mortality from mental, neurological, and substance use disorders in the global burden of disease study 2010. in: patel v, chisholm d, dua t, laxminarayan r, medina-mora me, eds. mental, neurological, and substance use disorders: disease control priorities. 3rd ed (volume 4). washington (dc): the international bank for reconstruction 3. bolíbar b, fina avilés f, morros r, et al.; sidiap group. [sidiap database: electronic clinical records in primary care as a source of information for epidemiologic research]. med clin (barc) 2012;138(14):61721. spanish. 4. correll cu, frederickson am, kane jm, manu p. equally increased risk for metabolic syndrome in patients with bipolar disorder and schizophrenia treated with second generation antipsychotics. bipolar disord 2008;10:788 97. 5. goff dc, sullivan lm, mcevoy jp, meyer jm, nasrallah ha, daumit gl, et al. a comparison of ten year cardiac risk estimates in schizophrenia patients from the catie study and matched controls. schizophr res 2005;80:45 53. 6. bobes j, arango c, aranda p, carmena r, garcia garcia m, rejas j, et al. cardiovascular and metabolic risk in outpatients with schizophrenia treated with antipsychotics: results of the clamors study. schizophr res 2007;90:162 73. 7. "nhlbi, estimate of 10-year risk for chd". nhlbi.nih.gov. retrieved 2013-0914. 8. goff dc, sullivan lm, mcevoy jp, meyer jm, nasrallah ha, daumit gl, et al. a comparison of ten-year cardiac risk estimates in schizophrenia patients from the catie study and matched controls. schizophr res 2005;80:45-53. 9. bobes j, arango c, aranda p, carmena r, garcia-garcia m, rejas j, et al. cardiovascular and metabolic risk in outpatients with schizophrenia treated with antipsychotics: results of the clamors study. schizophr res 2007;90:162-73. 10. malhotra n, grover s, chakrabarti s, kulhara p. metabolic syndrome in schizophrenia. indian j psychol med 2013;35:227-40 11. daumit gl, goff dc, meyer jm, davis vg, nasrallah ha, mcevoy jp, et al. antipsychotic effects on estimated 10-year coronary heart disease risk in the catie schizophrenia study. schizophr res 2008;105:175-87. 12. phutane vh, tek c, chwastiak l, ratliff jc, ozyuksel b, woods sw, et al. cardiovascular risk in a rst-episode psychosis sample: a 'critical period' 13. https://www.ncbi.nlm.nih.gov/pubmed/27863522 14. prescott e, hippe m, schnohr p, hein ho, vestbo j. smoking and risk of myocardial infarction in women and men: longitudinal population study. bmj. 1998; 316:1043-7. [pmc free article] [pubmed] [google scholar] 15. ossewaarde me, bots ml, verbeek al, et al. age at menopause, causespecic mortality and total life expectancy. epidemiology. 2005;16:556-62. [pubmed] [google scholar] volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 41gjra global journal for research analysis introduction water is an essential nutrient and component in a human's body. it is 73% of the ideal weight and about 50-60% of the total weight in adults. national research suggests adequate uid intake is measured in average uid intake. (manz et al, 2003) mild dehydration is a loss of 1-2% of body weight and caused by an acute uid loss such as vomiting, diarrhea, and excessive physical training. these incidents affect future health and increasing the risk of urinary stones. (armstrong et al, 2007 and walawender et al, 2018) poor hydration harms our health. under some circumstances, urine concentration makes a good marker for your hydration state. it correlates to the specic gravity and osmolarity of the urine. (guelinckx et al, 2015) hydration state can be measured by a noninvasive method i.e. urine color scale and specic gravity. urine color scale is validated as a hydration state marker in adults and children of 8-14 years old. by the age of 8, children can assess their urine. the awareness level in several countries is not signicantly different. in indonesia, the awareness level is similar to france (74%), mexico (84%), and usa (94%)(cridge et al, 2018 and baig et al, 2011) in 2005-2006, the research found that children and adolescents in the us did not take adequate uid recommended by the institue of medicine. using osmolarity of the urine, it reveals that 60% of samples from children of 9-11 years old had inadequate hydration state, mostly caused by not drinking water, lead them to a high risk of poor hydration state. (kenney et al, 2015) in line with portuguese research, many children are classied as hypohydration, so increasing water and water-rich foods intake is necessary. (padrao et al, 2016). the urine color scale has a positive correlation to the specic gravity. dark yellow or score 4 is a predictive marker for the specic gravity of 1.030. bongard et al, 2015) urine specic gravity assessment with a refractometer is a notable assessment proportionate to urinalysis. the refractometer described the urine specic gravity as an indicator of soluble substance and urine concentration. in general, dark yellow urine indicates high concentration. (bongard et al, 2015) retrospective research in the us evaluates the correlation between urine color and specic gravity in dogs, revealed a positive correlation. however, this research has not been done on humans both in developed and developing countries. (kavouras et al, 2016) material and method participant selection students in grades 4, 5, and 6 in singkuang and sikapas elementary school, district of muara batang gadis, mandailing natal, with urine samples were included. exclusion criteria were children with proteinuria, glucosuria, hematuria, bilirubinuria, and those whose parents refused to participate. children with fever, liver malfunction and any chronic diseases were also excluded. data analysis those who met inclusion and exclusion criteria were asked for written consent. data retrieval was done by interview and questionnaire about age, gender, familial socioeconomic state, nutritional state, parental info such as educational background and occupation, underlying disease, 24-hour uid intake, and others that may affect urine assessment. urine was obtained using 15ml urine pot to be examined by a relationship between urine color scale and urine specific gravity to hydration status in elementary school student original research paper dini arini hasibuan department of pediatric, faculty of medicine, university of sumatera utara, medan, indonesia nephrology background: inadequate hydration state in children causes several conditions such as imbalance mood, headache, delayed cognitive function, even death. it is imperative to access the status quickly, accurately by using urine color scale and measuring the urine specic gravity. the purpose of this study is to analyze the relationship between urine color scale and urine specic gravity to hydration status in children. method: a cross-sectional study was conducted in march 2019 in singkuang village. the samples were elementary children from 8 to 14 years old. all samples required to ll the questionnaire and to submit the urine sample. then, they were examined to assess hydration state. the urine was evaluated by using a urine color scale and refractometer. bivariate analysis, chi-square, was used to analyze the determinants. the condence interval was set to 95% and p<0.05 was signicant. result: there were 222 samples from elementary school class 4 to 6. there were 46 (20.7%) dehydrated children from a physical examination. there were 5 (2.2%) dehydrated children and 153 (65.9%) probably dehydrated children when to be assessed by urine color scale. there were 18 (8.1%), dehydrated children, when being assessed by urine specic gravity. there was no relationship between urine color scale to hydration status (p = 0.511). but the urine specic gravity was signicantly correlated to hydration status (p = 0.032) and urine color scale (p = 0.0001) conclusion: hydration status can be determined by evaluating urine specic gravity but not by evaluating urine color scale. abstract keywords : urine color scale, urine specic gravity, hydration status, children. oke rina ramayani* department of pediatric, faculty of medicine, university of sumatera utara, medan, indonesia *corresponding author tiangsa sembiring department of pediatric, faculty of medicine, university of sumatera utara, medan, indonesia volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra munar lubis department of pediatric, faculty of medicine, university of sumatera utara, medan, indonesia 144 x gjra global journal for research analysis urine color scale. about 2 drops or 0.1 ml of urine was transferred from the transparant pot for refractometer assessment by dropping and covering it on the prism glass and measured it through the refractometer hole. evaluation of children's hydration state was done using who standards. the data was written, collected, and input to the table master for further analysis with the computed statistical program. statistical method all data were analyzed using computerized software. characteristics of the subjects were described in the distribution of categorical data. we used a chi-square test with p <0.05 and ci 95%. results this research enrolled 222 elementary students age 8-11. their caharacteristic data is shown in table 1. table 1. subject's characteristics pearson chi-square test revealed p = 0.511, so there is no signicant correlation of urine color scale to their hydration state (p>0.05, table 2) * pearson chi-square statistical test using pearson chi-square revealed p = 0.032 in urine specic gravity and hydration state. there is a signicant correlation of urine specic gravity and hydration state (p<0.05, table 3) table 3. correlation of urine specic gravity to hydration state * pearson chi-square in table 4, pearson chi-square test reveals p = 0.0001 so there is a signicant correlation of urine color scale and specic gravity (p = <0.05). table 4. correlation of urine color scale and specic gravity * pearson chi-square discussion urine usually have colour of either pale yellow or light yellow, and can be turn to dark yellow if the urine became concentrated. fluid intake and few factors such as drugs, food, stress, and activity can affect urine colour. cloudy urine can be caused by infection with pus, presence of microscopic blood cells, urinary stone, food, vaginal uid, and dehydration state. urochrome was a pigment that gave characteristic of urine colour into yellow. medicines and other compounds can also affect urine colour. the most common thing that can turn urine colour was blood, which can turn urine colour into pink, red, or darker. blood in urine can be cause by diseases, and bleeding in small amount causes by drugs. basically laboratorium nding was essential if the urine colour was checked. (lockwood et al, 2018) in this study, there were few obstacles for assessed the colour of urine, of which there was to many that can affect urine colour. from food, drugs, infection,vaginal uid, pus caused by urinary tract infection, microscopic blood that cannot be conrmed by macroscopic ndings, direct interview, questionnaire by parents, but also needed urine laboratory to exclude factors in urine colour changing causal. also with renal disease factors like urinary tract infection and urinary stone that needed advance examination like urinalysis, urinary tract ultrasonography, urine culture to exclude factors that effect urine colour. in 24 hours composition and concentration of urinalysis can be change, therefore, a lot of examination tipe from specimen that can be evaluated. generally, around 10 cc urine can be used for urinalysis. urine specimen has to be cold rst if the specimen cannot be evaluated in 2 hours after the taking, because the urine can be damaged after 2 hours, became more alkali, and causes urinalysis not longer acccurated. (lockwood et al, 2018) evaluation of urine specic gravity for asses the capability of kidney to concentrated and diluted the urine and the connection with plasma for comparing the weight of urine (particle) to weight of water ltration. because urine consist of several substance like minerals and salts, the specic gravity of urine normally higher that water, usually around 1.0051.025, but the specic gravity of urine can increase with gain of several substance, such as protein or dehydration stated. other things that can increase the specic gravity of urine was glucose in urine, and increased of anti diuretic hormone (adh), because adh functioned to reabsorb water in tubule caused decrease of urine volume. and other several factors like trauma, stress, surgery, and drugs that can increase the secretion of adh. decreased of urine specic gravity can be caused by multiple factors such as diabetes insipidus where there were not or less adh that secreted due to the damaged of pituitary glnd, so kidney produce mre urine (15-20 litre per day) with decreased of urine specic gravity. kidney disease such as pyelonephritis and glomerulonephritis can interefere the kidney for ltered and reabsorbed water so can lower the urine specic gravity. kidney disease such as pyelonephritis and glomerulonephritis so it can interefe the kidney to absorband reabsorbed water, so it can lower. state of kidney volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra characteristics hydration status normal dehydrated sex male 96 (54.5%) 20 (43.5%) female age 6-11 years old 12-16 years old nutritional status mild malnutrition well nourish overweight obesity frequency of drinking water (24 hours) little (≤ 6 glasses) adequate (7-9 glasses) much (> 9 glasses) 80 (45.5%) 127 (72.2%) 49 (27.8%) 29 (16.5%) 110 (62.5%) 24 (13.6%) 13 (7.4%) 34 (19.3%) 118 (67%) 24 (13.7%) 26 (56.5%) 31 (67.4%) 15 (32.6%) 11 (23.9%) 31 (67.4%) 3 (6.5%) 1 (2.2%) 39 (84.8%) 7 (15.2%) 0 (0%) urine color scale hydration state p value normal dehydrated total euhydrated 53 (81.5%) 12 (18.5%) 63 (100%) 0.511* potential to dehydration 120 (78.9%) 32 (21.1%) 153 (100%) dehydrated 3 (60%) 2 (40%) 5 (100%) specic gravity hydration state p value normal dehydrated total hyperhydrated 22 (84.6%) 4 (15.4%) 26 (100%) 0.032 euhydrated 144 (80.9%) 34 (19.1%) 178 (100%) dehydrated 10 (55.6%) 8 (44.4%) 18 (100%) urine color scale specic gravity p valuehyperhydrated euhydrated dehydrated euhydrated 20 (30.8%) 45 (69.2%) 0 (0%) 0.0001potential to dehydration 6 (3.9%) 132 (86.8%) 14 (9.2%) dehydrated 0 (0%) 1 (20%) 4 (80%) x 145gjra global journal for research analysis failure also create vary sepsic gravity between 1.007-1.001 as hypertrhropy . (lockwood et al, 2018) this can affect study where the factor that can affect urine specic gravity such as kidney disease (pyelonephritis and glomerulonephritis), diabetes insipidus, and adh secretion that needed for laboratory urinalisys, kultur urine, blood sample, and kidney, can exluded nw diabetes insipidus and adh secretion needed evaluation of investigation like urinalysis, urine culture, adh secretion that needed further evaluation like urinalysis, and usg was needed to exluded other factor in changing of urine specic gravity. in result of study found signicant correlation between specic gravity and dehydration state in children's that maybe can be explained due to less factor that can affect urine specic gravity and several factors can be excluded with questionnaire so that in result got signicant correlation. can be concluded that the weakness from this study was there still need to have examination that support exclusion criteria such as kidney usg, blood examination, urine culture, laboratory urinalysis to proof kidney and urinary tract disease that can affect result of urine clour scale or specic gravity. study by mckenzie in united stated explained that urine clour scale was usefull diagnostic to assessed hypohydation status after exercise in hot weather. urine colour scale below 5 indicated loss of uid more than 2 % with sensitivity of 88,9% and specicity of 84,8%. this paramatre was helpful to assessed on eld when theres no equipment (for examples refractometry or osmometry ). (shirreffs et al, 2015) study of shirreffs in europe said that collection of urine for analysis can investigated and used for marking of hydration status. osmolarity of urine can exchange with urine specic gravity as potential marker. theres was correlation between urine colou scale to urine specic gravity and conduction force. use eight scale and weigth shoeed that theres linear correlation between urine colour scale to urine specic gravity and urine osmolarity to estimated the hydration status. (brewster et al, 2012) study by garcia in spain for adolescent stated that validation result showed that water balance, water intake, water excretion correlated with some of important marker from hydration status, these were urine specic gravity, total weight, and urine colour scale. recent study explained that urine specic gravity strongly correlated with urine osmolarity, so that recommended as promising marker for assessed the hydration status. urine colour scale was subjective and depend on several factors such as drugs and food, so this marker have to combinated with other methods. (garcia et al, 2016) chew in kuala lumpur compares urine colour scale that taken with handphone to urine laboratorium, stated that there was a strong correlation between urine osmolarity to urine specic gravity and urine colour scale to assessed hydration. (chew et al, 2018) trabelsi in tunisia explained that urine urine strip urine specic gravity had the same result compare the one that on laboratory to determined hydration status. in other study showed that theres a linear correlation between urine colour scale with urine specic gravity and urine osmolarity to determined hydration status. there were 6 studies that stated urine specic gravity or urine osmolarity with proof of a category as indicator to hydration status of male and athlete. (trabelsi et al, 2017) ersoy in turkey studied of hydration status in male soccer with urine colour scale, urine specic gravity (laboratorium, refractometry, and strip). he stated that there was no standard for examination of hydration status, even though with plasma and urine osmolarity, but urine colour scale can be used as valid method. for additionaly, monitoring of weight when the bladder was empty, urine analysis (colour scale, urine specic gravity, and urine osmolarity) was effective methods that strongly correlated with hydration status. (ersoy et al, 2016) overall there was a strong correlation between urine specic gravity and urine colour scale for hydration status. there was similarity of result and validity between urine colour and urine specic gravity to urine osmolarity and plasma ormolarity. this was convenient with the result of this study that there was signicant correlation between urine specic gravity to hydration status and urine colour scale to urine specic gravity. although there was distinction with result of study that there was no signicant correlation between urine colour scale with hydration status. conclusion there was no signicant correlation between urine color scale and hydration state. however, there was a signicant correlation of urine specic gravity to hydration state and urine color scale to urine specic gravity. references 1. manz f, wentz a. 24-h hydration status: parameters, epidemiology and recommendations. eur j clin nutr.2003;57(2):s10-s18. 2. armstrong le. assessing hydration status: the elusive gold standard. j am coll nutr. 2007;26(5):575s-584s. 3. walawender l, patterson j, strouse r, ketz j, saxena v, alexy e, et al. mobile technology application for improved urine concentration measurement pilot study. pediatr nephrol. 2018:1-8. 4. guelinckx i, marquis af, eon e, kavouras s, armstrong l. assessing hydration in children: from science to practice. ann nutr metab. 2015;66(3):5-9. 5. cridge h, wills rw, lathan p. correlation between urine color and urine specic gravity in dogs: can urine color be used to identify concentrated urine?. can vet j. 2018;59:178-180. 6. baig aa. biochemical composition of normal urine. sultan zainal abidin university; 2011. 7. kenney el, long mw, cradock al, gortmaker sl. prevalence of inadequate hydration among us children and disparities by gender and race/ethnicity: national health and nutrition examination survey, 2009-2012. am j public health. 2015:105(8):e113-e118. 8. padrao p, neto m, pinto m, oliveria ac, moreira a, moreira p. dietary intake according to hydration status in 9-10 year-old soccer players. nutr hosp. 2016;33(3):41-45. 9. bongard ej. uncomplicated urinary tract infection in primary care; evaluation of point of care tests and patient management. cardiff university; 2015. 10. kavouras sa, johnson ec, bougatsas d, arnaoutis g, panagiotakos db, perrier e, et al. validation of a urine color scale for assessment of urine osmolality in healthy children. eur j nutr. 2016;55:907-915. 11. lockwood w. the complete urinalysis and urine tests. www.rn.org. 2018;1-34. 12. padrao p, neto m, pinto m, oliveira ac, moreira a, moreira p. urinary hydration biomarkers and dietary intake in children. nutr hosp. 2016;33(3):35-40. 13. brewster k. an analysis of the hydration status of 15 to 18 year old adolescent males of the w-connection football club. the university of the west indies; 2012. 14. shirreffs sm. markers of hydration status. eur j clin nutr. 2003;57:s6-s9. 15. garcia ai, vaesken ml, partearroyo t. adaptation and validation of the hydration status questionnaire in a spanish adolescent-young population: a cross sectional study. nutr j. 2019;11:1-15. 16. chew n, azhar mn, lum l. pp018 a study of correlation between urine colourimetry using mobile phones with clinical dehydration status and laboratory urinalysis in patients with dengue fever. m-jem. 2018;3(2):1. 17. trabelsi k, stannard sr, chtourou h, moalla w, ghozzi h, jamoussi k, et al. monitoring athletes’hydration status and sleep patterns during ramadan observance: methodological and practical considerations. biol res. 2017:129. 18. ersoy n, ersoy g, kutlu m. assessment of hydration status of elite young male soccer players with different methods and new approach method of substitute urine strip. j int soc sports nutr. 2016;13(34):1-6. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 146 x gjra global journal for research analysis background of the study the birth of a baby is a signicant life event inuenced by .[1] cultural norms and expectations intra uterine growth retardation is dened by the american college of obstetrics and gynecology [acog] as weight for gestational age less than tenth percentile in a fetus and whose abdominal circumference are below the 2.5th percentile. intra uterine growth restriction is a global issue and an important public health problem which is associated with increased neonatal mortality &morbidity. in accurately dated pregnancies, approximately 80-85% of foetuses identied as being iugr are constitutionally small but healthy, 10-15% is 'true' iugr cases, and the remaining 5-10% of foetuses are affected by chromosomal/structural anomalies or chronic intrauterine infections. the causes of fetal growth restriction .can be divided into four groupsmaternal, fetal, placental, and unknown. maternal causes are small women, maternal genetic and racial background, maternal nutrition, diseases associated with pregnancy and any chronic diseases, diabetes, hypertension, exposure to any toxins and drugs. fetal causes include anomalies, viral and parasite infections and multiple gestation and placental causes are placental insufciency and placental anomalies. however cause [2]remains unknown in about 40% case timely diagnosis and management is very important in preventing perinatal mortality and morbidity related to intrauterine growth retardation. the clinical methods to diagnose intrauterine growth retardation include the palpation of the uterus for fundal height, liquor volume, fetal mass, and estimation of predictors such as falling or static weight of the mother in the second half of pregnancy and fall or static abdominal girth. ultra sonography is very useful to diagnose growth retardation. doppler velocimetry and biochemical markers [3]have also been used to assist the diagnosis. the incidence of iugr is six times higher in underdeveloped/developing countries when compared to that of developed countries, and this incidence can be further high in lower and middle income countries, as many infants are born in home with no birth [4]records. intrauterine growth retardation is observed in about 24% of newborns; approximately 30 million infants suffer from growth retardation every year. in india, the proportion of intrauterine growth retardation has been found to be 54%, whereas in china it is 9.4%. national neonatal perinatal database of india reported the incidence of iugr to be 9.65% 6among hospital born live birth infants . the high incidence of iugr in developing countries is mostly because of social reasons such as gender discrimination (it leads to poor nutritional supplement to the female gender when compared to the male gender, leading to poor health and malnutrition of female that in-turn leads to iugr fetus) and does not appear to reduce with interventions that are targeted toward the pregnant women. adolescent and pre-pregnancy nutrition, prepregnancy weights, poverty, and inter-pregnancy interval are the crucial determinants of fetal growth in low and middle income societies. social intervention such as taking care of female nutrition enrichment, marriage after 18 years of a girl, delaying of age at rst pregnancy, preventing female gender violence, and treating chronic disease and pregnancyinduced disorders will help to have a positive effect on reducing the incidence of iugr in developing countries. however, some evidence-based interventions have shown to reduce the incidence of iugr. the evidence-based interventions include balanced energy protein supplem enta tion, intermittent preventive treatment of malaria in pregna ncy, multiplemicronutrient supplementation, and smoking cessation. unfortunately, in spite of these initiatives, the overall outcome of these iugr has not changed much over time.in this regard researcher felt to give focus on the particular problem of the society. the present study will give effort to assess the occurrence of iugr objectives ÿ to identify the occurrence of intra uterine growth retardation (iugr). ÿ to nd out the contributing factors related to intra uterine growth retardation (iugr). ÿ to nd out the association between the occurrence of intra uterine growth retardation (iugr) and selected factors. methodology this cross sectional descriptive quantitative study consisted of total one hundred six antenatal mother(gestational age ≥ 35 weeks) selected from the antenatal inpatient departments of bankura sammiloni medical college and hospital, bank ura, in west bengal, india. main variables were occurrence of iugr, contributing factors of iugr including gestational age, maternal hb%, pregnancy induced hypertension and maternal systemic illness. in addition, we studied some background variables including the age of mother, gravida, type of family, history of consumption of tobacco, education the occurrence of intra uterine growth retardation and its contributing factors among antenatal mothers attending maternity units of hospital, west bengal,india. original research paper maitreyee ghosh researcher, deputy nursing superintendent, raghunatpur super specialty hospital, purulia,west bengal,india. nursing a descriptive study to assess the occurrence of intra uterine growth retardation (iugr) and its contributing factors among antenatal mothers attending maternity units of bsmc&h, bankura was undertaken with the objectives to identify the occurrence of iugr, to nd out the contributing factors related to iugr ,to nd out the association between the occurrence of iugr and selected factors. the conceptual framework of the study was based on shbone model of dr. kaoru ishikawa, a japanese quality control expert. survey research design was used to conduct the proposed study on 106 antenatal mothers in third trimester (≥35weeks) of gestation admitted the antenatal ward selected by non-probability convenience sampling. a valid and reliable semi structured interview schedule was used for collection of demographic data and record analysis proforma of usg report and birth weight were used to detect iugr. interview schedule and record analysis proforma were used to nd out the contributing factors related to iugr. analysis of nal data revealed that 16% of mothers had iugr fetus. signicant association was found between iugr fetus and mothers' age, socio economic status, family type and consumption of tobacco identied by chi square tests of association. abstract keywords : intra uterine growth retardation(iugr), gestation, contributing factor. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra mrs. pranati pal* guide, .principal, government college of nursing, r.g. kar medical college & hospital, kolkata, india. *corresponding author 42 x gjra global journal for research analysis and occupation of husband, monthly family income, socio economic status. the samples were selected by nonprobability convenience sampling technique.inclusion criteria were the antenatal mothers in their third trimester (gestational age ≥ 35 weeks) of pregnancy, willing to participate in the study, able to communicate in bengali. exclusion criteria were the antenatal mothers having twin pregnancy and bad obstetrical history. the ethical committee approved the study. self-introduction was given and rapport building was established with the subjects and health team members of the hospital an informed consent was obtained from the participants after explaining purpose of the study. at rst the interview schedule was administered to collect background data of the mothers. data related to contributing factors of iugr were recorded from the mother child protection (mcp) card. then the mothers were taken to radiology department with their family members. each and every mother had undergone ultra-sonography. bio physical measurement of foetus has been recorded at the time of ultrasonography. measurements were femur length, abdominal circumference, and head circumference. each mother took approximately 20 minutes. condentiality was assured. the results were analysed. these the diagnoses of iugr was based on criteria for detection of iugr are presented in table .1 criteria for detection of iugr source: national neonatal‐perinatal database (nnpd), the world health organization fetal growth charts. results: section 1 findings related to the demographic characteristics of the pregnant mothers. 79 antenatal women (74.5 %) belon ged to the age group of 17-22years.it revealed that 78 (73.6%) mothers were primi gravida. socio-economic status of majority (69.8 %) mothers was upper lower (iv) category. it also depicts that 85 (80.1 %) of the mothers had no history of tobacco consumption. section ii findings related to occurrence of intra uterine growth retardation (iugr).it revealed that17 foetus (16 %) had iugr. section iii findings related to the contributing factors related to iugr. table.2 frequency and percentage distribution of mothers according to the selected contributing factors of iugr. n = 106 data presented in the table 2 showed that the gestational age of majority (72.65 %) of mot hers ranged between 38 40 weeks. data also depicted that the hemoglobin level of nearly half of the mothers (58.5%) was >10 gm%. almost all the mothers (97.16 %) were not sufferingfrom hypertension and had no systemic illness (heart disease) (99.05 %). section iv: findings related to association between the occurrence of intra uterine growth retardation (iugr) and selected factors. ÿ statistically signicant association was found between occurrence of iugr and age of mothers, family type, and socio economic status of mother's family consumption of tobacco by mother. ÿ no statistically signicant association was found between occurrence of iugr and gravida of mothers, hemoglobin level of mothers. discussion this survey research study was conducted to investigate about the occurrence of intra uterine growth retardation (iugr) and its contributing factors among antenatal mothers.the present study is supported by a case control study conducted by vijoyanath et al to assess the maternal determinants of intrauterine growth retardation in rural community. in this study under reference the association between iugr and maternal risk factors such as mother's age, hemoglobin level, socio economic status of the mothers was [5]identied. the present study is supported by the prospective study conducted by haridas govinda warrier1, k m ashokan, et al to assess the fetal biometry in late 3rd trimester for .[6 ]gestational age indian standards in this study the researcher identied ultrasound (usg) study in antenatal patients is a very valuable tool especially when it comes to estimation of gestational age. fetal weight is mainly reected by the ac (abdominal circumference).in the present study also the researcher took the help of ultrasonography only to nd out iugr and abdominal circumference was used as the criteria for detecting iugr. the present study is supported by a retrospective study conducted by nihal riyami, md et al, department of obstetrics and gynecology, division of maternal fetal medicine, mount sinai hospital, university of toronto. to assess the utility of head/abdomen circumference ratio in the evaluation of severe early-onset of intrauterine growth restriction. ultrasound images were reviewed for fetal biometry, amniotic uid volume, and uterine and umbilical doppler ow studies within seven days of delivery, and the frequency of head circumference/abdominal circumference ratio ≥ 95th percentile for gestation was determined. sixty-two of 107 pregnancies (58%) with earlyonset iugr had an elevated hc/ac ratio (≥ 95th percentile), which was more than 10-fold greater than the expected proportion (p < 0.001). this is in contrast to the current belief .[7]that asymmetric iugr is conned to third trimester iugr in the present study also the researcher used the hc/ac ratio as a valuable tool for detection of asymmetric iugr in third trimester. conclusion & recommendations: in 3rd trimester of pregnancy ultra-sonography ndings were effective in detection iugr. it was concluded undoubtedly that the detection of iugr can help to reduce the maternal and neonatal mortality rate. timely diagnosis and management is very important in preventing perinatal mortality and morbidity related to intrauterine growth retardation. reference 1. s. meharban care of newborn. 5thed. sagar printe rsand publication; 2001. p. 23-26. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra gestational weeks th< 5 percentile of ac birth weight < th10 percentile hc/ac ratio 35 weeks 27.9 cm 1815 gm >1 36 weeks 28.7 cm 1961 gm >1 37 weeks 29.6 cm 2103 gm >1 38 weeks 30.6 cm 2240 gm >1 39 weeks 31.6 cm 2368 gm >1 40 weeks 32.7 cm 2487 gm >1 variables frequency percentage gestational age 35 -37 weeks 38-40 weeks 29 77 27.35 72.65 haemoglobin percentage ≤10gm% >10gm% 44 62 41.5 58.5 hypertension yes no 03 103 2.84 97.16 history of systemic illness yes no 1 105 0.95 99.05 x 43gjra global journal for research analysis 2. dutta dc. text book of obstetrics. 6th ed. calcutta: central publication; 2004. p. 462-64. 3. gardosi j. clinical startgies for improving the detection of fetal growth restriction. clinical perinatology. 2011 mar; 38(1):p. 21-31. 4. de onis m, blössner m, villar j. levels and patterns of intrauterine growth retardation in developing countries.eur j cli nutr. 1998; 52 (suppl 1):s5–15. [pubmed] 5. vijayanth r, vineetha g gopal, shameer p, sunnil a salim. a study on risk factors of intrauterine growth retardation. national conference on students medical research; trivandrum, kerala. 2008 april 11-12. p. 52-60. 6. haridas govinda warrier1, k m ashokan2 assistant professor, department of obstetrics & gynecology, kannur medical college, kerala, india, 2professor and head, department of obstetrics & gynecology, kannur medical college, kerala, india fetal biometry in late 3rd trimester for gestational age indian standards international journal of scientic study | march 2016 | vol 3 | issue 12. 7. nihal al riyami, md, melissa g. walker, msc, leslie k. proctor, msc, yoav yinon, md, rory c. windrim, mb, msc, john c.p. kingdom, md department of obstetrics and gynecology, division of maternal fetal medicine, mount sinai hospital, university of toronto, toronto on j obstet gynaecol can 2011;33(7):715–719. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 44 x gjra global journal for research analysis introduction 1stunting prevalence in southeast asia in 2015 was 26.3%. according to unicef (united nation children's fund) in 2016 showed that stunting prevalence in children below 5 years old in indonesia at 2013 was 33 % in cities and 42 % in 2countryside. according to ikatan dokter anak indonesia (idai) in 2016, indonesia become the fth place of the highest 3stunting prevalence in the world. stunting was disturbance linear growth causes by chronic malnutrition and or chronic infection or reccuring shown by the z-score height/age < -2 sd according to world health 4 organization (who). chang, et al, 2010, showed that stunting in early childhood related with the lack of ne motor works like movement of ngers and hand, hence the children will has 5more risk to be lower in cognitive and academic. children with anemia also one of the factor that can cause growth disturbance, decrease of cognitive function,ne psychomotor, gross pcychomotor, and language development 6compare to children that are not anemic. methods this study was approved by the health research ethical committee, medical faculty of university of sumatera utara/haji adam malik general hospital, medan, north sumatera. an analytic observational study with a cross sectional design was performed at elementary school in sikapas village, muara batang gadis, mandailing natal district, north sumatera from march 2016 to april 2016. the inclusion criteria were children that agreed to be checked anthropometry, haemoglobulin, and intelegent quotient. the exclusion criteria were children with vertebrae deformities, children with central neurology problems, children with severe disease that cannot follow cognitive function test, and children with symptomatic congenital disease (such as cardiac abnormalities etc). informed consent was obtained from all parents of the subjects prior to subject enrollment. characteristics of the subjects including sex, age, nutritional status, and cognitive function test. the anthropometry was measured for each subject with camry wight and height scales. the nutritional status of the subjects were plotted according to weight for length chart from cdc 2000 growth chart for subjects 5-18 years old. the haemoglobin test was performed with haemoglobin strip tes that only shown anemia (hb<12gr/dl) or not anemia (hb>12gr/dl). the cognitive function test was performed with wechsler intelligence scale for children iv (wisc-iv) tools test. data was analyzed with few steps. the rst step was analyzed to see the distribution and frequency of every variable. the second step was multivariate, chi-square test with by spss statistics ver. 18.0. statistical signicance was considered at p value <0.005. result there were 87 children with average age 10,45 years old, and 56,3% were boys and 43,7% were girls. in 87 children, there were 54% with stuntinf condition. the haemoglobin showed that 55,2% of the childred were not anemic. the cognitive test was shown on table 1. after classied, there were 44 children (50,6%) with normal cognitive test and 43 children (49,4%) with lack in cognitive. from table 2, achieved that in 47 children with stunting, 61,7% children had cognitive disturbance 38,3% did not have cognitive impairment. in children with no stunting, 65% did not have cognitive impairment and 35 % had cognitive impairment. tabel 1. children cognitive test stunting and anemia are associated with cognitive abilities in primary school children original research paper nur arafah departments of child health, university of sumatera utara medical school, medan, indonesia. clinical research background stunting and anemia in children are still a serious problem in indonesia. stunting was related to cognitive function in children.in addition ,anemia is also associated with that function. objective to analize the relationship between stunting and anemia with cognitive ability in primary school children in sikapas village, sumatera utara. methods a cross-sectional study was performed in sikapas village, sumatera utara, from march 2016 until april 2016. the population in this study was primary school children in sd negeri 384, sikapas vilage. stunting was assessed by cdc curve with the percentile height of body per age below the 3rd percentile. anemia as if hb less than 12 mg/dl.cognitive ability was examined by psychologist using weschler iv subtest. processing and data analysis was conducted using spss 18.0 for windows with a signicance level of p <0.05. results fifty four percents of student following the study suffered stunting, most students did not suffer anemia (55.2%) and 49.4% have impaired cognitive ability. bivariat analysis showed that there was a statistically signicant relationship between stunting and cognitive ability in children (p value = 0,023 and or = 2,992), while there was no statistically signicant relationship between anemia and cognitive ability in children (p value = 0,598 and or=1,379). conclusion it can be concluded that there was relationship between stunting with impaired cognitive ability. abstract keywords : stunting, anemia, cognitive ability, primary school children volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra munar lubis* departments of child health, university of sumatera utara medical school, medan, indonesia. *corresponding author isti ilmiati fujiati department of public health/medical research unit ,university of sumatera utara, medan, indonesia. children cognitive function n % 1 mental defective 14 16,1 2 borderline 29 33,3 3 low average 21 24,1 4 average 21 24,1 5 high average 1 1,1 6 superior 1 1,1 total 87 100,0 16 x gjra global journal for research analysis tabel 2. relation of stunting with children cognitive function *chi-square test in bivariate analaysis between stunting and cognitive function, the p value= 0.023 that can be concluded that there was signicant diference between them means that the children in normal height status are better in cognitive function. the odds ratio was= 2.992 measn that in children with stunting had 2.992 times the risk to have cognitive impairment compare to normal height children. from 39 children with anemia, 53.8% had cognitive impairment and in 48 without anemia there were 54,2% that had cognitive impairment as shown in table 3. bivariat analyzed was done and the p value= 0.598 so there is no signicant difference between anemia and the impairment of cognitive. table 3. relation of anemia with children cognitive function *chi-square test discussion stunting was indicator of problem in children nutrition causes by chronic malnutrition relate with environtment and 4,7 socioeconomic status. stunting prevalence in southeast 1asia on 2015 was 26.3%. the children in sikapas elementary school that suffer from stunting was 54%. anemia prevalence on the world was 47.4% or around 300 millions children suffer 8from anemia. in this study reported that 44.85% of the sample that had anemia. this study reported that in 47 children that had stunting majority had cognitive impairment that is 61,7% with p value= 0.023% with or 2.992%. this was in line with other study by suvarna and itagi, 2008, that found children with stunting had inferior iq and mentally retarded in positive correlated by 9 statistic. pradita, 2009, also showed that there are signicant 10 correlation between iq score in elementary school children. in wonogiri on elementary scholld children age 9-12 years old showed that children with stunting had 9.2 risk of getting iq 11score below average, and average achievements. if intake was inadequate, children's body will limit the social activity and cognitive growth, and the limit the energy for 12 overall growth. stunting was related with under-developed brain with dangerous consequences with lack of mental ability and capability of learning, lack of school performance, increasing of nutritional risk such as chronic disease, such as 13 diabetes, hypertension, and obesity in future days. there was combination of inadequate nutrition with unsupported environtment maybe disrupts the cognitive development on 14poor children. in this study 39 children with anemia, 53.8% had cognitive impairment and in 48 without anemia there were 54,2% that had cognitive impairment as shown in table 3. bivariat analyzed was done and the p value= 0.598 so there is no signicant difference between anemia and the impairment of cognitive. this was differ with kordas, et al, 2004, where he found children with anemia with hb <12 g/dl worse to done number sequencing compare to that was not anemic (p=0,004). zulaekah, et al, 2014 explained that children with anemia had low ne motor, gross motor score, and language 6 development compare to children with no anemia. carter, et al, 2010 and jauregui, lobera, 2014 was support iron 8,15deciency anemia can cause decit in kognitive function. iron was needed to form haemoglobin, an essential protein to bind oxygen. therefore, if iron was decrease, organs and tissues cannot get adequate oxygen and causes fatigue, decrease of performance, and immunity. inadequate iron that not treated can cause serious problem like delay of growth 16and cognitive development. in early life, brain, muscle and skeleton of babies was growing so fast. 95% brain was develop in rst 3 years of life. several essential nutrient for example amino acid and iron was highly needed for formation of synaps and neurotransmitter dan 5affect the speed of mind response. lack or excess of nutrient in age 0-2 years, commonly 5irreversible and will impact on short-term and long-term life. lack of nutrition affect brain area dan included for cognition, memor, and locomotor skills. brain need energy especially in early children and most of cerebri development happened in the rst two years of life. although the correlation of bad linear growh and impairment of neuro development was not yet 3understand very well. limitation of this study was the sample was not as much as other studies so can gave different interpretation. this study also only measure the hemoglobin with only hb test trip, this can make bias in anemia result. our study does not assessed the effect of socioeconomic parenteral education, and environtment hygienity on the suject cognitve test. conlusion of this study was, that the stunting can affect cognitive function, making it lower than the children with no stunting. but anemia did not proof to have effect on cognitive problems. further studies on cognitive problems on stunting and anemia are needed. references 1. unicef, who, world bank. levels and trends in child malnutrition. unicef/ who/ world bank group joint child malnutrition estimates, key ndings of the 2016 edition. new york: unicef; geneva: who; and washington, dc: world bank; 2016. 2. unicef. global databases, stunting disparity [internet]. may 2016 [cited on 24th september 2016]. available from: www.data.unicef.org. 3. ikatan dokter anak indonesia (idai). 15th pediatric update exploring the big picture of childhood stunting: indonesian perspective rst edition. bandung: idai; 2016. p4-10. 4. jayanti en. hubungan antara pola asuh gizi dan konsumsi makanan dengan kejadian stunting pada anak balita usia 6-24 bulan (studi di wilayah kerja puskesmas randuagung kabupaten lumajang tahun 2014).reseach fakultas kesehatan masyarakat universitas jember; 2014. 5. chang sm, walker sp, grantham-mcgregor s, powell ca. early childhood stunting and later fine motor abilities. development medicine & child neurology. 2010; 52: 831-6. doi:10.1111/j.1469-8749.2010.03640. 6. zulaekah s, purwanto s, hidayati l. anemia terhadap pertumbuhan dan perkembangan anak malnutrisi. kemas. 2014; 9 (2): 106-14. 7. prendergast aj, humphrey jh. the stunting syndrome in developing countries. paediatrics and international child health. 2014; 34 (4): 250-65. doi:10.1179/2046905514y.0000000158 8. carter rc, et al. iron deciency anemia and cognitive function in infancy. pediatrics. august 2010; 126 (2): e427-34. doi:10.1542/peds.2009-2097. 9. suvarna, itagi sk. nutritional status and level of intelligence of school children. karnataka j agric sci. 2009; 22 (4): 874-6. 10. pradita rra. hubungan stunting dengan skor iq anak usia sekolah dasar keluarga miskin di kabupaten klaten [reseach] surakarta: fakultas kedokteran universitas sebelas maret; 2009 11. kurniawaty e. hubungan status seng (zn) dengan intellingence quotient pada anak usia 911 tahun di sekolah dasar negeri 1 gondang wonogiri [research] semarang: universitas diponegoro; 2015. 12. subasinghe smlp, wijesinghe dgng. the effect of nutritional status on volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra stunting cognitive disturbance total or (95% ci) p* yes no n % n % n % yes 29 61,7 18 38,3 47 54,0 2,992 (1,246 –7,187) 0,023 no 14 35,0 26 65,0 40 46,0 total 43 49,4 44 50,6 87 100 anemia cognitive impairment total or (95% ci) p* ya tidak n % n % n % ya 21 53,8 18 46,2 39 44,8 1,379 (0,591 –3,219) 0,598 tidak 22 45,8 26 54,2 48 55,2 total 43 44 87 100 x 17gjra global journal for research analysis cognitive and motor development of preschool children. tropical agricultural research vol18. 13. lestari w, margawati a, rahludin mz. faktor risiko stunting pada anak umur 6-24 bulan di kecamatan penanggalan kota subulussalam provinsi aceh. jurnal gizi indonesia. 2014; 3 (1): 127-8. 14. lewit em, kerrebrock n. populationbased growth stunting. children and poverty. 1997; 7 (2): 14956. 15. jauregui-lobera i. iron deciency and cognitive functions. neuropsychiatr dis treat. 2014; 10: 2087-95. 16. purnamasari r. optimal duration time for iron supplementation. in: daud d, rauf s, salekede sb, lawang sa, eds. buku kumpulan makalah pertumbuhan ilmiah tahunan ilmu kesehatan anak viii. makasar: penerbit departemen ilmu kesehatan anak, fakultas kedokteran universitas hasanuddin; 2016. p329-33. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 18 x gjra global journal for research analysis introductionappendicitis remains the most common acute surgical condition of the abdomen. hyperbilirubinemia (elevated serum bilirubin) is accumulation of bilirubin above physiological level in blood stream. elevated serum bilirubin levels in acute appendicitis can either appear as a result of bacteremia, or endotoxaemia, both possible in the catarrhal and phlegmonous forms as well as in the gangrenous or perforated cases. the bacteria present in the portal blood are usually cleared by detoxication and immunological action of reticuloendot helial system of liver that act as rst line defence in clearing toxic substances, bacteria and their products. but when bacterial load overwhelms the kupffer cell function, the damage to hepatocytes is reected in serum bilirubin levels alone or in combination with liver enzymes depending upon the type, severity and site of lesion.[1]jaundice has been associated with appendicitis and studies have shown hyperbilirubinemia as a predictor of appendiceal perforation. [2,3] material & methodsthe study included 100 patients diagnosed to have acute appendicitis clinically, with raised white blood cell count ( >= 10,000 /cmm) warranting emergency, operative intervention. the liver enzymes and bilirubin levels were noted. subsequently these cases were operated and clinical diagnosis was conrmed intra-operatively and postoperatively by histo-pathological examination. their clinical and investigative data were compiled and analysed. results & discussionout of the 100 patients recruited in the study, all had appendiceal inammation on histo-pathological analysis. of the 100, histo-pathological analysis of 25 (25%) revealed a gangrenous appendicitis and 3 (3%) cases revealed perforated appendicitis. of the 25 patients of gangrenous appendicitis, 20 (80%) patients had elevated bilirubin levels and/or liver enzymes. 1 (33.33%) of the 3 patients of appendiceal perforation had elevated bilirubin levels. remaining 72 cases had normal or marginally elevated levels of bilirubin. overall sensitivity was 75% and specicity was 72%. the mechanism outlined is invasion of the gram-negative bacteria through the muscularis propria of the appendix, leading to direct invasion or translocation of the germs in the portal system and the liver, interfering with bilirubin excretion through bile ducts by endotoxin action. the presence of jaundice in sepsis is well documented, especially associated with gram-negative pathogens [4,5,6]. the hemolysis produced by certain bacteria (including e. coli), produces an increase in indirect and total serum bilirubin [7]. also, some endotoxins released in the peripheral blood stream are responsible for impeding the liver's mechanism for bilirubin uptake and canalicular excretion [8,9]. endotoxins produce cholestasis by damaging biliary salt transport through cytokine mediated mechanisms [10,11]. estrada et al. have formulated the hypothesis that jaundice can be associated with perforation of the appendix, serving as a severity marker [12]. they explain the elevated stb by the invasion of the gram-negative bacteria through the muscularis propria of the appendix, leading to direct invasion or translocation of the germs in the portal system and the liver, interfering with bilirubin excretion through bile ducts by endotoxin action. emmanuel et al. nd that stb has a specicity of 88% and a positive predictive value of 91% for perforated acute appendicitis [13], while sand et al nd an 86% specicity for gangrenous or perforated forms, compared with only a 35% specicity of the c reactive protein. hong, on a large series of 1195 patients, also nds as signicant the value of stb in the identication of perforation [14]. conclusionbroadly, we can say that hyper-bilirubinemia is a sensitive and specic, cheap pre-operative marker of gangrenous, perforated appendicitis. table 1type of appendicitis and frequency with hyperbil irubinemia hyperbilirubinemiaa marker for gangrenous and perforated appendicitis original research paper dr. amar chandrakant holambe mbbs pg resident, dept of general surgery, smt kashibai navale medical college & general hospital, pune-411041, maharashtra, india general surgery appendicitis is the most common acute surgical condition of the abdomen. simple case of appendicitis can progress to perforation within 48hrs of attack of acute appendicitis, which increases both morbidity and mortality. cholestasis and portal pyemia form the basis for sepsis in cases of appendicitis and the present study aimed to evaluate the co-relation of hyperbilirubinemia and severity of appendicitis. abstract keywords : appendicitis, hyperbilirubinemia, gangrenous, perforated volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. snehal nachiket purandare* mbbs, ms-general surgery professor, dept of general surgery, smt. kashibai navale medical college & general hospital, pune-411041, maharashtra, india*corresponding author histopathology frequ ency day of presentation after onset of pain no. of cases with hyperbilirubin emia appendicitis (without gangrene/perf oration) 72 st th1 -4 day 0 gangrenous appendicitis 25 th th5 -7 day 20 (80%) perforated appendicitis 3 th th8 -12 day 1 (33.33%) 58 x gjra global journal for research analysis table 2bilirubin levels in cases of gangrenous & perforated appendicitis references 1. khan s. evaluation of hyperbilirubinemia in acute inammation of appendix: a prospective study of 45 cases. kathmandu university med j. 2006;4(3):287-9. 2. estrada jj, petrosyan m, barhart j. hyperbilirubinemia in appendicitis: a new predictor of perforation. j gastrointest surg. 2007;11:714-8. 3. emmanuel a, murchan p, wilson i, balfe p. the value of hyperbilirubinemia in the diagnosis of acute appendicitis. ann r coll engl. 2011;93:213-7. 4. whitehead mw, hainsworth i, kingham jg. the causes of obvious jaundice in south west wales: perceptions versus reality. gut. 2001;48(3):409-13. 5. chand n, sanyal aj. sepsis-induced cholestasis. hepatology. 2007;45(1):23041. 6. orban c. diagnostic criteria for sepsis in burn patients. chirurgia (bucur). 2012;107(6):697-700. 7. shander a. anemia in the critically ill. crit care clin. 2004; 20(2):159-78 8. roelofsen h, van der veere cn, ottenhoff r, schoemaker b, jansen pl, oude elferink rp. decreased bilirubin transport in the perfused liver of endotoxemic rats. gastroenterology. 1994; 107(4):1075-84. 9. 11. bolder u, ton-nu ht, schteingart cd, frick e, hofmann af. hepatocyte transport of bile acids and organic anions in endotoxemic rats: impaired uptake and secretion. gastroenterology. 1997;112(1):214-25. 10. green rm, beier d, gollan jl. regulation of hepatocyte bile salt transporters by endotoxin and inammatory cytokines in rodents. gastroenterology. 1996;111(1):193-8. 11. 13. whiting jf, green rm, rosenbluth ab, gollan jl. tumor necrosis factoralpha decreases hepatocyte bile salt uptake and mediates endotoxininduced cholestasis. hepatology. 1995;22(4 pt 1):1273-8. 12. estrada jj, petrosyan m, barnhart j, tao m, sohn h, towgh s, et al. hyperbilirubinemia in appendicitis: a new predictor of perforation. j gastrointest surg. 2007;11(6):714-8. 13. emmanuel a, murchan p, wilson i, balfe p. the value of hyperbilirubinaemia in the diagnosis of acute appendicitis. ann r coll surg engl. 2011;93(3):213-7 14. hong yr, chung c-w, kim jw, kwon ci, ahn dh, kwon sw, kim sk. hyperbilirubinemia is a signicant indicator for the severity of acute appendicitis. j korean soc coloproctol. 2012;28(5):247-52. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra liver function test referenc e values gangrenous appendicitis perforated appendicitis total bilirubin 0.2-1.2 1.6-2.4 2.8 direct bilirubin 0.0-0.2 0.4-1.0 1.4 indirect bilirubin 0.2-1.0 0.8-1.2 1.4 sgot upto 45 45-56 59 sgpt upto 45 45-56 62 alp 53-128 55-156 154 x 59gjra global journal for research analysis introduction: in adults, hearing loss can often begin long before symptoms are noticed and the loss can progress slowly over time; if you suspect hearing loss get baselines hearing test and follow-up annually to look for changes. symptoms of hearing loss: 1. listening to television or radio at high volume 2. trouble understanding speech, especially in noisy areas 3. the perception that others are mumbling 4. difculty in hearing people on the phone 5. often asking people to repeat themselves 6. avoiding social situations 7. exhaustion after attending social events 8. tinnitus or ringing in the ears hearing loss can manifest in many different ways. depending on the degree or severity of the hearing loss, symptoms can range from occasional difculty understanding words to inability to communicate with others and social isolation. while there are a few different types of hearing loss and many different causes the symptoms are generally similar regardless of the type of cause. the most common type of hearing loss is sensorineural hearing loss and this type of hearing loss often results in decreased ability to hear high frequency sounds. people with high frequency hearing loss often miss the following sounds: ÿ female and young children's voice ÿ certain consonant sounds like s, sh, f, v, th, f, making it difcult to understand some words. ÿ the car's turn signal ÿ beeping sounds on timers and microwave oven ÿ song birds sensorineural hearing loss develops later in life, it can be caused by a wide variety of triggers, includeÿ aging (presbiacusis) ÿ blood vessel disease ÿ auto-immune disease ÿ infection such as meningitis, mumps, scarlet fever and measles ÿ traumatic injuries ÿ extremely loud noises exposure over a period of time ÿ meniere's disease ÿ acoustic neuroma ÿ drug toxicity ÿ cancerous growth in the inner ear the major factor affecting the prevalence of hearing impairment is age, with smaller contribution coming from gender, occupational group and occupational noise 1exposure. the major predictors of tinnitus are concerned with 2hearing impairment and tinnitus & hearing disability are 3, 4found to inuence quality of life adversely. only a few reports have provided reference data for age and gender related hearing threshold level for indians. in public health priority of hearing impairments and tinnitus in adults should be substantially higher than it presently appear, because hearing disorders constitute the most prevalent chronic impairment in the population. the situation has not changed 5 substantially since cochrane's assessment in 1971. the major factor associated with this high prevalence is age with noise being the chief preventable factor, especially in young people. because age is the major factor, the whole population prevalence of hearing impairments will increase over the next 20 years by upto 20% because of the demographics of the 6population. people with hearing disability and tinnitus have signicantly worse quality of life which can be ameliorated by the appropriate use of rehabilitation such as the use of a hearing 3, 4aid for most of the time. assessment of hearing threshold levels in clinically normal individuals and estimate the risk of age factor among them. original research paper dr. rajesh kumar a asst. professor (ent), govt. general hospital, anantapur. x 3gjra global journal for research analysis otolaryngology background: in the current study we estimated the hearing threshold in different age groups and compared the hearing threshold in older adults with younger adults. aims & objectives: 1.to identify the mean hearing threshold in different age groups & create baseline data of the hearing 2.to study the affect of age and gender on hearing threshold in adults. materials and methods: cross-sectional study, simple random sampling method, sample size of 100 belonging to age group of 15-69 yrs, with normal tympanic membrane and no h/o of noise exposure. these subjects were motivated to undergo pure tone audiometry to analyze their hearing threshold levels. data thus collected has been analyzed using tables and graphs, mean hearing threshold levels have been calculated. results: as the age increased the hearing threshold increased for all frequencies. hearing thresholds of 4 khz, 8 khz showered a statistical signicance between both genders for people older than 30 yrs, with the 4 khz frequency showing the largest difference. conclusion: it is very common among general population for hearing to get worse as they get older. this usually affects their ability to understand and they can hear low frequencies better than high frequencies, hence people with age related hearing loss nd it difcult to follow conversations in noisy environment. recommendations: after 40 years of age onwards, every individual must go for regular audiometric evaluation annually. in regular health check-up policies, pure tone audiometry must be included along with other routine investigations. abstract keywords : hearing threshold, pure tone audiometry, aging effect dr. niharika b* asst. professor (community medicine), govt. medical college, anantapur. *corresponding author dr. naveed ahamed md., hod (ent), govt. general hospital, anantapur. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 4 x gjra global journal for research analysis materials and methods: a cross-sectional study was conducted at government general hospital, anantapur district, andhra pradesh from jan 2018 to feb 2018. a total of 100 participants with normal tympanic membrane and without any history of occupational noise exposure were included in the study. the study subjects have been selected randomly from the patients' attendants and visitors in the ent inpatient ward, and have been motivated to participate in the current study and undergo audiometry in the department of ent, ggh, anantapur. a total of 100 subjects, were motivated to undergo audiometry, pure tone air conduction (ac) and unmasked bone conduction (bc) audiometry of both ears was performed. pure tone averages (ptas) and air-bone gap (abg) were calculated. audiometric measure: the testing was performed using 'labat asia' clinical audiometer (made in germany). pure tone audiometry was performed on both ears, one at a time, at frequencies of 0.250, 0.5, 1, 2, 4 & 8 khz. before the test, the volunteer was enquired to identify his or her better ear. on conrmation the test was started with his or her better ear. in case he or she could not notice any difference between the right and left ear, the test was started in the right ear at 1000 hz (intensity, 30 db hearing level) proceeding to higher octave frequencies. after testing at 8000 hz, lower octave frequencies were evaluated started at 250, 5000 hz. in case of no response at 30 db, the intensity was increased in 10 db steps until a response was recorded; then the descending bracketing method was initiated again. a pulsed tone of more than 200 milli seconds duration was given for each frequency being tested. volunteers were instructed to press a hand held response switch upon hearing a tone, to hold the key down as long as they hear the tone, and to release it when they no longer hear the tone. a short rest period was given in between testing of right and left ears for air conduction (ac) & bone conduction (bc) audiometry. bone conduction audiometry: bc was done for both the ears (one each at a time) at frequencies of 0.250 , 0.05, 1,2,4, 8 k hz placing the vibrator on the mastoid bone. the threshold seeking paradigm used the same threshold seeking method used in the pure tone test conguration. the threshold levels at all measured frequencies for ac & bc audiometry were plotted as an audiogram to graphically show the hearing threshold trends. the hearing tests were carried out in a soundproof room in the department of otorhinolaryngology of govt. medical college, anantapur. clinical examination of ear, nose and throat was performed by an otolaryngologist. it was found that all subjects had a normal tympanic membrane, with no history of noise exposure. the subjects who had a history of noise exposure, tympanosclerosis on examination and pta average more than 30 db between the two ears were excluded from the study. statistical analysis: the data thus collected was presented in the form of tables, bar graphs, pie charts and analyzed using means and proportions. results: it is clear from figure 1 that there were more male participants than females in the present study. the reason may be that, generally females in india are reluctant to undergo audiometry which is conducted in closed sound proof room. but, it is observed from figure 2 that younger age females are more compared to younger age males because younger age females are more concerned about their hearing loss due to social stigma attached to it and came forward for audiometry. in old age, females are reluctant to know about their hearing status and audiometric examination as they were busy with their family responsibilities. fig 1: pie chart showing sex distribution of study subjects fig 2: bar graph showing age and gender distribution of study subjects the results in table 1, shows various presenting symptoms of hearing loss of the study participants in the present study. majority of them presented with tinnitus occasionally followed by unable to understand speech in noisy environment. table 1: list of presenting symptoms of hearing loss in study subjects. the results in table 2, show that there is no uniformity or a pattern in mean hearing thresholds in our cases between right and left ear in men and women. the observations in table 3 show that, from younger age to older age the mean hearing threshold levels were increased parallel to age; mean hearing threshold levels for women increased more than men. table 2: age group verses mean hearing threshold levels in db volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra s.no symptoms of study subjects no. of subjects (%) 1 listening tv or radio at high volume 3 (3%) 2 trouble understanding speech in noisy environment 5 (5%) 3 the perception that others are mutating 0 (0%) 4 difculty hearing people on phone 2 (2%) 5 often asking people to repeat themselves 3 (3%) 6 avoid social situations 2 (2%) 7 exhaustion after attending social events 2 (2%) 8 tinnitus or ringing in ear occasionally 9 (9%) age group (yrs) mean hearing threshold values males females right left right left 20-29 21.4 21.5 22.6 23.1 30-39 22.1 21.8 23.1 22.4 40-49 24.2 20.0 24.5 23.3 50-59 26.4 25.2 33.3 38.6 60-69 29.7 31.2 44.8 39.1 table 3: age & gender verses mean hearing threshold levels in study subjects. in figure 3 & 4, the graph represents, mean threshold levels of males and females have increased with age. fig 3: line diagram showing mean audiograms for males vs age group fig 4: line diagram showing mean audiograms for females vs age group discussion: irrespective of the sample size, there was a signicant affect of age on hearing thresholds with reduced auditory sensitivity and increased thresholds at all frequencies in the older groups. although clinically classied as normal the analysis separated younger and older individuals by indicating different thresholds for each. sensitivity assessments at higher frequencies showing 7,8increased thresholds in parallel with increasing age. in the present study, age associated hearing loss initially affected 7,9,10,11,12 higher frequencies which coincided with other studies. mean hearing threshold level in each group in decibels at different frequencies in men and women and in right and left years was also evaluated and ndings show that with advancing age there was decrease in hearing acuity between 41 to 60 yrs and further decrease above 60 yrs which was 13, 14, 15, 16,17, 18coinciding with previous studies. the present study shows older group adults had high pure tone threshold sensitivity compared to younger adults which is similar to other studies. in the present study woman had higher thresholds compared to men which are contrary to 19, 20, 21previous studies. as per who, a speech frequency pure tone average (pta 0.5 12-4) of greater than 25 db hearing loss is the initiation of 22communication impairment in daily life . various researchers used pta for three to four frequencies in the conversational frequency scales. however, pta 0.5-1-2-4 has been widely 23, 24used . the result of this study indicates that there is a signicant relationship between age and average hearing threshold. however, this is not noise induced hearing loss, because in nihl, the hearing threshold frequencies 500, 1000, 2000 hz is better than hearing threshold at 4000 hz frequency, 25, 26accompanied by improvement in frequency at 8000 hz . this notch is not present in our study. however, in older patients, it is difcult to distinguish between the effects of noise and age related effects without seeing the previous 27audiogram. conclusion & recommendations: it is very common among general population for hearing to get worse as they get older. about 25-40% of people over the age of 65 are affected. half of all people above the age of 75, and 80% of 80 yr old are hard of hearing. this usually affects their ability to understand what people are saying more than the range of tones they can hear and they can hear low frequencies better than high frequencies. that's why people with age related hearing loss nd it particularly difcult to follow conversations in noisy environments. the exact causes of age related hearing loss are not known. changes in the inner ear and brain are thought to play a role. nowadays, there are various sound amplifying hearing aids which improve hearing in those individuals and help them understand conversation. all of these hearing aids lter out 28background noise. so, the present study recommends that after 40 yrs of age, every individual must undergo regular audiometric examination annually. in regular health check-up policies pure tone audiometry must be included along with other routine investigations. acknowledgement: the authors appreciate the audiologist, mr. vannuru swamy k and mrs. geetha p in the department of ent, ggh, anantapur, a.p. for their valuable services in the research work. references: 1. davis a.c. the prevalence of hearing impairment and reported hearing disability among adults in great britain. international journal of epidemiology 1989; 18: 911-7. 2. davis a. the aetiology of tinnitus: risk factors for tinnitus in the uk population a possible role for conducting pathologies? in: reich g e, vernon j a eds. proceedings of the 5th international tinnitus seminar. portland, or: american tinnitus association, 1996. 3. davis a c, roberts h. tinnitus and health status: s f – 36 prole and accident prevalence. in : reich g e, vernon j a eds. proceedings of the 5th international tinnitus seminar. portland, or: american tinnitus association, 1996. 4. davis a c, stephens sdg, rayment a, thomas k. hearing impairment in middle age: the acceptability benet and cost of detection (abcd). british journal of audiology 1992; 26: 1-14. 5. cochrane al . effectiveness and efciency. random reection on health services. london: the nufeld provincial trust, 1971. 6. davis a. epidemology. in : sdg ed. adult audiology . london: butterworth heinemann, 1997. (kerr a ed. scottbrown’s otolaryngology , 6th ed. , vol 2.) 7. patricia g. stelmachowicz, kathryn a. beauchaine, ann kalberer, and walt jesteadt normative thresholds in the 8to 20-khz range as a function of age the journal of the acoustical society of america 86, 1384 (1989); https://doi.org/10.1121/1.398698. 8. pedalini meb, sanchez tg, dantonio a, dantonio w, balbani a, hachiya a, et al. média dos limiares tonais na audiometria de alta freqüência em indivíduos normais de 4 a 60 anos pró-fono: revista de atualização cientíca, 12 (2) (2000), pp. 17-20. 9. willott jf aging and the auditory system: anatomy, physiology, and psychophysics, singular publishing group, inc, san diego (1991). 10. corso jf age and sex differences in pure-tone thresholds arch otolaryngol, 77 (1963), pp. 385-405. 11. russo icp achados audiométricos em uma população de idosos presbiacúsicos brasileiros em função do sexo e da faixa etária pró-fono: revista de atualização cientíca, 5 (1) (1993), pp. 8-10. 12. quaranta a, sallustio v, scaringi a cochlear function and speech recognition in the elderly audiology, 40 (2001), pp. 301-307. 13. glorig a, davis h. age, noise and hearing loss. ann otol rhinol laryngology 1961;79:556-71. 14. konig e. pitch discrimination and age. acta otolaryngologica 1957;48:47589. 15. glorig a, nixon j. hearing loss as a function of age. laryngoscope 1962;72:1596-610. 16. corso jf. aging and auditory threshold in men and women. archsenvir hlth 1963;6:350-356. x 5gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra age & gender vs hearing threshold levels males females mean hearing threshold young adults (18-35 yrs) right ear 21.5 23.0 22.4 left ear 21.2 22.3 21.9 mean hearing threshold 21.4 22.7 middle age (36-55 yrs) right ear 24.2 24.1 24.2 left ear 23.1 24.8 23.4 mean hearing threshold 23.7 24.5 older adults (55 yrs & above) right ear 28.1 44.8 31.4 left ear 27.8 39.1 30.0 mean hearing threshold 27.9 41.9 17. kim hn, lee hk, moon sk. incidence of presbycusis of korean population in seoul, kyunggi and kangwon provinces. j korean medical sciences 2000;15:580-584. 18. kaewboonchoo o, saleekul s, jaipukdee s. age related changes in hearing level among thai people. j med assoc thai 2007;90(4):798-804. 19. ankur, & dhar, u. & sood, a.. (2013). effect of age and sex on hearing by pure tone audiometry. jk science. 15. 189-193. 20. garstecki dc, erler sf. older adult performance on the communication prole for the hearing impaired: gender difference. j speech language hearing research 1999;42:785-96. 21. takashi t, yoshinori m, kazuo m, seiko m. age effect on hearing. a study of japanese.audiol japan 2002;45(3):24150 22. informal working group on prevention of deafness and hearing impairment programme planning ( 1991: geneva, switzerland) & world health organization. programme for the prevention of deafness and hearing impairment. ( 1991) . report of the informal working group on prevention of deafness and hearing impairment programme planning, geneva, 18-21 june 1991. world health organization. https : // apps. who.int/ iris/handle/ 10665/ 58839 23. engdahl b, tambs k occupation and the risk of hearing impairment – results from the nord-trøndelag study on hearing loss, scand j work environ health 2010;36(3):250-257. 24. lin fr, niparko jk, ferrucci l. hearing loss prevalence in the united states. arch intern med. 2011;171(20):1851–1853. doi: 10.1001 / archinternmed. 2011.506 25. coles rr, lutman m e, bufn j t: guidelines on the diagnosis of noise induced hearing loss for medico-legal purposes. clin. otolarygol, allied sci 2000; 25: 264273. 26. m c bride di, williams s. audiometric notch as a sign of noise induced hearing loss. occup environ med 2001; 58 :46 -51. 27. juwarna, w. & adnan, a. & siti hajar haryuna, tengku. (2018). noise induced hearing loss in begerpang palm oil mill workers. otorhinolaryngology clinics. 10. 56-60. 10.5005/jp-journals-1003-1291. 28. nlm citation: institution for quality and efciency in health care (iqwig); 2006hearing loss and deafness,. normal hearing and impaired hearing 2008 may 15. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 6 x gjra global journal for research analysis introduction periapical lesion is a local response of bone around the apex of tooth that develops after the necrosis of the pulp tissue or extensive periodontal disease. the successful treatment of periapical inammatory lesion depends on the reduction and elimination of the offending organism. root canal therapy, periapical surgery, or extraction of the tooth might be the treatment alternatives. most of the time teeth with periapical lesions heal satisfactorily after non-surgical endodontic intervention. abramovitz et al. discussed the guidelines of case selection for apical surgery and non-surgical retreatment. they reported that treatment of 24.5% of the 1cases was impossible without surgical therapy. apical surgery is done to surgically maintain a tooth that has an endodontic lesion which cannot be resolved by conventional endodontic re-treatment. the success of surgical therapy depends on complete periapical repair and regeneration, therefore a biocompatible material is required like a new material biodentine. in 2009 biodentine was introduced as a tricalcium silicate cement. it possess excellent handling characteristics because of outstanding viscosity and 2short setting time of 12 minutes. the healing of hard and soft tissue is mediated by wide range of intra and extracellular events that are regulated by signaling proteins. platelets play a crucial role not only in hemostasis, but also in wound healing process. platelets contain important gf that, which are responsible for increasing collagen production, recruiting other cells to the site of injury, initiating vascular in growth, and inducing cell differentiation. these are all crucial steps in early wound healing. platelet-rich brin (prf), a secondgeneration platelet concentrate, has shown to be superior to prp. it was rst developed in france by choukroun et al. in 32001. prf allows one to obtain brin membranes enriched with platelets and gf after starting from an anticoagulantfree blood harvest. this means that prf could release gf with 4 5its own biological scaffold for wound healing process. the present case describe the management of the periapical inammatory lesion using biodentine with prf which acts as a source of gf at the healing site, thereby accelerating soft 6 7and hard tissue healing. case presentation a 21-year old female patient reported to the out-patient department of periodontics, farooqia dental college and hospital, mysuru, karnataka with a chief complaint of pain in the upper front tooth region since three days. the patient gave a history of trauma 4 years back (figure 1a). examination of the head and neck revealed no palpable lymph nodes. all vital signs were found to be within normal limits. on clinical examination revealed draining sinus tract in relation to 21 and congenitally missing 11, 12. radiographic examination revealed well-dened periapical radiolucency around the apices of maxillary left central and lateral incisors and impacted supernumerary tooth in the periapical area of 21, 22 (figure 1b,1c). figure 1:preoperative clinical view, draining sinus tract wrt 21(a),preoperative radiograph showing the periapical lesion and impacted supernumerary tooth in the periapical area of 21, 22(b, c). biodentine as a biocompatible retrograde filling material with platelet-rich fibrin (prf) as an autologous biomaterial in the management of periapical lesion original research paper dr. deepak prasad professor and head of the department, department of periodontics farooqia dental college and hospital, mysuru, karnataka dental science the successful treatment of periapical inammatory lesion depends on the reduction and elimination of the offending organism. periapical surgery, one of the treatment alternatives, includes the curettage of all periapical soft tissues and sometimes application of different biomaterials to enhance the new bone formation in the defect site like using platelet-rich brin (prf) which acts as a source of growth factors at the healing site. prf features all the necessary parameters permitting optimal healing. a cystic lesion, which is unable to heal non-surgically, heals well with surgical intervention and use of mineral trioxide aggregate (mta) as retrograde lling has been reported in literature. another material with largely improved handling properties; biodentine™ (septodont, st. maurdesfossés, france) was introduced in 2011. it is a calcium silicate based material and manufacturers claim that it can be used for crown and root dentin repair treatment, repair of perforations or resorptions, apexication, and root end llings. this article presents a case of surgical management of a large cystic lesion using biodentine™ as retrograde lling material. abstract keywords : autologous growth factors, biomaterial, platelet concentrate, platelet-rich fibrin, biodentine retrograde filling material. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. sheshadri puttaswamy professor, department of periodontics farooqia dental college and hospital, mysuru, karnataka. dr. heena naz kaouser senior lecture, department of periodontics, farooqia dental college and hospital, mysuru, karnataka. dr. anvitha d reader, department of periodontics, farooqia dental college and hospital, mysuru, karnataka. dr. aashique muhammed p s* iii year post graduate student department of periodontics farooqia dental college and hospital, mysuru, karnataka. *corresponding author 36 x gjra global journal for research analysis management the treatment plan was root canal therapy in the left central, lateral incisors and right canine followed by surgical enucleation of the lesion and root-end surgery because of the time constraint of the patient toward nonsurgical approach. the canals were obturated with gutta-percha prior to the surgery (figure 2a, 2b). after effective local anesthesia with 2% lignocaine, a full-thickness muccoperiosteal ap was reected (figure 2c). a defect was visible in the cortical plate with the central incisor, which was enlarged to aid in complete curettage of the granulation tissue and allowed room for retrograde instrumentation after root-end resection. palatal ap elevated and removed impacted supernumerary tooth (figure 2d). this was followed by irrigation with betadine and sterile saline solution. the root-end resection was carried out followed by retrograde cavity preparation and retrograde cavity was lled with biodentine as retrograde restorative material of 3 mm thickness (figure 2e, 2f, 2g). figure 2: the canals were obturated with gutta-percha prior to the surger y (a, b ) , inc is ion and fu l l th ickness muccoperiosteal ap reection and visible defect after enucleation and removal of impacted supernumerary tooth(c, d),the root-end resection followed by retrograde cavity preparation and retrograde cavity was lled with biodentine of 3 mm thickness(e, f, g). prf preparation was performed using the procedure 8 9described by dohan et al. the prf protocol is very simple. a blood sample was taken without anticoagulant in 10 ml tubes, which was immediately centrifuged at 3000 rpm for 10 min. the prf clot was then mixed with allograft and packed into the defect to completely ll the bony crypt (figure 3a, 3b). wound closure was then obtained with 4-0 silk sutures (figure 3c). figure 3: prepared prf clot mixed with allograft and packed into the defect (3a, 3b), wound closure with 4-0 silk sutures (3c). non-steroidal anti-inammatory analgesics were prescribed and the patient was advised to use chlorhexidine mouth wash for a week. the sutures were removed after 1 week, and satisfactory healing was observed. the patient was recalled at 3 and 6 months. follow-up radiographs at these intervals showed satisfactory bone regeneration in the periapical defect (figure 4).crown preparations done in respect to 13, 21 and 22 and follow up after 6 months and prosthetic rehabilitation done. figure 4: postoperative clinical view after 3 months showing soft tissue healing (a),3 and 6 months postoperative radiograph showing enhanced bone healing(b,c),prosthetic rehabilitation after 6 month(d,e). discussion biodentine displayed bioactivity, i.e., activation of angiogenesis and activation of progenitor pulpal cells promoting healing and remineralization. it has shown increased sealing ability compared to mta. the formation of mineral tags was similar to those observed with mta along with resistance to acid degradation, as observed in inammatory sites. the main difference between biodentine and commercially available mta calcium silicates is the absence of calcium aluminates and calcium sulfate in the formulation which are known to bring decreased mechanical strength as well as longer setting time. “the richest of resources in nature lie in the nature itself.” the world seems to be going back to natural substitutes for all its queries and dilemmas. modern day medicine and surgery are certainly no exception to this rule. utilizing naturally derived blood concentrates without having to use anti-coagulants can be utilized as a substitute to enhance tissue regeneration, fast wound healing and enhance collagen synthesis. conclusion this article has shown that routine endodontic therapy followed by surgical intervention with a placement of biocompatible retrograde lling material like biodentine for management of endodontic periapical lesions of chronicity would positively affect the treatment outcome. prf is a totally autologous blood concentrate system that does not require the use of external anticoagulants.prf improves early wound closure, maturation of bone, and the nal aesthetic result of the periodontal soft tissues. financial support and sponsorship nil. conflicts of interest there are no conicts of interest. references 1. abramovitz i, better h, shacham a, shalomi b, metzger z. case selection for apical surgery: a retrospective evaluation of associated factors and rational. j endod 2002;28:527-30. 2. ahmed hm, al rayes mi, saini d. management and prognosis of teeth with traumatic induced crown fractures and large periapical cyst like lesions following apical surgery with and without retrograde lling. j conserv dent 2012;15:77-9. 3. choukroun j, adda f, schoef er c, vervelle a. une opportunite´ enparoimplantologie: le prf. implantodontie 2000;42:55-62. 4. choukroun j, diss a, simonpieri a, girard mo, schoefer c, dohan sl, et al. platelet-rich brin (prf): a second generation platelet concentrate-part iv: clinical effects on tissue healing. oral surg oral med oral pathol oral radiol endod 2006;101:e56-60. 5. choukroun j, diss a, simonpieri a, girard mo, schoefer c, dohan sl, et al. platelet-rich brin (prf): a second generation platelet concentrate-part v: histologic evaluations of prf effects on bone allograft maturation in sinus lift. oral surg oral med oral pathol oral radiol endod 2006;101:e299-303. 6. choukroun j, diss a, simonpieri a, girard mo, schoefer c, dohan sl, et al. platelet-rich brin (prf): a second generation platelet concentrate-part iv: clinical effects on tissue healing. oral surg oral med oral pathol oral radiol endod 2006;101:e56-60. 7. choukroun j, diss a, simonpieri a, girard mo, schoefer c, dohan sl, et al. platelet-rich brin (prf): a second generation platelet concentrate-part v: histologic evaluations of prf effects on bone allograft maturation in sinus lift. oral surg oral med oral pathol oral radiol endod 2006;101:e299-303. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 37gjra global journal for research analysis 8. dohan dm, choukroun j, diss a, dohan sl, dohan aj, mouhyi j, et al. plateletrich brin (prf): a second generation platelet concentrate-part i: technological concept and evolution. oral surg oral med oral path oral radiol endod 2006;101:e37-44. 9. dohan dm, choukroun j, diss a, dohan sl, dohan aj, mouhyi j, et al. plateletrich brin (prf): a second-generation platelet concentrate-part ii: plateletrelated biologic features. oral surg oral med oral pathol oral radiol endod 2006;101:e45-50. 10. dohan dm, choukroun j, diss a, dohan sl, dohan aj, mouhyi j, et al. plateletrich brin (prf): a second-generation platelet concentrate-part iii: leukocyte activation: a new feature for platelet concentrates? oral surg oral med oral pathol oral radiol endod 2006;101:e51-5. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 38 x gjra global journal for research analysis 18.dr manya thakurroy.cdr introduction for many years surgeons have ligated the superior pole of the thyroid gland near the entrance of the vessels aiming to avoid injury to external laryngeal nerve. there have been numerous modications in the techniques of thyroid surgeries with better understanding of the anatomy and the physiology of the thyroid gland. the clinical signicance of superior laryngeal nerve (sln) has been clearly overshadowed by emphasis on recurrent laryngeal nerve. the principles of head and neck surgery are based on identication & preservation as opposed to avoidance of important structures. paralysis of the sln can be signicant to those whose career depends heavily on full range of voice e.g singers teachers , hawkers , telemarketing professionals to name a few. damage to the nerve can manifest as paralysis to the cricothyroid muscle. mostly it is asymtomatic, but clinical symptoms of unilateral injury may include hoarse monotonus and breathy voice. bilateral injury will have same changes with easy fatigue of voice. the clinician may nd signs of bowing and inferior displacement of affected cord on 1laryngoscopy. the present study is a nonrandomized prospective study which focuses primarily on intra operative identication and preservation of ebsln during thyroid surgery in 90 patients. material and methods this study was non randomized prospective study conducted at department of orl & hns, tertiary care center india. the subjects were fnac proven euthyroid patients undergoing thyroid surgery in ent department of saims from july 2011 to july 2014.the patients were pre operatively assessed to exclude vocal cord palsy by video laryngoscopy & voice analysis. the exclusion criteria was patients presenting with history of recent hoarseness or who have received neck radiation and with history of previous neck surgery, anaplastic thyroid carcinoma, grave's disease, completion thyroidectomy and abnormal vocal cord function pre-operatively initially cadaver dissection was done in dept of anatomy and the course of the nerve and position was studied intra operatively (as shown in fig 1 -9). an attempt to identify and preserve external laryngeal nerve was made during surgery by individual ligation and skeletonization of superior pole vessels in all patients subjected to thyroid surgery. intra-operative relationship between the superior thyroid artery and the external laryngeal nerve was assessed and classied according to cernea's classication.the voice assessment was done both pre operatively and after the surgery by video laryngoscopy and egg (dr speech software).the fundamental frequency of all patients was assessed and compared and documented before & after the surgery by voice analysis (egg). fig 1 neck dissection (left) picture showing superior laryngeal nerve along with external laryngeal nerve* and internal branch of superior laryngeal nerve ibsl, upper pole of thyroid gland tg ,superior thyroid artery sta fig 2 neck dissection (left) picture showing ebsln* , upper pole of thyroid gland tg, upper pole of thyroid gland tg ,superior thyroid artery sta fig 3 neck dissection (left) picture showing ebsln*, upp er pole of thyroid gland tg ,superior thyroid artery sta surgical anatomy of external laryngeal nerve in relation to thyroid surgery : our experience original research paper dr brajendra baser professor & hod (former) saims medical college,indore director,akash hospital indore ent objectives to study surgical anatomy of external laryngeal nerve and it's variation in relation to thyroid surgery. methodology – a non-randomized prospective study was conducted in patients undergoing thyroid surgery in saims, indore. the eln was identied and preserved intra operatively. the function of nerve was assessed and documented by pre op & post op egg and video laryngoscopy. resultsintraoperative identication of eln leads to almost negligible changes in voice quality. a permanent drop in fundamental frequency (fo) was seen in signicant number of patients when the nerve was not identied during surgery. conclusion today in the era of 21st century where we are reaching new horizons, efforts to further rene thyroid surgery continues. good range of voice is not only important for singers but for teachers, politicians, rj, public speakers etc too. an attempt to preserve external laryngeal nerve should be done to preserve voice quality as an integral part of surgery. abstract keywords : external laryngeal nerve,voice quality, thyroid surgery, superior thyroid pedicle, fundamental frequency volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr vishal rattan munjal prof & hod saims medical college,indore dr manya thakur roy* assistant professor ent, pt jnm medical college raipur cg ,india *corresponding author 48 x gjra global journal for research analysis surgical technique fig 4 keeping close to capsule of gland in the avascular cricothyroid space of reeve an attempt to identify the nerve by dissecting laterally and at the junction of superior thyr oid pole is made. capsular dissection, skeletonization and individual ligation of superior pole vessels is carried out to identify and preserve external laryngeal nerve. the superior vascular pedicle is clamped and sectioned after 2identication of the superior laryngeal nerve. fig 5 intra operative picture showing ebsln* and thyroid gland with type i variation fig 6 intra operative picture of ebsln*, thyroid gland & superior thyroid artery showing type ii variation. fig 7 intra operative picture showing ebsln* , thyroid gland & superior thyroid artery with type ii variation. fig 8 intra operative picture showing ebsln, superior thyroid artery and thyroid gland with type iii variation. fig 9 intra operative picture showing ebsln * & thyroid gland with type iv variation results total number of patients who underwent thyroidectomy was 90, out of those 22 were males and 68 were females. the gender distribution ratio in this study among male : female is 1:3.the youngest person in the study group is 19 years old, the oldest person is 68 years old and the mean age is 43.5 years as shown in table 1 below table 1 showing age wise distribution table 2 showing type of nerve according to position with reference to cernea's classication. on assessment of voice by egg , in 82 patients there was almost negligible changes in pre op & post op (f ) of voice. in o 8 patients permanent drop of f0 patients was seen in 5 cases where nerve could not be identied and in 3 patients with type 2 b variation. in present study the eln injury was 6.8%. in our study cernea type 2a was the most common position followed by type 2b the type 1.several other authors also advocate cernea type 2a as the most common position found intraoperatively as mentioned below in table 3. discussion the external laryngeal nerve which is a branch of the superior laryngeal nerve, supplies the cricothyroid muscle is not routinely identied by surgeons during thyroidectomy, as it is a very ne nerve and its course is highly variable. its injury results in loss of the high pitch of the voice and injury to the superior laryngeal nerve results in choking on swallowing food and liquids due to the epiglottic sensation being lost. in order to prevent injury to the nerve, surgeons routinely ligate the superior thyroid artery with its venae comitantes very close to the superior pole of the thyroid without actually identifying or tracing out the nerve course. according to chosky and nicholson the nerved can also be stretched and injured by a retractor or transected when the superior thyroid vessels are 6divided. cernea et al described the classification of the different types of elns as follows (fig. 10): type 1: nerve crossing the superior thyroid vessels 1 or more cm superior to the apex of the superior thyroid pole type 2: nerve crossing the superior thyroid vessels less than 1 cm superior or inferior to the apex of the superior thyroid pole type 2a: nerve less than 1 cm superior the apex of the superior thyroid pole, and type 2b: nerve inferior to the apex of the superior thyroid pole. type 2a and 2b nerves are considered to be the ''nerves at an volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra types variations of the nerve cernea et al present study type i crosses sta > 1 cm above upper pole 60% 22.01% type iia crosses sta < 1 cm above upper pole 17% 49.5% type iib crosses sta under cover of upper pole 20.2% 28.4% study type percentage present study type 2a 49.50 % aina & hassan et all3 type 2a 56% seon-bae & hye-yoon et all4 type 2a 58% anand mishra & hema5 type 2a 53.84% x 49gjra global journal for research analysis increased risk'' of iatrogenic lesion during a thyroidectomy, 7,8owing to their low-lying course fig. 10 showing variation in course of external laryngeal 9nerve according to cernea's classication. the incidence reported in the literatures of injury to ebsln intraoperatively in thyroid surgery is not very well docum ented as that of the recurrent laryngeal nerve which has been reported to be from 0.3% to 56% earlier.10. in present study the eln injury was 6.8% in fact, lennquist et al has described this nerve as the ''neglected'' nerve in thyroid gland surgery, despite the fact that injury to these nerves can also cause signicant 11disability. a full understanding of the anatomy of the superior laryngeal nerve and its branches is necessary for all the head and neck surgeons and could prepare the surgeon to reduce this risk of damage. especially when the nerve has a variable course as per the cenea's classication type 2a and 2b injury can occur easily if not taken care. there are various studies which have suggesterd that nerve could be easily identied by giving few extra minutes,while dissecting the upper pole. according to mishra ak et al nerves could be identied in 72 (92.31%) out of 78 patients in which superior pole was dissected during 12 thyroidectomy. pagedar na et al conducted a study in canada on 178 patients undergoing thyroidectomy over a period of 4 years only 3 out of 178 nerves (1.7%) could not be 13identied using the routine technique. aina en et al conducted a study on the external laryngeal nerve in which total of 202 external laryngeal nerves were identied during 14 thyroid surgery, which was 92.7 %. in present study out of 117 nerves at risk 4 could not be identied (3.4%) conclusion today in the era where advancement in every eld is taking place, efforts to further rene thyroid surgery continues. the voice quality is not only important for singers, speakers or hawkers but for normal persons too. the aim of the study is not only to treat the disease but also try to improve quality of life after surgery. injury to the eln may result in transient loss of high pitched voice but often may lead to permanent change. patients like orators, singers and teachers who heavily depend on their voices may lose their livelihood. it is possible to identify the external laryngeal nerve with little effort in almost all cases and as in larger number of patients position of nerve comes under high risk. for eln preservation it is always advisable to identify and preserve it thus avoiding critical alterations in the voice quality. a permanent drop in fundamental frequency was seen in a signicant number of patients in the cases where nerve was not identied during the surgery. careful dissection & spending few extra minutes during surgery can render almost near normal voice quality for all the patients. key home message – the author highly recommend prevention of voice quality for all the patients undergoing thyroid surgery and sensitize surgeons about careful dissection and preservation of eln in each and every case which is often ignored routinely by many surgeons. it is injustice on the surgeon's part to cause a voice change which could have easily been prevented by spending another minute or two on dissection and identication of the nerve. funding: no funding sources conflict of interest: none declared ethical approval: the study was approved by the institutional ethics committee acknowledgments we are thankful to the dept of anatomy saims, indore for helping us in cadaver dissection and studying the anatomy of nerve. references 1. e n. aina and a.n. hisham external laryngeal nerve in thyroid surgery: recognition and surgical implications;anz j. surgery;volume 71 ; 211213;nov-2001 2. standring s, berkovitz bkb. thyroid gland. in: standring s, ellis h, healey jc, johnson d, williams a, collins p et al (eds) gray’s anatomy, 39th edition, london; churchill livingstone, 2005:560-564. 3. georgina magoma, hassan saidirelation of the external laryngeal nerve to superior thyroid artery in an african population;anatomy journal of africa;28-30;june 2013 4. seong-bae hwang,hye-yoon leethe anatomy of the external branch of the superior laryngeal nerve in koreans;april 2012;1-7 5. anand kumar mishra, hema temadariindian journal of medical sciences;volume 61;jan-2007;36 6. choksy sa, nicholson ml. 1996. prevention of voice change in singers undergoing thyroidectomy by using a nerve stimulator to identify the external laryngeal nerve. br j surg 83:1131– 1132. 7. cernea cr, ferraz ar, nishio s, dutra a jr, hojaij fc, dos santos lr. 1992b. surgical anatomy of the external branch of the superior laryngeal nerve. head neck 14:380–383. 8. aina en, hisham an. 2001b. external laryngeal nerve in thyroid surgery: recognition and surgical implications. aust nz j surg 71:212–214. 9. cernea cr, ferraz ar, nishio s. surgical anatomy of the external branch of the superior laryngeal nerve. head neck. 1992;14(5):380-3. 10. jansson s, tisell le, hagne i, sanner e, stenborg r, svensson p. partial superior laryngeal nerve (sln) lesions before and after thyroid surgery. world j surg 1988; 12: 521-7 11. friedman m, toriumi dm. 1986. functional identication of the external laryngeal nerve during thyroidectomy. laryngoscope 96:1291–1292 12. mishra ak, temadari h, singh n, mishra sk, agarwal a. the external laryngeal nerve in thyroid surgery: the 'no more neglected' nerve. indian j med sci. 2007;61(1):3-8. 13. nitin a, pagedar md, jeremy l, freeman md. frcsc, “external branch of the superior laryngeal nerve”. arch otolaryngol head neck surg. 2009;135(4):360-2. 14. aina en, hisham an. external laryngeal nerve in thyroid surgery: recognition and surgical implications. anz j. surg. 2001;71:212-4 volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 50 x gjra global journal for research analysis introduction circumcision is one of the oldest and the most common surgical procedure in children worldwide. the practice of 1circumcision is thought to be at least 15,000 years old. approximately one third of males worldwide are 2circumcised. however, the practices and procedures of circumcision , and complications of various procedures are not well documented. the goal of circumcision is to remove enough shaft skin and 3inner foreskin to uncover the glans. as with any surgical procedure, there are risks associated with circumcision and the principles common to all methods of circumcision to reduce risks are: asepsis adequate but not excessive excision of the outer 4and inner foreskin haemostasis and cosmetic appearance. various techniques are available for circumcision, namely plastibell, gomco clamp, mogen clamp, metal shield,accucirc,alisklamp,ismail clamp,kirve clamp,bone cutter method, 5dorsal slit (open cut) method etc. since it was rst reported in 1956, plastibell circumcision (pc) 6 7-10has gained widespread use. plastibell method has become quite popular and appears to be more preferable procedure because it is quick and easy technique, causes minimal tissue trauma and minimal blood loss. it also provides good cosmetic results. this study was thus undertaken to document experience with the use of plastibell device for circumcision in pediatric patient of general surgery department at l g hospital, ahmedabad. methods this is a prospective study of 30 male children less than 10 years who underwent plastibell circumcision in the department of surgery at l g hospital ahmedabad during may 2017 to january 2019. children from age group upto 10 years were included in the study. children who had congenital abnormalities like hypospadias, de-ranged coagulation prole and any other medical illnesses were excluded. pre-op consent was taken from the parents after explaining them the benets and possible complications of the procedure. under aseptic precaution,local anesthesia was given in the form of ring block with 0.5% lignocaine (1 mg/kg) applied to the base of the penis, or the procedure was done under short general anesthesia. the plastibell device is a plastic ring with handle(gure 1) and it has a deep groove running circumferentially . adhesions present between glans and foreskin were divided with an artery forceps. then the foreskin was longitudinally cut at 12'o clock; prepuce retracted and glans penis exposed. the plastibell comes in multiple sizes ranging from 1.1 to 1.7. sizes between 1.1 and 1.5 were utilized in our study . an appropriate size of plastibell device which snugly ts in two third of glans penis was selected .plastibell device was then placed on the glans and the foreskin was brought over it. a linen thread ligature which comes with the device was tied rmly around the foreskin, crushing the skin against the groove in the plastibell. the handle of the ring was broken and plastibell method for circumcision in pediatric patients original research paper dr. shakib j. masu professor, department of general surgery, sheth l.g.municipal general hospital, maninagar, ahmedabad, gujarat, india dr. md. shehzad khan resident doctor, department of general surgery, sheth l.g.municipal general hospital, maninagar, ahmedabad, gujarat, india x 37gjra global journal for research analysis general surgery background: plastibell technique is a well-proven paediatric method of circumcision with respect to the results and complications. although, literatures abound on its wide acceptability, there are few studies on procedure and complications of plastibell circumcision. the objective of this study was to evaluate the cases of circumcision by plastibell device in tertiary care centre. methods: this is a prospective study of 30 male children less than 10 years who underwent plastibell circumcision in the department of surgery at l g hospital ahmedabad during may 2017 to january 2019 results: out of the total 30 cases, the successful rate of plastibell circumcision without any complication was recorded in 25 (83.33%) cases while remaining 5(16.66%) cases developed minor complications conclusions:. the classical plastibell circumcision has good safety prole with few easily correctable early complications as well as less operative time and less bleeding. abstract keywords : plastibell ; circumcision dr. kalpit suthar* assistant professor, department of general surgery, sheth l.g.municipal general hospital, maninagar, ahmedabad, gujarat, india *corresponding author dr. ayan shah resident doctor, department of general surgery, sheth l.g.municipal general hospital, maninagar, ahmedabad, gujarat, india dr. apurva gupta resident doctor, department of general surgery, sheth l.g.municipal general hospital, maninagar, ahmedabad, gujarat, india dr. krushnadevsinh jadeja resident doctor, department of general surgery, sheth l.g.municipal general hospital, maninagar, ahmedabad, gujarat, india volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 38 x gjra global journal for research analysis the excess skin protruding above the groove was excised. the compression of foreskin against the underlying plastic shield by ligature will cause necrosis of the foreskin and the ring will fall within 3 to 7 days leaving a circumferential wound that will heal within few days. all children were discharged on same evening on oral analgesics and local antibiotic ointment. on discharge; parents were given specic instructions on care of the device. all patients were called for follow-up in opd on 3rd pod and on day of separation of the plastibell and were told to return earlier, in case of any complication. the patients in which the ring was not separated within 14 days were called for follow-up and the ring was removed by cutting the ligature and excising necrotic foreskin. results in our study, 30 cases of plastibell circumcision fullling the inclusion criteria were included and analyzed. the main indication for circumcision in this study was phimosis (n=28;93.33%). the average age of patient was 4.5 yr. the mean weight was 16 kg (12.2kg to 20 kg). the model plastibell size was 1.3 cm (n=22; 73.33%)(chart-2). the mean surgical time was 10±2 mins. the mean number of days for plastibell to separate was 5.2 days with a range from 3 days to 12 days for all children; plastibell ring separation was earlier in early age groups. out of the total 30 cases, the successful rate of plastibell circumcision without any complication was recorded in 25 (83.33%) while remaining 5(16.66%) cases developed some minor complications. the most common complication was delayed separation of the ring recorded in 2 cases, other complications included bleeding in 1 case, localized supercial infection in 1 case, and inadequate skin removal occurred in 1 case. (table 1) conclusion ÿ the main indication for circumcision in our setup was phimosis. ÿ plastibell circumcision method has less operative time and less bleeding. ÿ though complications were present, they were few and could be managed easily. ÿ the model size of 1.3cm was ideal for most patients. ÿ plastibell circumcision is safe in pediatrics. declarations funding: self conict of interest: none table 1: figure 1: plastibell device with suture figure 2: plastibell device applied on penis figure 3: after separation of plastibell ring references 1. darby r. “where doctors differ”: the debate on circumcision as a protection against syphilis. soc hist med. 2003;16:57–78. 2. who/unaids. male circumcision: global trends and determinants of prevalence, safety and acceptability. geneva: world health organization, 2008. 3. al-samarrai ay, mofti ab, crankson sj, jawad a, haque k, al-meshari a. a review of a plastibell device in neonatal circumcision in 2,000 instances. surg gynecol obstet 1988;167(4):341-3. 4. kaplan gw. complications of circumcision. urol clin north am 1983;10(3):543-9. 5. neonatal and child male circumcision: a global review. page-13 6. bode c, ademuyiwa a, jeje e, elebute o, adesanya o, ikhisemojie s. preferred methods of male neonatal circumcision among mothers in lagos nigeria. j west afr coll surg. 2011;1(2):29–37 7. kariher dh, smith tw. immediate circumcision of the newborn. obstet gynecol. 1956;7(1):50–53. 8. al-samarrai ay, mofti ab, crankson sj, jawad a, haque k, al-meshari a. a review of a plastibell device in neonatal circumcision in 2,000 instances. surg gynecol obstet. 1988;167(4):341–343. 9. hammed a, helal aa, badway r, goda sh, yehya a, razik ma, elshamy a, elsamahy o. ten years experience with a novel modication of plastibell circumcision. afr j paediatr surg. 2014;11(2):179–183. 10. mousavi sa, salehifar e. circumcision complications associated with the plastibell device and conventional dissection surgery: a trial of 586 infants of ages up to 12 months. adv urol. 2008:606123. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra no. of patients delayed separation of ring 2 bleeding 1 infection 1 inadequate skin removal 1 proximal migration of ring 0 total 5 introduction: blood transfusion is identied as one of the eight essential components of comprehensive emergency obstetric care [1]which has signicantly reduced maternal mortality. anaemia and obstetric haemorrhage contribute to majority of blood transfusions in obstetrics. in developing countries, anaemia is still the most common problem in pregnancy.1015% of direct maternal deaths in india is due to anaemia. according to who anaemia is prevalent in 65-75 % of [2]pregnant women in india. nearly half of the global maternal deaths due to anaemia occur in south asian countries,80% [3]alone is contributed by india. obstetric haemorrhage is another leading cause of maternal [4]mortality in developing countries. it accounts for 24% of an [5]estimated 127,000 maternal deaths annually. the frequency of blood transfusion in obstetric care is reported to be 0.23.2% [6,7]in high resource countries. but several recent reports have shown an alarming increase in pph requiring blood [8]component transfusions. blood transfusions are generally considered safe and life-saving, but there are concerns of adverse effects like transfusion reactions, transfusiontransmitted infections, immunisations and increased risk of thrombosis, which are important reasons for lowering blood [9]transfusion rate. this study retrospectively reviewed blood transfusion patterns in patients admitted to our obstetric unit and analysed the obstetric indications, risk factors for transfusion, timing of transfusion and the various blood components and their volumes used. methods: this was a retrospective study of 502 patients admitted to the obstetrics department of a large tertiary care center in delhi, who received blood component transfusion. the study period was 10 months from january 2019 to october 2019.the blood products that were transfused were whole blood (wb), red cell concentrates (rcc), freshfrozen plasma(ffp) and platelet concentrates (pc). haemoglobin concentration (hb) of > 7 g/dl is required to maintain appropriate haemodynamics and oxygen supply. blood transfusion was indicated when haemoglobin concentration was < 7 g/dl. in addition to this, the patient's age, medical condition, vital signs, state of haemorrhage, blood biochemical data and need for emergency caesarean section were taken into consideration. rcc transfusion was performed to achieve a hb concentration of 7-8 g/dl. ffp was supplemented when required until the coagulation function normalized. pc transfusion was undertaken to achieve a platelet count above 2 50,000/mm in labouring patients and above 75,000 for caesarean section. the main objective of the study was to nd out the indication of blood component transfusion in obstetric care.the secondary outcome measure were the risk factors for transfusion, type of blood product used and their transfused volume. results: obstetric patients who underwent blood component transfusion: during the study period there was a total of 7,557 deliveries in our hospital. 502 women admitted to obstetrics department received blood transfusion. 126(25%) were prim gravidas and (74.9%) were multigravidas. there were 199 (39.6%) antepartum transfusions and 303 (60.3%) intrapartum and postpartum transfusions. 190 (37.8%) who received blood component transfusion had caesarean section and 218 (43.4%) had vaginal delivery. the mean age of patients who received transfusion was 26 years. table 1: demographics of obstetric patients with blood transfusion (n=502) obstetric and hematologic indications for blood component transfusion table-2 shows the 502 cases of blood component transfusion. 328, (65.3%) was for anaemia correction alone and 174 (34.6%) for obstetric haemorrhage. emergency lscs with severe anaemia accounted for 190 (37.8%) cases. the a retrospective analysis of transfusion management in obstetrics in a tertiary care center original research paper dr jharna behura md mrcog * department of obstetrics and gynaecology, kasturba hospital, delhi. *corresponding author x 39gjra global journal for research analysis obstetrics & gynaecology background: severe anaemia in pregnancy and obstetric haemorrhage remain major causes of maternal mortality and morbidity in developing countries. blood transfusion is a lifesaving intervention responsible for decreasing maternal mortality signicantly. methods: this was a retrospective study of 502 patients who received blood transfusion from january 2019 to october 2019.hb concentration < 7g/dl was determined to be an indication for transfusion of blood product. results: the most common indication for blood transfusion was anaemia correction in antenatal and intrapartum (65.3%) period followed by obstetric haemorrhage (34.6%). antepartum transfusions were given in (25. 2%).intrapartum and postpartum transfusions in (74.7%). the commonest cause in obstetric haemorrhage was pph (51. 7%).major and massive obstetric haemorrhage occurred in (4.02%). conclusion: severe anaemia in pregnancy needs to be diagnosed and treated early to signicantly reduce the need of blood transfusion in developing countries. the safety, adequacy and effectiveness can only be achieved if unnecessary transfusions can be prevented. abstract keywords : blood transfusion, anaemia, obstetric haemorrhage dr anjali mathur md department of pathology, kasturba hospital, delhi. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra mean age in years 26 ± 4.8 primipara, n (%) 126 (25%) multipara, n (%) 376 (74.9%) antepartum transfusions, n (%) 199 (39.6%) intrapartum & postpartum transfusions, n (%) 303 (60.3%) caesarean delivery, n (%) 190 (37.8%) assisted vaginal delivery, n (%) 218 (434.4%) 40 x gjra global journal for research analysis underlying conditions for obstetric haemorrhage on analysis were aph 40 (7.9%) mainly due to placenta previa and placental abruption. most of the above cases underwent peripartum transfusion except a few who had secondary haemorrhage. majority of the obstetric haemorrhage was due to postpartum haemorrhage 90 (19.5%). uterine rupture was seen in 7 cases. genital tract trauma was seen in vaginal wall or cervix and in 2 cases anterior wall haematoma was seen in previous 3 lscs. there were 8 cases of ruptured ectopic and 2 cases of emergency obstetric hysterectomy for placenta accreta. table 2: blood transfusion for obstetric indication (n = 502) table 3: during the study period 60 units of whole blood, 675 units of red cell concentrates, 139 units of ffp and 80 units of platelets were transfused. majority of patients 273 (54.3%) received single unit transfusion mostly for correction of anaemia. among the 174 obstetric haemorrhage group there were 6 patients (3.44%) with major obstetric haemorrhage who received more than 4 units of prbc and other blood components. one patient had massive obstetric haemorrhage requiring 12 units of prbc and 12 units of ffp. 4 units of ffp alone was required in two patients with severe preeclampsia who presented with haematuria postoperatively. only platelet transfusion was required in 4 patients who presented with thrombocytopenia only. table 3: type and number of blood component transfusion discussion: this study highlights the fact that severe anaemia during pregnancy and obstetric haemorrhage are the two leading causes for blood component transfusion in obstetrics. majority of the antepartum transfusion (65.3%) were for the correction of severe anaemia and its complications. this is in accordance with ndings reported by patel et al and chhabra [11,12]and namgyal. the incidence of blood product transfusion in our delivering obstetric patients was 4%, which is higher than previously [13]reported incidences, 0.3-1%. the reason could be the high prevalence of severe anaemia in our pregnant patients which decreases the women's reserve to tolerate bleeding either during or after childbirth. patients who were posted for emergency lscs had severe anaemia requiring blood component transfusion in 37.8% of cases signifying that antenatal care needs to be improved and anaemia should be diagnosed early and actively treated to prevent the need of these transfusions. deleterious effects of chronic tissue hypoxemia along with risk of major blood losses during the perioperative period need to be anticipated and managed. single unit transfusion occurred in majority of women who were admitted with severe anaemia. however most of the patients with haemorrhage required 2-4 units. vachhani etal observed that single unit transfusion has not declined much [14]and has reported it to be 15.12%. however in our study it was 46.4%. the probable explanation could be that a lot of women have moderate to severe anaemia in the pre-pregnant state. these women after becoming pregnant have lower haematocrit values due to physiological changes and dilutional effect, but they can tolerate this chronic anaemia better. this may be one of the reasons for the reduced need of multiple blood component transfusion in these patients rather than those who had haemorrhage. chronic anaemia is better tolerated than acute anemia. in chronic anaemia, cardiac output does not change usually until hb concentration falls [15]below 7 g/dl. blood transfusion has been identied as an in important indicator of severe obstetric morbidity. transfusion rates have been increasing in recent years due to the increase in the rates of pph.in our study 34.6% of blood component transfusion was due to obstetric haemorrhage. 19.6% had pph. six women (3.44%) , who had major obstetric haemorrhage requiring more than 4 units of packed rbc, had a history of prior cs with abnormal placentation. severe obstetric haemorrhage was seen in one patient who had a caesarean hysterectomy for atonic pph followed by dic. regarding component transfusion in the whole study 89.4% received prbc. most women with obstetric haemorrhage required two units of prbc. most women with major obstetric haemorrhage required plasma and platelet transfusion which highlights the importance of coagulation factors in the management of obstetric haemorrhage. major obstetric haemorrhage was a signicant risk factor for dic and icu admissions. conclusion: severe anaemia and obstetric haemorrhage are the two most important indications for blood transfusion in obstetrics. while obstetric haemorrhages are sudden and unpredictable, transfusions for severe anaemia can be prevented. early detection and treatment of anaemia in the reproductive age group, regular antenatal care along with optimal treatment of anaemia during pregnancy will signicantly decrease the need for blood transfusion. ceasarean section with abnormal placentation was found to be a signicant risk factor in major obstetric haemorrhage. identifying these risk factors and lowering the ceasarean section rate might be the best way to reduce the rate of major and massive obstetric transfusions. funding: no funding sources conict of interest: none declared. references: 1. cruz.jr. reduction of maternal mortality: the need for voluntary blood donors. int j gynaecology obstet 2007; 98:291-3 2. kalaivani k. prevalence and consequences of anemia in pregnancy. indian j volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra obstetric indication frequency percent anc with severe anaemia 138 27.4 emergency lscs with severe anaemia 190 37.8 antepartum haemorrhage 40 7.9 ruptured ectopic 08 1.5 rupture uterus 07 1.3 miscarriage 06 1.1 postpartum haemorrhage 98 19.5 obstetric hysterectomy 02 0.3 severe preeclampsia & eclampsia 11 2.1 puerperal sepsis 02 0.3 units transfused whole blood (n = 60) no. % packed rbc/ (rcc) n= (675) no. % ffp (n=139) no. % platelet (n=80) no. % 1 40 66.6 233 34.5 2 10 16.6 147 21.7 08 5.7 16 20 3 28 4.1 02 1.4 02 2.5 4 08 1.1 20 14.3 07 8.7 5 03 0.4 6 01 0.1 7 01 0.1 01 1.2 8 01 0.7 9 01 1.2 10 11 12 01 0.1 02 1.4 med res 2009; 130:627-33 3. demaeyer e, adiels-tegman prevalence of anaemia in the world. world health stat q 1985; 38:302-16 4. loudon i. maternal mortality in the past and its relevance to developing countries today. am j clin nutr 2000; 72:241s-6s 5. prevention of postpartum haemorrhage initiative; 2011. available from: http://www.pphprevention.org/pph.php. [last accessed on 2012 sep 18] 6. ekeroma aj, ansari a, stirrat gm. blood transfusion in obstetrics and gynaecology. br j obstet gynaecol 1997; 104:278-84 7. balki m, dhumne s, kasodekar s, seaward g, carvalho jc. blood transfusion for primary postpartum haemorrhage: a tertiary care hospital review. jogc 2008; 30:10002-7. 8. lutomski je, byrne bm, devane d, greene ra. increasing trends in atonic postpartum haemorrhage in ireland: an 11-year population-based cohort study. bjog 2012;119;306-14 9. hirayama f. current understanding of allergic transfusion reactions: incidence, pathogenesis, laboratory tests, prevention and treatment. br j haematol 2013; 16:434-44 10. rawn j. the silent risks of blood transfusion. curr opin anaesthesiol 2008; 21:664-8 11. patel vp, patel rv, shah pt, patel ck. study of role blood transfusions in obstetric emergencies. int j reprod contracept obstet gynaecol 2014; 3:1002-5 12. chhabra s, namgyal a. rationale use of blood and its components in obstetric-gynaecological practice. j mahatma gandhi inst med sci 2014; 19:93-9. 13. m. balki, s. dhumne, s. kasodekar, g. seaward, and j.c. carvalho, “blood transfusion for primary postpartum haemorrhage: a tertiary care hospital review,” journal of obstetrics and gynaecology canada, vol 30, no 11, pp. 1002-1007, 2008 14. vachhani jh, joshi jr, bhanvadia vm. rational use of blood; a study report of single unit transfusion. indian j hematol blood transfus. 2008; 24:69-71 15. czer ls, shoemaker wc. optional haematocrit value in critically ill postoperative patients. surg gynaecol obstet 1978;147:363-8 x 41gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra epidemiology more than 10 million cases per year worldwide, 2.79 million cases of tuberculosis in india. tuberculosis is a leading killer of people who are hin infected. about a decade back, abdominal tuberculosis accounted for 0.8 % of hospital 1 2administration . and 0.7% of surgical admissions, , with 3similar prevalence in children admitted to a hospital . both the incidence and severity of abdominal tuberculosis are expected to increase with the increasing incidence of hiv infection in india; hiv seroprevalence was signicantly higher in patients with abdominal tuberculosis than in 6voluntary blood donors (16.6% vs 1.4) . manuscript introduction: tuberculosis can quite rightly be termed india's “national disease”. the abdomen is the most common site of extrapulmonary involvement. it is caused by mycobacterium tuberculosis and continues to be a common cause of morbidity 1and mortality in india . both incidence and severity of abdominal tuberculosis are expected to increase with the 2, 3, 6, 9increasing incidence of hiv infection in india . it may involve any organ but till recently the liver was seldom considered to be the site of tuberculosis involvement except in few case of disseminated tuberculosis. major i ty pat ients with hepatic tuberculosis have the milliary type consisting of widespread multiple granuloma. classic well-formed granulomas have been observed individuals with early hiv 3, 6, & 9disease . while patients with advanced hiv disease the granulomas are less well formed are more necrotic and may 4contain abundant bacilli . though primary tuberculosis of liver is rare, it can be involved secondarily due to pulmonary and extrapulmonary 4&5tuberculosis. this incidence is around 10-15%. gupta et al documented incidence in 63% of hepatic involvement of pulmonary and extra pulmonary tuberculosis and 46.1% 1patient presenting as pyrexia of unknown origin so identication of risk factors and early diagnosis are the key issues for effective interventions. keeping all these views in mind, the present study was conducted with the following objectives 1. to study liver tuberculosis in adults in relation to primary tuberculosis with clinical presentations, age and sex. 2. to correlate gross morphological appearances with histopathological features. 3. to study liver tuberculosis in adults in relation to liver function test (lft) and cause of death. material and methods: the present study was based on autopsy material.this was a descriptive cross sectional retrospective and prospective study carried out during 4½ years at tertiary care hospital. all the adult autopsies during this 4½ years period were screened for liver tb. details of clinical history, examination and results of various investigative procedures with particular reference to liver function tests were obtained from hospital records whenever available. standard routine procedure were used for xation, embedding and sectioning. all sections were stained with hematoxylin and eosin. in selected cases special stains like ziel neelsen stain was also performed acid fast bacilli. observation and results: in present study tuberculosis comprised 10.17% of all liver disease and 20% of secondary liver disease and 23.73% of all infections. young adults were commonly affected with m: f ratio was 2:1. the commonest clinical features were fever 60%, 1, 2 & 4abdominal pain 42.86%, and weight loss 28.5% .in present study hepatic tuberculosis was secondary tuberculosis and as a part of disseminated tuberculosis. tuberculous involvement of liver in majority cases was in the form of multiple grey white tubercles ranging from pin head to 0.5 cm with central caseation with normal intervening parenchyma. in present study the granuloma lesion were commonly seen in most of cases , while caseating granulomatous lesion were seen in case of disseminated tuberculosis (fig. 1,2,) though main lesion in hepatic tuberculosis is granulomatous lesion along with nonspecic changes such as fatty change, focal cellular collections, brosis are also seen. in one case which was hiv positive shows the classical picture of tuberculosis granuloma (fig. 3). comprised by central caseation surrounded by epithelioid cells, langhans giant cell. liver function test (lft) shows nonspecic changes do not help in the diagnosis. only 5 (14.3%) cases out of 35 showed autopsy study of liver tuberculosis in adult patients in tertiary care hospital in mumbai original research paper dr. ujwal k. rathod associate professor, dept. of pathology, hinduhrudaysamrat balasaheb thackeray medical college, juhu, mumbai-400056. x 125gjra global journal for research analysis medical science liver involvement in tuberculosis, through common both in pulmonary and extra pulmonary tuberculosis 1, 2 & 4is usual clinical silent . in present study we came across 35 cases of hepatic tuberculosis, comprised 10.17% of all liver disease and 20% of secondary liver disease and 23.73% of all infections. young adults were commonly affected with m: f ratio was 2:1. the commonest clinical features were fever 60%, abdominal pain 42.86%, and weight loss 28.5% 1, 2 & 4. in present study hepatic tuberculosis was secondary tuberculosis and as a part of disseminated tuberculosis. histology (majority cases) showed multiple granuloma comprising of central caseation surrounded by epithelioid cells and langhans giant cell. it is a known fact that silent liver diseases are common amongst apparently healthy individuals and are sometimes diagnosed only at autopsy. abstract keywords : liver tuberculosis. autopsy. millind patil associate prof., dept of pathology, ltmmc &gh, sion, mumbai-400022. dr. smita santosh chavhan* associate professor, dept. of community medicine, hinduhrudaysamrat balasaheb thackeray medical college, juhu, mumbai-400056. *corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. riya rathod medical ofcer at mt agrawal dispensary, mumbai. 126 x gjra global journal for research analysis 1, 2 & 4deranged lft . there is slight alteration in sgot/sgpt 5was most frequent observation with mild hyperbilirubinemia . most of the patients came in gasping condition and died 7.within 24 hours of admission in present study 7(20%) of 35 cases of hepatic tb were known cases of pulmonary tb and 3 (8.6%) females out of 12 were pregnant. in our study afb could be demonstrated in 2(5.7%) of 35 cases.in present study the 1, 2 & 4commonest cause of death were disseminated tb . table : age and sex distribution of tuberculosis cases chart: signs and symptoms in tuberculosis cases fig. 1 multiple caseating granuloma in hepatic tb (h & e 10x) fig. 2 multiple caseating granuloma in hepatic tb (h & e 40x) fig. 3 single caseating granuloma surrounded by epithelioid giant cells in hiv positive patient in background of fatty changes in hepatic tb (h & e 40x) conclusion: it may be concluded from present study that hepatic involvement is not uncommon and hepatic tuberculosis was secondary tuberculosis and as a part of disseminated tuberculosis. young adults were commonly affected with m: f ratio was 2:1. the commonest clinical features were fever 60%, abdominal pain 42.86%, and weight loss 28.5%1, 2 & 4. the study was conducted on the specimen collected from the mortuary and not reect the actual pattern of liver tb and emphasizes the need for further studies for early detection and treatment of the vulnerable group of people in the local population. autopsy study is a good stepping stone towards achieving good morphological accuracy. liver tb continue to be an important cause of morbidity and mortality in tropical countries. early diagnosis and prompt interventions improve the survival and outcome of the disease. since tb remains a potentially curable disease. references: 1. a.r. chogle : hepatic involvement in tuberculosis. journal of association of physicians of india 2000;vol 48 (2): 181-182.. 2. kapoor vk: abdominal tuberculosis : the indian contribution. indian journal of gastrogenterology, 1998; 17: 141. 3. lewsin k.j.: clinical pathologic ndings of the liver in the aids am j clin. path. 1985; 83: 582-588. 4. d n amrapurkar, k b chopra, a y phadake, et al. indian journal of gastroenterol, 1995; 14(1):21-22. 5. gupta s, meena h s, chopra r. hepatic involvement in tuberculosis. j. assoc physician in india 1993; 41:20-22. 6. rathi pm, amrapurkar dn, chopra kb, et al. impact of hiv infection in tuberculosis (abstract). indian j gastroenterol. 1999; 12(suppl 2):a2. 7. as purl ak nayyar & jc .vij indian j.tub1994; 41:131. 8. nityanand hk agrawal manmeet singh, tuberculosis liver tb j.assoc physician india. 9. chaisson re, schecter gf, theuer cp, rutherford gw, echenberg df, hopewell pc: tb in patients with the acquired immunodeciency syndrome clinical features, response to therapy and survival, am. rev respir. dis 1987; 136: 570-574. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra sr. no. age tb (n = 35) male female 1. young adults (18-40yrs) 8 9 2. middle age (41-60yrs) 9 2 3. elderly (> 61) 6 1 total 23 12 introduction: urinary bladder carcinoma is one of the commonest malignancies in the western world with the united states of america (usa) reporting nearly 68000 new cases per year. majority of cases are potentially detectable at an early stage when the disease is imminently treatable (1). it is more common in males, with a male: 1 female ratio of 3:1. urine cytology has historically been used for screening, diagnosis and monitoring of cases of urothelial cancers since 1945 when famously dr george papanicolaou published his seminal work on cytology smears (2). from his ve categories for reporting of cytology slides we have evolved today to seven categories as propounded by tps; figure 1. his classication was widely used until recently when studies indicated two divergent classes of urothelial cancers with totally different clinicopathological and molecular attributes. the lguc are usually non-invasive and have low rate of progression to invasive carcinomas, of the order of 1-5% with very low disease related mortality. on the other hand, hguc are invasive, frequently metastatic and have a high mortality rate. the hguc cases are often found to have mutation of p53 gene in the tumor cells which are lacking in lguc. it was observed that timely detection of these cases can change the course of their management and signicantly improve their prognosis. in 2013, the groundwork for tps was done in a conference held in paris which culminated in the formation of an objective system of reporting of urinary cytology, on the lines of the bethesda system for reporting of cervical and thyroid cytology. tps has seven different diagnostic categories namely; category i – non-diagnostic or unsatisfactory, cate gory ii negative for high grade urothelial carcinoma (nhguc), category iii – atypia, category ivsuspicious for high grade urothelial carcinoma (shguc), category vlow grade urothelial neoplasia (lgun), category vi high grade urothelial carcinoma (hguc) and category vii of other non-urothelial malignancies both primary and metastatic. since the advent of this new reporting system, there has been a paradigm shift in the reporting of urine cytology in most of the western cancer care centres. however, the same enthusiasm has not been seen in most of the south asian countries and response has been much of skepticism. there is a perceived need to adopt this new method of urine cytology reporting in order to achieve its objectives. in furtherance of our previous retrospective descriptive study the authors have felt a need to adopt tps as the sole reporting system of urine cytology at all centres across our country. materials and methods: objectives of this study included rstly, to classify all urine cytology samples received in the period between 01 jan 2017 to 31 mar 2019 at the department of pathology as per tps and secondly to analyze the spectrum of various categories, and correlating it with biopsy ndings, where available, in positive hguc cases. procedure: all preserved smears of urine cytology from 01 jan 2017 to 31 mar 2019 were retrieved from the archives of the department of pathology. all cases comprised of at least one smear each stained with giemsa and pap stains respectively. the slides were reviewed by two experienced pathologists (mst and psm). all cases were reclassied into various categories as specied by tps. in cases with differences of opinion between the two pathologists a nal category was ascribed to the cases only after reaching a consensus opinion. corresponding biopsy reports, where available, of the cases reported as suspicious or positive for hguc were matched with the cytology ndings for verication and corroboration of the cytologic diagnosis. the slides were examined using olympus microscope model umdob3. results: a total of 661 geimsa and pap stained urine cytology smears from 121 patients (91 males and 30 females) were studied; utility of the paris system of urine cytology reporting: a general population context original research paper ms tevatia md, consultant & hod, dept of pathology, command hospital, pune ps mishra md, classied specialist, department of pathology, command hospital, pune pathology background: the paris system (tps) for reporting urinary cytology is an exercise by experts in the eld of urinary system pathology to streamline reporting of urine cytology smears on the lines of cervical cytology reporting system. the primary aim of our study was to nd out cases of high-grade urothelial carcinoma (hguc) using tps in a general population. materials and methods: a retrospective study was done to classify as per tps, all urine cytology smears prepared for various cases of suspected malignancy in the period between 01 jan 2017 to 31 mar 2019 at a tertiary care centre in india. all slide smears were reviewed by two experienced pathologists and reclassied into various categories as specied by tps. histopathology/biopsy reports, where available, were corroborated for correlation with nal cytology reports. results: a total of 661 geimsa and pap stained urine cytology smears from 121 patients (91 males and 30 females) were studied. a total of 11 cases were categorized as category i, 88 as category ii, 03 as category iii, 09 as category iv ,06 in category v and 04 as category vi. there were no cases in category vii. conclusion: consolidating on previous data from our published study the authors further highlight that tps is an effective and objective tool for reporting urine cytology specimens and is recommended for early detection of hguc cases. the detection rate of low-grade urothelial carcinoma (lguc) by this system is low, in keeping with ndings of other studies on this subject. abstract keywords : urine cytology, high grade urothelial carcinoma, the paris system volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra ak baranwal* md, phd, senior adviser, department of pathology, command hospital, pune *corresponding author atul sahai md, classied specialist, department of pathology, command hospital, pune 16 x gjra global journal for research analysis table 1. eleven smears were discarded for poor quality of staining and lack of clinical details in requisition forms. a total of 11 cases were categorized as category i, 88 as category ii, 03 as category iii, 09 as category iv ,06 in category v and 04 as category vi. there were no cases in category vii. only 14 patients (11 male & 03female) for whom urine cytology sample were received, had undergone urinary bladder biopsy and their reports were available in records. statistical analysis: the mean age of the patients for whom samples were received was 60.3 years, median being 63.4 years and mode 61 years. table1: total number of patients of the 14 patients (excluding 1 biopsy for a recurrent case), for whom histopathological reports were also available in records, 11 were males and 03 females. 04 biopsies were reported as hguc (all males including one recurrence) and 09 were reported as lguc and included 03 females. four cases were of benign conditions including one case of cystitis cystica et gladularis and non-specic inammation; table 2. table 2: histopathological reports of available biopsy reports discussion: this study is one of the rst descriptive retrospective studies of its kind from our country which sets to nd out efcacy of tps in reporting of urine cytology smears. urine cytology remains one of the most widely used non-invasive investigations for the early diagnosis, screening and monitoring of urothelial carcinoma. it is best suited for a resource poor country like india. there was a predominance of males in our study with a sex ratio of 3.5:1 (m: f) consistent with the available literature on urothelial carcinomas (3). an average of nearly 6 smears for each patient were examined which is found to be adequate in most other studies for the purposes of screening and monitoring. we extended the period and number of cases examined for our study as compared to the previous one enhancing its validity and veracity. this is in keeping with widely accepted standard clinical practice followed the world over for suspected urothelial carcinoma cases as well as for the monitoring of proven cases (4). the average age of patients in our study was 60.3 years which is similar to other studies on urothelial cancers. the average age for the females 58 years while for males it was 62.5 years which again is in line with occurrence of urothelial carcinomas a little earlier in females as described in most of other studies and texts (5). on scrutiny of the cytopathological reports of the urine sample maintained in the departmental archives the authors found that 2 samples were reported as hguc while one of the cases was reported as suspicious by previous methods. the reports as per tps for all these cases changed to hguc, possibly signifying more objective approach by tps as compared to the previous system. most other studies have also come out with higher objective reporting categories while employing tps in their studies (5,6). there were no samples reported as unsatisfactory by previous reporting system while in our study, nearly 09 % of the samples were reported as category i or inadequate. few of the cat i may have been earlier adequate, however as the sample volume of urine specimen was not known, any sample which failed to demonstrate 10 well visualized preserved urothelial cells was considered inadequate. few slides were poorly stained/ had air bubbles/ other artifacts for which the authors considered them inadequate in this study. in three smears unavailability of clinical input on requisition form rendered them inadequate for reporting. most of the cases were in category ii of tps, comprising of approximately 73% of the total samples which is in accordance with the published literature (7). the category of atypia (category iii) comprised of just 03 cases or 2.4% which is a signicant deviation from our previous study possibly due to increased sample size and better sample handling and minimizing of preanalytical fallacies by the staff (8). however, it was within the low range of most other studies as recorded in available literature (9). reporting rate of atypia ranging from 1.3-23.2% has been recorded by various institutions (1,2,9). urine cytology is a widely accepted method for follow up of high-grade urothelial lesions, however it can be combined with other ancillary investigations like uorescent in-situ hybridization (fish) to increase its sensitivity especially for category iii cases. category iv cases were 09 or about 7.5% of total 121 cases which is signicantly more than our previous study, although it still is consistent with ndings of other studies (3,10). category v consisted of 06 cases which is similar to our previous report and in line with world literature (10). category vi or hguc cases were 04 or 3.3%, which is a signicant detection rate of hguc in general population; however, the same cannot be said of screening test in high risk cases. our study consisted of all urine samples from patients who represented general population as cytology was asked for to detect infections, inammation or malignant cells (3,6,7,11). most other studies have addressed cytology reporting in high risk cases or tested value of tps as screening tool for hguc; our study though incorporating the said objective was still aimed at general population thereby increasing its scope to scrutiny in future. this also perhaps is the most important limitation of our study. no cases were reported in category vii, which is consistent with our conventional knowledge that non-urothelial and secondary malignancies of urinary bladder account for lesser than 5% of all cases (12). our study has added advantage of representing pan-india population with all ethnic and regional being represented in our cases making it possibly rst such study from this sub-continent. conclusion: tps, after its recent adoption by some centres has been proven to be an important screening, diagnostic and monitoring tool for urothelial malignancies. while most cases in our study were non-neoplastic benign conditions, tps did prove to be critical in identifying suspicious and frank hguc cases in general population vis-à-vis previous reporting system, re-iterating a felt need by authors to adopt it as the sole reporting system for urine cytology by all institutions. more studies are required to further establish importance of tps in urine cytology reporting. conflicts of interest: the authors have none to disclose. acknowledgements: the authors deeply acknowledge the contributions of staff at command hospital, southern command, pune. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra male 91 female 30 total 121 x 17gjra global journal for research analysis figure 1 : history of urine cytology reporting systems (reproduced with permission) figure 2 high grade urothelial carcinoma (upper panel); low grade urothelial carcinoma (lower photograph) references 1. sebastia antony., jacques ferley., isabelle soerjomataram, ariang zaor., ahmedin jamal., freddie bray. bladder cancer incidence and mortality: a global overview and recent trends. european urology jan 2017; vol 71, issue 1; pages 96-108. 2. papanicolaou gn, marshall vf. urine sediment smears as a diagnostic procedure in cancers of the urinary tract. science 1945; 101:519 ±20. 3. christopher l. owens, vade busche, francis h burroughs, dorothy l rosethal. a review of reporting systems ad terminology for urine cytology. cancer cytopathology jan 2013/volume121; issue1, pages 9-14 4. sheldon bastacky, m.d. stacey ibrahim, m.d.sharon p. wilczynski, m.d. william m. murphy, m.d. the accuracy of urinary cytology in daily practice.cancer (cancer cytopathology) june 25, 1999 / volume 87 / number 3 5. sheldon bastacky, m.d. stacey ibrahim, m.d.sharon p. wilczynski, m.d. william m. murphy, m.d. the accuracy of urinary cytology in daily practice.cancer (cancer cytopathology) june 25, 1999 / volume 87 / number 3 6. güliza. barkan.eva m. wojcik. ritu nayar. spasenija savic-prince. marcus l. quek. daniel f.i. kurtycz. dorothy l. rosenthal.the paris system for reporting urinary cytology: the quest to develop a standardized terminology. acta cytologica 2016;60:185–197.published onlie: june 18,2016. doi: 10.11 59/000446270 7. bernard teˆtu. diagnosis of urothelial carcinoma from urine. modern pathology (2009) 22, s53–s597 8. renu k. virk, schuharazad abro, julianne muus martinez de ubago, stefan e. pambuccian, marcus l. quek, eva m. wojcik, swati mehrotra, grazina u. chatt, güliz a. barkan, the value of the urovysion® fish assay in the riskstratication of patients with “atypical urothelial cells” in urinary cytology specimens, diagnostic cytopathology, 2017, 45, 6, 481 9. esposti et.al. the cytologic diagnosis of transitional cell tumors and its histological basis.acta cytologica, 1970,14: 145-55. 10. khalifa se. standardization of reporting of urine cytology : the paris system. adv cyt path, 2(1) : 00008 11. peter a humphrey et.al. the 2016 who classication of the tumors of urinary system and male genital organs. 12. christopher v et.al. adequacy of voied urine cytology specimens: the role of volume and repeat void upon predictive value of high grade urotelial carcinoma; cancer cytopathology 2016,124 : 174-80. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 18 x gjra global journal for research analysis introduction supracondylar humerus fractures being the most common pediatric fracture around the elbow and are nearly three1–13fourth of all upper-extremity fractures. gartland's classication is used to describe this fractures as nondisplaced fractures (type i), hinged fractures with the posterior cortex intact (type ii), and completely displaced fractures (type iii).4 percutaneous pinning of supracondylar humerus fractures in children after closed reduction is an effective way to maintain an anatomic reduction of a displaced fracture till bony union and was rst described by 5casiano in 1960. closed reduction and percutaneous kirschner wire (k-wire) xation is now considered as standard method for surgical management of displaced extension type (gartland type ii and type iii) supracondylar humerus fractures. many investigators have used two crossed pins (one 5-7introduced medially and one laterally). others have used two or three lateral pins only and without any medial pin.8 the optimal conguration of percutaneous pin xation is however still debatable. biomechanically, a crossed pin conguration (one medial and one lateral) provides increased stability but carries the risk of iatrogenic ulnar nerve injury during insertion of the medial 9-11pin. conversely, lateral pin xation avoids the danger of iatrogenic ulnar nerve injury but has been proven to be mechanically less stable compared to crossed pin 12-16conguration. there are studies which have proven that lateral-only xation is good enough for maintaining reduction while simultaneously avoiding injury to the ulnar nerve.17 this retrospective study was conducted to nd out the outcome of percutaneous lateral pinning in the management of displaced supracondylar fracture of humerus in children, also to see the associated complications with this method of xation. materials and methods this retrospective study comprising of 25 cases of displaced fracture supracondylar humerus, treated by lateral and cross pinning was carried out at orthopedics department, h. b. t. medical college and dr. r. n. cooper municipal general hospital, mumbai from july 2018 to june 2019. a written informed consent was obtained from all the patients (by their parents). the inclusion criteria was closed supracondylar fracture of humerus extension type ii and type iii in children less than 14 yrs of age. patients with a) extension type i of fractures, b) exion type injuries, c) compound fractures d) patients completed the age of 14 years e) pervious history of fractures or nerve injury around elbow, were excluded from the study. all the necessary preoperative work-up was done in the form of thorough clinical and radiological examination. the fractures were classied as per the gartland's classication system. all patients were operated under general anesthesia within 48 h after trauma. under general anesthesia, using carm image intensier, closed reduction was done. the forearm was then pronated and the elbow acutely exed and held temporarily by adhesive tape. pronation de-rotates the distal fragment from its frequently medially rotated position and locks it in correct alignment.  when satisfactory reduction had been achieved then xation was done by two divergent lateral k-wires of 1.5 or 2.0 mm size. adequate reduction was assessed by anterior humeral line passing through the centre of capitulum. pins were placed in divergent conguration with the adequate separation at the fracture site. if doubt in stability of xation was there, a third lateral pin was added. vascularity of distal limb were also checked at this point. the pins were bent and cut off outside the skin and a well-padded, above-elbow, back-slab was applied and vascularity of the distal part of limb checked again. the patient was carefully observed for 48-72 hours with proper limb elevation and then discharged in above elbow pop back slab. the follow-up was done as follows: the rst follow-up on the 7th day to inspect pin tract infection and swelling; the second follow-up on the 2nd week to see pin tract infection and the pin conguration; the 3rd follow-up on the 4th week for the removal of plaster slab as well as pins and to start physiotherapy; the 4th follow-up on the 8th week post-operatively to see the progress of rehabilitation and any other complications; and the nal follow-up on the 6 months post-operatively to see the nal functional and radiological outcome of supracondylar humerus fractures in children with lateral pinning: a retrospective analysis original research paper ganesh r. yeotiwad assistant professor, h.b.t. medical college and dr.r.n. cooper hospital, mumbai, maharashtra-400056 orthopaedics supracondylar humerus fractures being the most common pediatric fracture around the elbow. closed reduction and percutaneous kirschner wire (k-wire) xation is now considered as standard method for surgical management of displaced fractures. the optimal conguration of percutaneous pin xation is however still debatable. this study was conducted to nd out the outcome of percutaneous lateral pinning in the management these fractures. functional outcome was calculated as per flynn's criteria. total of 25 cases were studied, out of which, 20 (80 %) had excellent, 4 (16 %) had good, 1 (4 %) had fair outcome. no poor outcome at the nal follow-up of 6 months. no case postoperative of ulnar nerve palsy was seen. we conclude that closed reduction and xation of gartland type ii and iii paediatric supracondylar fractures with lateral pinning is safe and effective without the risk of iatrogenic ulnar nerve injury. abstract keywords : supracondylar humerus, paediatric fracture, flynn's criteria, lateral pinning harshad g. argekar associate professor, h.b.t. medical college and dr. r. n. cooper hospital,mumbai, maharashtra-400053 sagar g. daliya* post-graduation student, h.b.t. medical college and dr. r. n. cooper hospital,mumbai, maharashtra-400056*corresponding author chintan s. vaidya post-graduation student, h.b.t. medical college and dr. r. n. cooper hospital,mumbai, maharashtra-400056 volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 110 x gjra global journal for research analysis result of the study. the nal results were analyzed using the flynn criteria.  this criteria is divided into two components, the functional and the cosmetic component and both are further sub-divided as excellent, good, moderate and poor at an interval of ve degrees. results there were 25 children in this study, 15 children were male and 10 children were females. the children were aged 1.5 years to 13 years with median age of 7.28 years.(table 1) there were 14 left sided and 11 right-sided fractures. 18 children had injury while playing, 3 children had met with a road trafc accident and 4 had a fall from a height. all were closed fractures. the extension type ii were 10 and 15 were of extension type iii. 21 cases were treated by two divergent lateral k-wires while 4 cases were treated with three divergent lateral k wires. none of the fractures required open reduction. pre-operatively, there were no cases of vascular or nerve injuries. during follow-up, none had secondary displacement of wires and loss of reduction. post-operatively, 2 patients got pin tract infection, which was supercial and healed after removing pins and oral antibiotic administration. postoperatively, no ulnar nerve injury or vascular injury were noted in any patients. callus formation was seen in all patients at the 4th week postoperatively follow up before removing the k-wires. no case of nonunion was seen. results were analyzed using 7flynn's criteria (table 2). table 1: distribution of patients as per age and sex table 2: flynn et al. criteria for grading all patients were followed at 8 weeks and 6 month postoperatively. functional outcome, as per flynn's criteria, 18 (72 %) had excellent, 4 (16 %) good, 2 (8 %) fair and 1(4 %) poor results at 8 weeks, which was improved to 20 (80 %) excellent, 4 (16 %) good, 1 (4 %) fair and no poor result at the nal followup of 6 months (table 3). the average loss of range of movement as well as carrying angle was of 4 degrees. table 3: final results of lateral k-wire xation of supracond ylar fracture humerus during this study, complications like vascular injury, compartment syndrome, myositis ossications, ulnar nerve palsy, signicant mal-union and non-union were not seen. discussion closed reduction and percutaneous pin xation for the management of pediatric supracondylar humerus fractures is widely accepted and practiced, but the optimal pin 1,19–21conguration is still controversial. chakraborty et al. and balakumar and madhuri found crossed (medial/lateral) pinning to be superior than two parallel lateral pin 22,23xations. however, many studies have reinforced the observation that both lateral-entry pin xation and crossed pin conguration are effective in the management of type iii 21,24,25gartland supracondylar fractures in children. 26sankar et al. studied the loss of pin xation in supracondylar humerus fractures. he concluded in all cases, loss of xation was due to technical errors that were identiable during intraoperative uoroscopic images. all these errors could have been prevented with proper reduction and xation technique. three types of of pin-xation errors were identied as: (1) failure to achieve bicortical xation with two pins or more, (2) failure to engage both fragments with two pins or more, and (3) failure to achieve adequate pin separation (>2 mm) at the fracture site. 27sapkota et al. suggested lateral pinning with 2 or 3 k-wires for proper stabilization and ideal conguration to be divergent to hold medial and lateral columns as the treatment of supracondylar fracture without risk of iatrogenic ulnar nerve injury. pathania et al. studied the surgical complications and also compared the functional and radiological result of lateral pinning and crossed pinning in supracondylar fractures in children. they concluded that xation of supracondylar humerus fracture of gartland type ii and iii can be done by both ways either cross or lateral pinning but in view of ulnar nerve injury and extension lag which is more commonly associated with cross pinning, lateral pinning is comparatively safe and reliable for both 28types of supracondylar fractures of humerus in children. govindasamy et al. did a retrospective study on cross pinning versus lateral pinning in supracondylar fracture in children and concluded that both xation techniques were good in terms of stability, function and cosmetic outcome. the problem with cross pinning was iatrogenic ulnar nerve injury due to medial pinning which was 11%. so lateral pinning is reliably safe method and provides adequate stability in displaced 29supracondylar fractures. 17skaggs et al. concluded that lateral-only pins provide adequate stability without endangering the ulnar nerve for xation of both type ii and iii supracondylar humerus fractures. they also advised avoiding the regular use of crossed pins in the treatment of pediatric supracondylar humerus fractures. in our study also, we found that lateral 2-3 pins were enough to provide a stable xation and give excellent to good functional and radiological outcome without any risk of ulnar nerve injury. conclusion as the xation remained stable with lateral pinning and provided excellent to fair functional as well as cosmetic outcome with no loss of reduction during follow up, it can be concluded that closed reduction and xation of gartland type ii and iii supracondylar fractures with lateral pinning is safe and effective without the risk of iatrogenic ulnar nerve injury. references 1. otsuka ny, kasser jr. supracondylar fractures of the humerus in children. jaaos-journal am acad orthop surg. 1997;5(1):19–26. 2. waters pm, mih ad, beaty jh, kasser jr. fractures of the distal radius and ulna. rockwood wilkin’s fract child. 2006;6:337–98. 3. boyd hb, altenberg ar. fractures about the elbow in children. arch surg. 1944;49(4):213–24. 4. gartland john j. management of supracondylar fractures of the humerus in children surgery gynecology & obstetrics. 145-159. august; 1959. 5. casiano e. reduction and fixation by pinning “banderil lero” style—fractures of the humerus at the elbow in children. mil med. 1960;125(4):262–4. 6. swenson al. the treatment of supracondylar fractures of the humerus by volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra age/sex 0-5 years 6-10 years more than 10 years total male 4 8 3 15 female 3 6 1 10 results rating cosmetic factor: carrying angle loss ( in degrees) functional factor: motion loss (in degrees) satisfactory excellent 0-5 0-5 good 5-10 5-10 fair 10-15 10-15 unsatisfactory poor >15 >15 results rating cosmetic factor: carrying angle loss ( in degrees) outcom e in patients functional factor: motion loss (in degrees) outcom e in patients satisfa ctory excellent 0-5 19 0-5 20 good 5-10 5 5-10 4 fair 10-15 1 10-15 1 unsatisf actory poor >15 0 >15 0 x 111gjra global journal for research analysis kirschner-wire transxion. jbjs. 1948;30(4):993–7. 7. flynn jc, matthews jg, benoit rl. blind pinning of displaced supracondylar fractures of the humerus in children: sixteen years’experience with long-term follow-up. jbjs. 1974;56(2):263–72. 8. ariño vl, lluch ee, ramirez am, ferrer j, rodriguez l, baixauli f. percutaneous xation of supracondylar fractures of the humerus in children. j bone joint surg am. 1977;59(7):914–6. 9. skaggs dl, hale jm, bassett j, kaminsky c, kay rm, tolo vt. operative treatment of supracondylar fractures of the humerus in children: the consequences of pin placement. jbjs. 2001;83(5):735–40. 10. lyons jp, ashley e, hoffer mm. ulnar nerve palsies after percutaneous crosspinning of supracondylar fractures in children’s elbows. j pediatr orthop. 1998;18(1):43–5. 11. rasool mn. ulnar nerve injury after k-wire xation of supracondylar humerus fractures in children. j pediatr orthop. 1998;18(5):686–90. 12. gordon je, patton cm, luhmann sj, bassett gs, schoenecker pl. fracture stability after pinning of displaced supracondylar distal humerus fractures in children. j pediatr orthop. 2001;21(3):313–8. 13. lee ss, mahar at, miesen d, newton po. displaced pediatric supracondylar humerus fractures: biomechanical analysis of percutaneous pinning techniques. j pediatr orthop. 2002;22(4):440–3. 14. zionts le, mckellop ha, hathaway r. torsional strength of pin congurations used to x supracondylar fractures of the humerus in children. j bone joint surg am. 1994;76(2):253–6. 15. kallio pe, foster bk, paterson dc. difcult supracondylar elbow fractures in children: analysis of percutaneous pinning technique. j pediatr orthop. 1992;12(1):11–5. 16. davis rt, gorczyca jt, pugh k. supracondylar humerus fractures in children: comparison of operative treatment methods. clin orthop relat res. 2000;376:49–55. 17. skaggs dl, cluck mw, mosto a, flynn jm, kay rm. lateral-entry pin xation in the management of supracondylar fractures in children. jbjs. 2004;86(4):702–7. 18. bloom t, robertson c, mahar a, pring m, newton po. comparison of supracondylar humeral fracture is not anatomically reduced. in: read at the annual meeting of the pediatric orthopaedic society of north america hollywood, fl. 2007. 19. beaty j, kasser jr. fractures about the elbow. instr course lect. 1995;44:199–215. 20. ozturkmen y, karamehmetoglu m, azboy i. closed reduction and percutaneous lateral pin xation in the treatment of displaced supracondylar fractures of the humerus in children. acta orthop traumatol turc. 2005;39(5):396–403. 21. foead a, penafort r, saw a, sengupta s. comparison of two methods of percutaneous pin xation in displaced supracondylar fractures of the humerus in children. j orthop surg. 2004;12(1):76–82. 22. chakraborty mk, onta pr, sathian b. displaced supracondylar fracture of humerus in children treated with crossed pin versus lateral pin: a hospital based study from western nepal. j clin diagnostic res west nepal j clin diagn res. 2011;5(6):1260–3. 23. balasubramanian balakumar vm. a retrospective analysis of loss of reduction in operated supracondylar humerus fractures. indian j orthop. 2012;46(6):690. 24. yen y-m, kocher ms. lateral entry compared with medial and lateral entry pin xation for completely displaced supracondylar humeral fractures in children: surgical technique. jbjs. 2008;90(supplement_2_part_1):20–30. 25. maity a, saha d, roy ds. a prospective randomised, controlled clinical trial comparing medial and lateral entry pinning with lateral entry pinning for percutaneous xation of displaced extension type supracondylar fractures of the humerus in children. j orthop surg res. 2012;7(1):6. 26. sankar wn, hebela nm, skaggs dl, flynn jm. loss of pin xation in displaced supracondylar humeral fractures in children: causes and prevention. jbjs. 2007;89(4):713–7. 27. sapkota k, shrestha b. study of supracondylar fracture of distal humerus in children and its management with lateral k-wire fixation. nepal j med sci. 2014;3(1):38–43. 28. pathania vp, dubey n, gupta s. treatment of displaced supracondylar fracture of humerus in children by lateral entry pinning versus cross pinning. int j sci study. 2016;4(1):70–4. 29. govindasamy r, gnanasundaram r, kasirajan s, thonikadavath f, tiwari rk. cross pinning versus lateral pinning in type iii supracondylar fracture: a retrospective analysis. int j res orthop. 2016;2(3):138–42. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 112 x gjra global journal for research analysis background mycobacterium tuberculosis (m. tuberculosis) is an ancient human pathogen, which has plagued countless human societies despite the introduction of curative and preventive therapy in the last century. in recent years, international attention has turned toward the evolving burden of drug resistance. multi-drug resistant tuberculosis (mdr tb) has emerged in epidemic proportions in the wake of widespread hiv infection in the world's poorest populations, including sub-saharan africa. extensively drug-resistant tb (xdr tb) was rst reported in 2006 but has now been documented on six 1continents . these trends are critically important for global health, since drug-resistant tb mortality rates are high and second and third-line agents for the treatment of drugresistant tb are less potent and less tolerable than rst-line therapies. drug resistant tuberculosis (dr-tb) poses a great threat to the eradication of tb. therefore, preventing the disease is the key to saving lives and resources. social and behavioural variables play a big part in this prevention. it is important to determine the social factors that may lead to dr-tb in order to set up prevention programs and more efcient treatment regimens drug resistance in tuberculosis is a global problem and india is no exception to this. however, this rise is mainly among the previously treated cases as previous antituberculosis therapy is the single most important risk factor for the development of drug resistance. the worldwide prevalence of drug resistant tuberculosis is on the rise and multiple studies give varying data regarding the adverse drug reaction of multi drug resistant tuberculosis. this study was taken up to determine the adverse drug reactions prole of a patient, previous history of anti tubercular drug intake and pattern of drug resistant. globally, 5% of tb cases were estimated to have had mdr-tb in 2013 (3.5% of new and 20.5% of previously treated tb cases). drug resistance surveillance data show that an estimated 480,000 people developed mdrtb in 2013 and 210,000 people died. extensively drug-resistant tb (xdr-tb) has been reported by 100 countries in 2013. on 2average, an estimated 9% of people with mdr-tb have xdr-tb . who 2014 global report on tuberculosis97,000 patients were ndstarted on mdr-tb treatment in 2013. 2 line drugs have a lot of side effects. in india, the prevalence of multi-drug resistant tb (mdr-tb), dened as resistance to isoniazid and rifampicin with or without resistance to other drugs, is found to be at a low level in most of the regions. data from several studies conducted by trc and nti, have found mdr-tb levels of less than 1% to 3% 3, 4in new cases and around 12% in re-treatment cases the disease is not only medical problem or a public health problem but is also a critical social problem of great magnitude. base line and adequate information on adverse nddrug reactions prole of 2 line drug in mdr and xdr tb, is required for its control and effective treatment. psychiatric disorder can either be induced by treatment regiments or psychosocial factors. cycloserine administration is frequently 9reported to be associated with psychiatric disorders. india may be considered as one of the global epicentre of tb including the drug resistant one and many patients are being treated with second line anti-tb drugs. however, there is limited data on psychiatric disorders from the second line antitb drugs on the indian patients. indian patients are different from their global counterparts both by genetic structure and phenotype; hence prone to differ in anti tb drug action and pharmacokinetics also. therefore, there is need for more data from the indian patients related to second line anti-tb drugs including the psychiatric disorders. hence, the present study was been planned to systemically generate and analyze the psychiatric disorders of the second line anti tb drugs on eastern indian patients. methods this cross sectional study was designed to include all patients psychiatric disorders in patients receiving treatment for drug resistant tuberculosis registered under dr-tb centre in a tertiary care hospital original research paper dr rupam kumar ta associate professor. department of pulmonary medicine. burdwan medical college, burdwan x 3gjra global journal for research analysis pulmonary medicine background: the emergence of drug resistant mycobacterium has become a signicant public health problem creating an obstacle to effective tuberculosis (tb) control. psychiatric disorder can either be induced by treatment regimens or psychosocial factors. cycloserine administration is frequently reported to be associated with psychiatric disorders. in this study, we have examined the prevalence and characteristics of psychiatric disorders among patients receiving treatment for drug resistant tb registered in a tertiary care hospital aims and objectivesto evaluate the psychiatric disorders of patients receiving intensive phase treatment of multi drug resistant tuberculosis (mdr) and extensively drug resistant tuberculosis (xdr) as per who-umc causality assessment scale. methods: 76 patients of mdr and xdr tuberculosis were admitted in dr-tb (drug resistant tb) centre, burdwan medical college and hospital and the adverse drug reaction prole particularly the psychiatric symptoms of 2nd line drugs were analysed during the intensive phase for a year after fullling the inclusion and exclusion criteria. treatment was given as per guidelines by revised national tb control program pmdt (programmatic management of drug-resistant tb). results: psychiatric disorders were found in 8(10.5%) patients among whom suicidal attempt 3(3.9%) and depression 3(3.9%) were the most common followed by paranoia and hallucination in 1 patient each. conclusions: the psychiatric reactions were common in the later phase of the regimen and in patients with bmi ≤18. hence vigilant monitoring is required for these types of patients throughout the course of treatment and sputum smear and culture conversion is very well correlated with clinical and radiological improvement. abstract keywords : psychosis, dr tb, cycloserine, depression, hallucination. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. pronoy sen* st1 year junior resident, department of pulmonary medicine. burdwan medical college, burdwan *corresponding author 4 x gjra global journal for research analysis receiving treatment for drug resistant tb over a period of one year. so there was no prespecied sample size for this study. this study was conducted at dr-tb centre, burdwan medical college and hospital. permission of institutional ethics committee was obtained for the study. written informed consents were obtained from all participating patients. 75 patients were included in the study. they were followed every ndmonth for 6 (9) months in intensive phase after the start of 2 line drugs and adverse drug reactions were recorded, as the maximum adverse reactions usually occur in this period. treatment was given as per guidelines by revised national tb control program pmdt (programmatic management of drug5resistant tb) (erstwhile dots plus). inclusion criteria 1. patient of age >18 years. 2. both sexes. 3. patients with proved drug resistant tuberculosis. exclusion criteria 1. patient admitted <7 days in dr-tb centre. parameters studied include: 1. hb%, tc, dc, esr 2. blood urea, serum creatinine 3. liver function test 4. fbs/ ppbs 5. sputum for afb stain and gram stain 6. line probe assay 7. urine albumin, sugar and microscopy 8. chest x-ray pa view. after selection of each patient on the basis of inclusion and exclusion criteria a written informed consent was taken. data was collected using a pretested pro forma meeting the objectives of the study. detailed history, physical examination and necessary investigations were undertaken. the purpose of the study was explained to the patient and informed consent obtained. at the end of the study the data was complied, tabulated for analysis. all the collected data were analysed by using spss version 16 statistical software. descriptive statistics were applied to the data. all data were presented as number and percent. chi square test and fisher exact test were applied wherever applicable to nd out statistical differences and p value <0.05 were considered statistically signicant. results in our study among the 76 cases, most of them were pulmonary tuberculosis (96%) whereas only 4% were extra pulmonary tuberculosis. majority were from age group 21-30 (44%), that is, the most productive age group of life. majority 64% either thstudied upto 5 standard or are illiterate (fig 1). majority (95%) live in a kuchcha house. 32% of patients were farmers, 23% were housewives and 12% were labourers. most of them (84.2%) had no co morbidities but among the rest a signicant number of patients (6.6%) had diabetes mellitus. majority 67 out of 76 had a history of incomplete atd intake (88.2%). figure 1. distribution of age group in mdr and xdr tb patients table 1: psychiatric disorders in patients receiving treatment for dr tb table 2: action taken for patients having psychiatric disorders after receiving dr tb treatment discussion the present study has found that the second line anti-tb drugs are prone to produce adverse drug reactions in almost every patient. in the later phase many patients suffered from psychiatric disorders. in our study psychosis was detected in 6 some patients whereas in the study by hire et al psychosis was 7reported in fewer patients and in the study by dela ai psychosis was reported in more patients. ndtable 2: comparison of various studies related to adrs of 2 line anti tubercular drugs cycloserine was replaced with pas in a number of patients. there are several possible explanations for the differences in the number of patients requiring drugs to be replaced from the regimen. these include genetic and phenotypic differences of the patients of eastern india as well as variation in ability of the health care workers to detect adrs and provide management. the major strength of the study was complete follow up of the patients for a long duration. the study also utilized the standard tools like who-uppsala monitoring center tool for causality assessment which is simple and widely used worldwide. however, there were few weaknesses in the study. these include limited sample size, no formal sample size preestimation and possibility of under-reporting of psychiatric disorders. conclusions adverse drug reactions are common ndings with second line anti tb drugs. almost all major systems are affected by the adrs due to these drugs though the large proportion is nonserious and self limiting. psychiatric disorders usually cluster around later phase of treatment. patients with low bmi are more prone to develop psychiatric disorders. on replacement volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra names of adrs our study (n=76) (%) rohan hire et al (central india, 7n=110) % dela ai (gujarat, india 8n=72) % psychosis 10.5 4.5 14.38 of cycloserine with pas most of the patients overcame the psychiatric disorders. however, there is need for further studies to explore the serious psychiatric disorders and validation of the present ndings in larger sample population. references 1. t. taivainen, m. tuominen, and p. h. rosenberg, “spread of spinal anaesthesia using various doses of plain 0.5% bupivacaine injected at the liv-v interspace,” acta anaesthesiologica scandinavica, vol. 33, no. 8, pp. 652–655, 1989. 2. p. vichitvejpaisal, o. svastdi-xuto, and s. udompunturux, “a comparative study of isobaric and hyperbaric solution of bupivacaine for spinal anaesthesia in caesarean section,” journal of the medical association of thailand, vol. 75, no. 5, pp. 278–282, 1992. 3. n. solakovic, “comparison of hemodynamic effects of hyperbaric and isobaric bupivacaine in spinal anesthesia,” medicinski arhiv, vol. 64, no. 1, pp. 11–14, 2010. 4. r. martin, c. frigon, a. chrétien, and j.-p. tétrault, “onset of spinal block is more rapid with isobaric than hyperbaric bupivacaine,” canadian journal of anaesthesia, vol. 47, no. 1, pp. 43–46, 2000. 5. h.-k. king, “spinal anesthesia for cesarean section: isobaric versus hyperbaric solution,” acta anaesthesiologica sinica, vol. 37, no. 2, pp. 61–64, 1999. 6. a. jankowska and y. veillette, “comparison of differential blockade during spinal anesthesia using isobaric vs hyperbaric lidocaine 2%,” canadian journal of anaesthesia, vol. 47, no. 2, pp. 137–142, 2000. 7. n. solakovic, “level of sensory block and baricity of bupivacaine 0.5% in spinal anesthesia,” medicinski arhiv, vol. 64, no. 3, pp. 158–160, 2010. 8. a. c. p. lui, t. z. polis, and n. j. cicutti, “densities of cerebrospinal uid and spinal anaesthetic solutions in surgical patients at body temperature,” canadian journal of anaesthesia, vol. 45, no. 4, pp. 297–303, 1998. 9. g. hocking and j. a. w. wildsmith, “intrathecal drug spread,” british journal of anaesthesia, vol. 93, no. 4, pp. 568–578, 2004. 10. m. g. richardson and r. n. wissler, “density of lumbar cerebrospinal uid in pregnant and nonpregnant humans,” anesthesiology, vol. 85, no. 2, pp. 326–330, 1996. 11. e. kalso, m. tuominen, and p. h. rosenberg, “effect of posture and some c.s.f. characteristics on spinal anaesthesia with isobaric 0.5% bupivacaine,” british journal of anaesthesia, vol. 54, no. 11, pp. 1179–1184, 1982. 12. j.m. malinovsky, g. renaud, p. le corre et al., “intrathecal bupivacaine in humans: inuence of volume and baricity of solutions,” anesthesiology, vol. 91, no. 5, pp. 1260–1266, 1999. 13. m. p. vercauteren, h. c. coppejans, v. l. hoffmann, v. saldien, and h. a. adriaensen, “small-dose hyperbaric versus plain bupivacaine during spinal anesthesia for cesarean section,” anesthesia and analgesia, vol. 86, no. 5, pp. 989–993, 1998. 14. b. gunaydin and e. d. tan, “intrathecal hyperbaric or isobaric bupivacaine and ropivacaine with fentanyl for elective caesarean section,” journal of maternal-fetal and neonatal medicine, vol. 23, no. 12, pp. 1481–1486, 2010. x 5gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: after a baby is born and the umbilical cord is cut, some blood remains in the blood vessels of the placenta and the portion of the umbilical cord that remains attached to it. after birth, the baby no longer needs this extra blood. this blood is called placental blood or umbilical cord blood. umbilical cord blood has been found to be a rich source of life saving haematopoietic stem cells. stem cell therapy – the emerging therapy refers to the therapy wherein a damaged tissue that cannot heal itself is repaired by the use of stem cell. cord blood is more like a 'biological future health insurance' for the newborn baby and its future offsprings and siblings. stem cells from cord blood are discarded everyday in all maternity hospitals as a bio-medical waste; however this precious source can give a renewed hope to many and prove to be a life 1saver. umbilical cord blood can be collected without risk to the mother or infant donor. stem cell therapy in the coming decades may provide solutions to incurable ailments and severe injuries. over 400,000 cord blood units are stored for use in more than 100 quality controlled public international 2, 3, 4 cord blood banks. currently 134 private cord blood banks 5world wide are known to store more than 780,000 units. there are two types of cord blood bank public cord blood bank and private cord blood bank. at present there are 14 approved umbilical cord blood (ucb) banks operating in the country. most of these are in the private sector and 4 in public sector. since the rst successful umbilical cord blood transplant in 1988, it has been estimated that more than 35,000 transplants have been performed in children and adults for the correction of inborn metabolism, hematopoietic malignancies and 6, 7 genetic disorders of the blood and immune system. diseases like leukemia, metabolic disorders and immune deciencies etc have been successfully treated with umbilical cord blood transplantation. further stem cell breakthrough is expected to promote effective low cost treatment for diseases like 8 diabetes, stroke, spinal cord damage etc. at present, in india there are over 30 clinical trials that use umbilical cord stem cell therapy. these trials were approved based on the positive outcomes of the previous phases. some of the clinical trials were focused on neurological medical conditions include autism, cerebral palsy, spinal cord problems, hearing loss and hypoxic ischaemic encephalopathy, autoimmune disorder such as multiple sclerosis, diabetes, rheumatoid arthritis etc., myocardial infarction, inherited or acquired disorders such as hiv, thalassaemia, sickle cell, scid etc. that 9require gene therapy and orthopaedic disorders. with approximately 72000 births daily, resulting in discarding of 72000 umbilical cords a day, the storage of stem cell rich blood derived from these umbilical cords can prove to be the 8 best possible insurance against life threatening diseases. the studies have shown that, though most women want to do the best for their children, they lack information on the benet of umbilical cord blood collection and banking. so encouragement during antenatal period is very important. so, it was decided to conduct a study to assess effect of awareness programme on knowledge regarding collection of cord blood and stem cell among antenatal women. materials and methods: type of study: this is an one group pretest posttest descriptive cross-sectional study. place of study: the study has been conducted at antenatal opd of nrs medical college & hospital, kolkata, west bengal. sample size: thirty ve antenatal women attending antenatal opd of n.r.s medical college & hospital. sampling technique: systematic random sampling technique was used to select antenatal women. variables under study: independent variable was awareness programmme regarding collection of cord blood and stem cell. dependent variable was knowledge among antenatal women regarding collection of cord blood and stem cell. demographic variables were age, education, occupation, monthly family income, number of pregnancy, number of live births, place of living, type of family, knowledge from any media regarding collection of cord blood and stem cell. effect of awareness programme on knowledge regarding collection of cord blood and stem cell among antenatal women in a selected hospital, kolkata, west bengal original research paper rituparna sahoo msc, nursing superintendent, tapan sinha memorial hospital, metro railway, kolkata x 33gjra global journal for research analysis nursing hypothesis: mean post test knowledge score is different than mean pre test knowledge score of antenatal women regarding the collection of cord blood and stem cell at 0.05 level of signicance. introduction: awareness programmes are conducted mainly to raise knowledge of the people. knowledge is power and a weapon to tackle an adverse situation and promote health in the desirable direction. this may be true in cord blood and stem cell collection where practice can be more to do better for the society. objectives: this study was conducted to assess the effect of awareness programme on knowledge regarding collection of cord blood and stem cell among antenatal women. materials and methods: thirty ve antenatal women were selected for awareness programme. it was passed through pre test and post test design with systematic random sampling technique. results: the result revealed that the mean post test knowledge score (13.9) was signicantly higher than mean pretest knowledge score (7.54). the computed “t value” 20 (“t”=2.032 at df = 34 at 0.05 level of signicance) was statistically signicant. there was signicant association between the knowledge of mothers and education at 0.05 level of signicance. conclusion: awareness programme was effective. abstract keywords : antenatal women, awareness programme, cord blood and stem cell kamalika das principal nursing ofcer, nursing training school, college of medicine and sagore dutta hospital das palash* md, associate professor, department of community medicine, college of medicine and sagore dutta hospital, kolkata *corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 34 x gjra global journal for research analysis the symbolic representation of the research keys : k1 knowledge test to assess the knowledge of antenatal women regarding collection of cord blood and stem cell before giving awareness programme. k2 knowledge test to assess the knowledge of antenatal women regarding collection of cord blood and stem cell after giving awareness program. a intervention means administration of awareness program to antenatal women regarding collection of cord blood and stem cell. the sample was the antenatal women attending antenatal opd of selected hospital. inclusion criteria: antenatal women, irrespective of gestational age of attending antenatal opd, of the selected hospital, who are willing to participate in the study and who are available at the time of study were included in the study. exclusion criteria: antenatal women who were seriously ill and who cannot understand bengali and/or english and women who are not available at the time of study were excluded. interviewing was used as data collection technique. the interview proforma was predesigned, pretested and semistructured schedule for the data collection related to demographic characteristic and general information. statistical analysis: after collection of data the statistical analysis has been done by applying t-test and chi square test. t test was being used to analyse the data collected before and after intervention with awareness programme. the chisquare test was used to analyse the collected demographic data to nd out the association between demographic data with the pre-test knowledge score of the group. result: total thirty ve antenatal women participated in the study. age, occupation, number of live births, place of living, type of family and information from media source regarding collection of cord blood and stem cell were observed. table 1: frequency and percentage distribution of samples related to age, occupation, number of live births, place of living, type of family and information from media source regarding collection of cord blood and stem cell n = 35 table 2: distribution of mean, mean difference, sd, independent t value of pre-test and post-test knowledge score of group n= 35 t= 2.032, df = 34, p < 0.05* the mean post test knowledge score was signicantly higher than mean pre test knowledge score with t value 18.93 for 34 degree of freedom at the 0.05 level of signicance which is suggestive of effectiveness of awareness programme. table 3: association between pre-test knowledge level of antenatal women regarding collection of cord blood and stem cell and selected variables. n = 35 2 table value: χ = 3.84, df = 1, p > 0.05, *p < 0.05 there was no signicant association between pre test knowledge score and selected variables (age, number of pregnancy, number of live births and type of family). there was signicant association between pre test knowledge score and education of women. discussion: so many studies were conducted in international, national & state level in relation to issues like collection of card blood & stem cell among antenatal women. in this study it was depicted that awareness progrmme remained effective for enhancing the knowledge level among the antenatal women on collection of card blood and stem cells. mean post test knowledge score was signicantly higher ( t value 18.93 for 34 df at .05 level of signicance). and it was also revealed in the study that there was no such signicant association between the pretest knowledge score and selected variables other than educational level of women. in an exploratory study by tiwari n, turbekhar r, girishankar 10n, on perception of ucb banking amongst youth in india in the year 2016 it was found that more than 50% of sample populations were unaware regarding ucb banking and present study result was also showing the majority (74.29%) of mother had poor knowledge level regarding this issue. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra sample characteristics frequency percentage 1.age (years) 18-25 26-33 24 11 68.57 31.43 2. occupation housewife housemaid business 28 4 3 80.00 11.43 8.57 3. no. of live births 0 1 >1 21 10 4 60.00 28.57 11.43 4. place of living rural urban 13 22 37.14 62.86 5. type of family nuclear joint 21 14 60.00 40.00 6. information from media source regarding collection of cord blood and stem cell no yes 31 4 88.57 11.43 group test mean mean difference median sd paired t value antenatal women pre test post test 7.46 13.74 6.36 7 14 1.93 1.75 18.93* variable chisquare value p value signicance at 0.05 level age (years) 18-25 26-33 education up to secondary hs and above no of pregnancy primigravida multigravida no of live births 0 ≥1 type of family nuclear joint 0.006 5.424* 1.230 0.972 0.020 0.940 0.020 0.280 0.320 0.890 not signicant signicant not signicant not signicant not signicant 11another national level study by pandey d, kaur s, kamath a in the year 2016 titled as “banking umbilical cord blood (ucb) stem cells awareness, attitude and expectations of potential donors from one of the largest potential repository (india)” was conducted where it concluded that obstetricians should play an active role in spreading information about umbilical cord stem cell banking among pregnant women and their family members. the current study failed to elicit the role of doctors. 12an experimental study was conducted at tamil nadu by edwin francis c, deenajothy r, hemamalini m on effectiveness of structural teaching programme (stp) on knowledge regarding stem cell and cord blood banking among antenatal mothers. it depicted like present study that the stp was effective motivational way for the antenatal mother to enhance their knowledge about cord blood collection and banking strategy. their study results indirectly supported present study results. there is a quasi–experimental study which was conducted by 13hend ma and harem fm at riyadh, kingdom of saudi arab on effect of educational intervention on knowledge and attitude of nursing students regarding stem cells therapy. the mean post test knowledge score was higher than the mean pre test knowledge score like present study. another national level study conducted at sri manakula vinayagar medical college hospital, puduchery (sep 2015 to 14dec 2015) by poomalar gk, jayasree m, on awareness of cord blood banking among pregnant women in semi urban area. in that study there was signicant association between age and educational status of the respondents. in the present study there is also signicant association between pre test knowledge score and educational level of the respondents (pregnant women). conclusion: it could be presumed that awareness programme on collection of cord blood and stem cell was effective as it enhances the knowledge of antenatal women.the awareness programme on collection of cord blood and stem cell among antenatal women could be used as an effective teaching strategy to improve knowledge and willingness to donate umbilical cord blood. it is the right of the people to be aware of the treatment modalities and the risks versus benets of new treatment modalities like stem cell therapy. implication: the nding of the present study can be applicable in various areas of nursing education like nursing practice, nursing classroom session, administration and research in health. recommendation: to achieve signicant result similar study can be conducted on perinatal care providers especially nurses and midwives and obstetricians who should have sufcient level of education to explain and provide necessary information to pregnant women and awareness programmes need to be arranged by govt. to increase knowledge of people. the clinicians, policy maker have to take the responsibilities to create awareness among public. different print and electronic media can be used to get effect. continuous education modules can be introduced for updating the knowledge of the caregivers. these upcoming technologies need to be a part of the curriculum of the medical graduates. references: 1. nietfeld jj, pasquini mc, logan br, verter f, horowitz mm. lifetime probabilities of hematopoietic stem cell transplantation in the us. biology of blood and marrow transplantation. 2008 mar 31;14(3):316-22. 2. lauber s, latta m, kluter h, muller-steinhardt m. the mannhein cord blood bank: experiences and perspectives for the future. transfuse made hemother. 2010;37:90-7 3. navarrete c, contreas m. cord blood banking. a historical perspective. br j haematol. 2009;147:236-45. 4. garcia j. allogenic unrelated cord blood banking worldwide: an update. transfuse apher sci. 2010;42:257-63. 5. ballen kk, barker jn, stewart sk, greene mf, lane ta. collection and preservation of cord blood for personal use. biol blood marrow transplant. 2008;14:356-63. 6. g ballen kk, gluckman e, broxmeyer he. umbilical cord blood transplantation : the rst 25 years and beyond. blood 2013;122:491-8 7. munoz j, shah n, rezvani k, hosing c, bollard cm, oran b, et al. concise review : umbilical cord blood transplantation: past, present and future. stem cells transl med 2014; 3:1435-43. 8. dastur, a.; umblical cord blood banking, journal of obstetrics and gynecology of india, vol. 55, no. 6, nov/dec 2005, pg. 502-504. 9. alan trounson, courtney mcdonald. stem cell therapies in clinical trials: progress and challenges. cell stem. july, 2015, 11-22. 10. tiwari n, tiwari a, turbekhar r, girishankar n. perception of ucb banking amongst youth in india. imperial journal of interdisciplinary research. 2016 sep 1;2(10). 11. pandey d, kaur s, kamath a. banking umbilical cord blood (ucb) stem cells: awareness, attitude and expectations of potential donors from one of the largest potential repository (india). plos one. 2016 may 26;11(5):e0155782. 12. edwin francis c, deenajothy r, hemamalini m, immanuel dt. effectiveness of structured teaching programme on knowledge regarding stem cells and cord blood banking among antenatal mothers at mogappair, chennai. 13. hend m. azzazy (1,2) and hanem f. mohamed effect of educational intervention on knowledge and attitude of nursing students regarding stem cells therapy iosr journal of nursing and health science (iosr-jnhs) ,(mar. apr. 2016), pp 75-80 www.iosrjournals.org. 14. poomalar gk, jayasree m. awareness of cord blood banking among pregnant women in semi urban area. international journal of reproduction, contraception, obstetrics and gynecology. 2016 x 35gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction acute kidney injury (aki), previously known as acute renal failure, is characterized by the sudden impairment of kidney function resulting in the retention of nitrogenous and other [1]waste products normally cleared by the kidneys . aki is current dene by a rise from base line of s.creatnine of at least 0.3mg/dl within 48 hrs or at least 50% higher than baseline within 1 week, or a reduction in urine output to less than 0.5ml / kg/hr for longer than 6 hrs. acute kidney injury (aki) is a common complication in hospitalized patients. with the changing denition, the [2]epidemiology of aki has changed . aki, particularly in hospitalized patients, is associated with signicant morbidity and mortality. however, most epidemiologic studies on aki were compartmentalized into 2 entities: [3](i) hospital-acquired aki (haaki) and [4](ii) community-acquired aki (caaki) . the acute kidney injury (aki) incidence in icu patients varies widely from 3% to 30%, with mortality ranging from 36% to 90%, depending on the type of icu, study population, the period during which the study is conducted, and the criteria used to dene aki. rifle classication scheme and acute kidney injury network (akin) classication scheme have been proposed to achieve early diagnosis of aki. a new consensus denition merging the criteria has also emerged from the kidney disease [5]improving global outcomes . in 2007, the acute kidney injury network (akin) group pro p a study of acute kidney injury in critically ill medical and surgical patients in bundelkhand region original research paper dr. n.s. sengar professor, department of nephrology, m.l.b. medical college, jhansi dr. sudhir kumar professor and head, department of plastic surgery, m.l.b. medical college, jhansi general medicine introduction: acute kidney injury (aki), previously known as acute renal failure, is characterized by the sudden impairment of kidney function resulting in the retention of nitrogenous and other waste products normally cleared by the kidneys. the acute kidney injury (aki) incidence in icu patients varies widely from 3% to 30%, with mortality ranging from 36% to 90%, depending on the type of icu, study population, the period during which the study is conducted, and the criteria used to dene aki.the present study was undertaken to study the clinical prole of aki prospectively in various medical and surgical intensive care units in our hospital—a tertiary care center in north india. aims and objectives: to assess the incidence of aki among critically ill patients,determine the prevalence of aki in intensive care unit patients,characterize differences in etiology and severity of aki and to determine the impact of aki on patients outcomes alongwith a comparative study to know the epidemiological and clinical proles of aki in surgical & medical icu units. materials and methods: the study included a total of 170 patients and was carried out in the department of general medicine, m.l.b. medical college, jhansi (u.p.) from march. 2018 to oct. 2019.patients with suspected acute kidney injury (aki) in medical & surgical icu units,staying for a minimum of 48 hrs in icu and with age more than 12 yrs were included in the study while those who remained in the icu for less than 6 hrs,having preexisting end-stage kidney disease on chronic dialysis,with prior renal transplant and who already had developed ckd were excluded. results: a total of 45.29% patients of the total critically ill patients developed aki in our study from akin criteria out of which most of the patients were from medical icu where akin grade iii was the most common grade of aki.age >60, male gender were prevalent in the majority of aki patients and represented 31.17% and 71.43% population respectively. male to female ratio was around 2.5:1.sepsis was the most common cause of aki in the critically ill patients of our study and it was found in 35.06% of the patients which was followed by acute gastroenteritis and various types of poisoning that constituted 18.18% of patients.of the 77 patients developing aki, 40(51.94%) were having qsofa score between 0 to 1 while rest 37(48.06%) were having qsofa score of 2-3.crude mortality rate among patients with aki in our study group was 36.36%%.almost half of the patients having aki (49.35%) were improved.majority of the patients did not require rrt and were treated conservatively. 72.72% of the total patients with aki didn't require any rrt while it was given in 27.28% patients.the patients who received rrt were mostly from medical icus among those who were put on rrt,57.14% expired while 23.81% patients improved.anuria was the commonest factor warranting need of rrt and it was present in 90.48% of those patients while acidosis was present in 76.19% patients. abstract keywords : acute kidney injury, critically ill patients, renal replacement therapy. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. gopambuj singh rathod* junior resident, department of medicine, m.l.b. medical college, jhansi *corresponding author dr. shyam mohan yadav junior resident, department of medicine, m.l.b. medical college, jhansi dr. mohd. imran junior resident, department of medicine, m.l.b. medical college, jhansi 28 x gjra global journal for research analysis osed a modied version of the rifle criteria, which aimed to improve the sensitivity of aki diagnostic criteria. there were several changes: an absolute increase in scr of at least 0.3 mg/dl (26.5 �mol/l) was added to stage 1; the gfr criterion was removed; patients starting rrt were classied as stage 3, [6-7]irrespectively of scr values . depending upon the type of surgical procedure that a patient undergoes, aki complicates the perioperative hospital stay for [8-9]up to 50% of surgical patients . yet aki remains among the most under diagnosed postoperative complications despite increasing understanding of its epidemiology and outcomes. reduced urine output despite adequate uid administration is usually the rst sign of acute renal failure. this will be fol lowed by a r ise in serum creatinine and urea concentrations. early renal support (haemodialysis or haemoltration) will control serum electrolytes and accommodate the large volumes of nutritional supplem en [10]tation required in a major burn . one of the life threatening complications of severe burns is acute renal (kidney) failure (aki). aki is a sudden loss of the kidney's ability to excrete waste, concentrate urine and [11]conserve electrolytes . aki is treated with dialysis. as burns associated with aki will worsen the prognosis, early preventive measures taken to reduce this complication include proper uid replacement, infection prevention, early wound debridement, and excision of dead tissue. there are few comparative studies on hospital-acquired aki (haaki) in medical, surgical, and icu patients. studies on haaki were mostly centered around the critically ill icu patients or only on some specic sub-groups of medical and surgical patients. there are few comparative studies of haaki in medical, surgical, and icu patients. haaki is quite common in this part of the country. therefore, this comparative study was conducted to know the epidemiological and clinical proles of aki in surgical, medical, and icu units at our [2]centre . with the application of these criteria, prevalence of aki in icu setting is >40% if sepsis is present and the mortality rates [13-14]varied from 15% to 60% . longer hospital stay and economic burden are inevitable. in contrast to western literature, few reliable statistics are available regarding aki [15]in india . the last 20 years have seen the major changes in the practice of medicine; a particularly striking development has been arrival of intensive care units (icus). the evolution of the icus has had signicant implications for clinical nephrologists especially in relation to the nature, epidemiology and management of acute renal failure (aki). acute renal failure seen in icu patients population is different from non-icu setting. acute renal failure occurs frequently in the setting of critically ill patients in icu. despite major advances in the management of the critically ill and the renal replacement therapy, the mortality rate of aki has not decreased appreciably over the past 30 years. this seems to be due to the changes inthe spectrum of aki. the pattern of aki varies from place to place. the present study was undertaken to study the clinical prole of aki prospectively in various medical and surgical intensive care units in our hospital—a tertiary care [16]center in north india . aims and objectives ÿ to assess the incidence of aki among critically ill patients. ÿ to determine the prevalence of aki in intensive care unit patients. ÿ to characterize differences in etiology and severity of aki and to determine the impact of aki on patients outcomes. ÿ comparative study to know the epidemiological and clinical proles of aki in surgical & medical icu units. materials and methods the study includes acute kidney injury (aki) in medical and surgical icu patients, m.l.b medical college, jhansi (u.p.). and a total of 170 patients were selected for the study. the study was carried out in the department of general medicine, m.l.b. medical college, jhansi (u.p.) from march. 2018 to oct. 2019. inclusion criteria ÿ patients with suspected acute kidney injury (aki) in medical & surgical icu units. ÿ patients staying for a minimum of 48 hrs in icu. ÿ age of patients more than 12 yrs. exclusion criteria ÿ patients remained in the icu for less than 6 hrs. ÿ patients with preexisting end-stage kidney disease on chronic dialysis. ÿ patients with prior renal transplant. ÿ patients who already have developed ckd. location and period of study the study was carried out in the department of general medicine, m.l.b. medical college, jhansi (u.p.) from march. 2018 to oct. 2019. diagnosis: serum creatinine and urinary output is the key parameter in evaluating both renal function and the patient's circulatory state. in an oliguric state, however, it must be determined whether the reduced urine volume is due to functional renal (or pre-renal) failure or to organic (or renal) failure. prolonged functional renal failure is often observed before organic failure develops. in non-oliguric renal failure, urine volume is of no value in the diagnosis. urine and serum osmolality and electrolyte concentrations are useful in the differential diagnosis. methodology: ÿ a patient was considered to have aki when he had an increase in serum creatinine of at least 50% from baseline or a reduction in urine output to <0.5 ml < kg per hour for more than 6 h. ÿ as suggested by the acute dialysis quality initiative working group , for patients whose preexisting renal function was not known, a normal gfr before admission to icu was assumed. ÿ patients were classied daily using the akin criteria. ÿ patients are considered as having new aki if they did not have aki on icu admission and subsequently reached at least class akin-grade 1 during their follow-up. ÿ deterioration of aki was diagnosed if the patient had increased in akin class compared to the initial classication. ÿ the most severe degree of aki was recorded, that is, patients with injury to the kidney at admission to icu who volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 29gjra global journal for research analysis later developed failure of kidney function were classied as having grade-iii akin. data collection: data were collected including the following: ÿ primary admission diagnostic categories. ÿ co-morbidities. ÿ need for mechanical ventilation. ÿ presence of sepsis ÿ akin grades i,ii and iii. ÿ renal replacement therapy for aki. ÿ emergency surgery; elective surgery; and nonsurgical admission. ÿ icu stay. ÿ mortality. statistical analysis: categorical variables are presented as number (frequency) and analyzed using chi-square or fischer exact test where appropriate test. student's t-test or the mann–whitney u-test is used for quantitative data. all variables signicant in univariate analysis were analyzed by a multiple regression logistic model. the logistic regression forward method was used for multivariate analysis of the risk factors, and the results were tabulated as odds ratio and condence interval. the level of signicance was set at p < 0.05. the relationships between different factors and mortality were evaluated using a cox proportional hazards model, and survival curves were constructed. variables with p < 0.05 were included in the model. the software spss v15.0 for windows was used for statistical analysis. results the present study was carried out on 170 cases in the department of medicine, m.l.b. medical college, jhansi (u.p.) from march. 2018 to oct. 2019. in this study we studied 170 patients of suspected acute kidney injury and assessed the incidence of acute kidney injury in such patients and various factors related to this disorder. table 1: incidence of aki in study population (from akin criteria) out of total 170 patients, 77 patients developed aki that made 45.29% of the total. table 2: severity of aki with akin scoring (on the basis of creatinine) out of 77 patients who developed aki, 25 patients (32.47%) had grade-i, 10 patients (12.99%) had grade-ii and 42 patients (54.54%) had grade-iii acute kidney injury. table 3: age wise distribution of patients having aki (akin criteria) out of total 77 patients who developed aki according to akin criteria, patients with age >60 were most common and constituted 31.17% while the 2nd most common age group was between 46-60 yrs in which 20 patients developed aki that was 25.97% of the total. the least common group consisted of the patients having age between 31-45 yrs where a total of 16 patients developed aki that constituted 20.78%. table 4: distribution of patients having aki according to their sex. ( akin criteria) patients were divided on the basis of their sexes. there were 109 males (64.11%) and rest 61 were females (35.88%). of the 77 patients developing aki,55 were males that made 71.43% while rest 22 were females that was 28.57%. table 5: distribution according to qsofa score. on the basis of qsofa score, patients were put into two categories. 1st category with qsofa 0-1 had 115 patients (67.65%) while the 2nd category with qsofa 2-3 had 55 patients (32.35%). of the 77 patients developing aki, 40(51.94%) were having q sofa score between 0 to 1 while rest 37(48.06%) were having qsofa score of 2-3 and this difference was statistically signicant (p-value : 0.018). table 6: distribution of total patients on the basis of outcome patients were divided on the basis of their outcomes. out of 170 patients, 124 patients (72.94%) were improved, 35(20.59%) were expired, 9 patients(5.29%) were left against medical advice and 2 were referred(1.18%). 38 patients (49.35%) who developed aki were improved, 28(36.36%) were expired and 9 (11.69%)left against the medical advised while 2 patients(2.60%) were referred and this difference was statistically signicant (p-value : 0.004). table 7: electrolyte abnormalities hyponatremia was the most common electrolyte abnormality in patients with aki which was present in 25 (32.47%) patients followed by hypokalemia which was present in 20 (25.97%) pat ients and minimum pat ients were found wi th volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra total patients aki patients % 170 77 45.29% grade no. of patients % grade-i 25 32.47% grade-ii 10 12.99% grade-iii 42 54.54% total 77 100 age (years) no. of patients percentage 18-30 17 22.08% 31-45 16 20.78% 46-60 20 25.97% > 60 24 31.17% total 77 100% sex no. of patients (total) % no. of patients (aki) % male 109 64.11% 55 71.43% female 61 35.88% 22 28.57% total 170 100 77 100% qsofa score total no. of patients % no. of patients having aki % 0 – 1 115 67.65% 40 51.94% 2 – 3 55 32.35% 37 48.06% total 170 100 77 100 outcome total no. of patients % no. of patients having aki % improved 124 72.94% 38 49.35% expired 35 20.59% 28 36.36% lama 9 5.29% 9 11.69% referred 2 1.18% 2 2.60% total 170 100% 77 100 electrolyte abnormalities patients with electrolyte abnormalities without aki (n=93) % patients with electrolyte abnormalities (n=77) % hyponatremia (< 135) 13 13.98% 25 32.47% hypernatremia (>150) 5 5.38% 3 3.90% hypokalemia (< 3.5) 5 5.38% 20 25.97% hyperkalemia (> 5) 6 6.45% 1 1.30% 30 x gjra global journal for research analysis hyperkalemia is 1 (1.30%). for hyponatremia (< 135) and hyp okalemia (<3.5), the data was found statistically signicant i.e. p-value 0.02 and 0.001 respectively. table 8: etiology of aki majority of patients with aki were found having sepsis,27 out of 77 which was 35.06% and 2nd most common cause was acute gastroenteritis and poisoning which was the cause in 14 patients i.e. 18.18% and lowest patients were found having aki due to malaria i.e. 1 patient(1.30%). study was found significant for acute gastroenteritis, sepsis and obstructive uropathy with p-values <0.05 for each of them. table 9: department wise distribution aki patients. out of 77 patients who developed aki, 55 were from medical icu (71.43%) and rest 22 (28.57%) were from surgical icu. table 10: need for renal replacement therapy in aki patients out of 77 patients who developed aki, in 21 (27.27%) patients rrt was done while in 56 (72.73%) rrt was not used and they were managed conservatively, when compared to the group where aki was not found, study was found statistically signicant with p-value < 0.01. table 11: presence of causative factors in patients under went rrt out of 21 patients, who underwent rrt, anuria 19 (90.48%) was the most common factor followed by acidosis 16 (76.19%). table 12: outcome of patients on rrt out of 21 patients, who underwent rrt, 5 (23.81%) were impr oved, 12 were expired and 4 (19.05%) left against medical advice. discussion the present study was carried out on 170 cases in the department of medicine, m.l.b. medical college, jhansi (u.p.) from march. 2018 to oct. 2019. in this study we studied 170 patients of suspected acute kidney injury and assessed the incidence of acute kidney injury in such patients and various factors related to this disorder. in a large multinational cross-sectional study where the epidemiology of aki in icu patients was explored it was found that aki occurred in more than half of the patients, precisely in 57.3%.( hoste, e.a.j.et al (2015). other studies evaluated incidences of aki in critically ill patients and found proportions varying from 29% to 77% using akin denition. in our study the incidence of aki using akin denition was found in 45.29% patients. out of all the patients who developed aki on the basis of akin, most were from grade-iii. this might be due to the fact that our hospital is a tertiary referral center where most of the referred patients presented in more severe [17]stages of renal injury . in another study, data from 582 critically ill patients were collected and retrospectively reviewed. patients were divided into two groups: without aki development and with aki development. baseline characteristics, laboratory, and other clinical data were compared between these two groups, and correlations between the characteristics and aki development were examined. patients with aki development were further divided into two groups according to the survival outcome, and variables associated with the outcome were determined. results: aki was developed in 54.12% (n = 315) of patients. [18](de-yuan zhi et al, china, 2017) in our study aki was more common in males (71.43%) than in females while it was more common in individuals with age more than 60 years (31.17%). a prospective observational [19]study by korula s et al in 2016 had mean age of 59.17±14.01 and males were 64.3%. in another study of aki, the mean age was 60 years and 63% of patients were male. (incidence, timing and outcome of aki in critically ill patients varies with the denition used and the addition of urine output criteria j. [20]koeze et al 2017 ) a study based in united kingdom showed 16% of the aki patients were older than 65 years while a study in united states showed that 12.4% of the patients were above the age of 65. in accordance with previous literature, our study highlights the potential risk of aki in critically ill, elderly patients especially above the age of 60 years. several large scale studies conducted world-wide have established that aki in critically ill patients is associated with statistically signicant increase in mortality. sepsis was the most common cause of aki in the critically ill patients of our study and it was found in 35.06% of the patients which was followed by acute gastroenteritis and various types of poisoning that constituted 18.18% of patients. the role of sepsis in aki has been well documented in western literature, causing nearly 50% of the aki cases in few studies. a recent indian study by singh et al.found that although nephrotoxic drugs were the most common cause of aki in the medical ward, sepsis was the most common cause in surgical ward and icu. a study by sandeep et al.,., which evaluated acute renal failure in icu, found sepsis to be more common than nephrotoxic drugs. kaul et al.,., in their study have reported acute diarrhea as the most common cause. acute ge was the second most common cause of aki in our study. the higher number might be attributed to the fact that our institution is a tertiary care center, managing patients referred after developing renal complications. [21]a study conducted by rubina naqvi et al 2017 on acute volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra etiology variables no. of patients with aki % no. of patients with without aki % p-value age 14 18.18% 34 36.56% 0.045 sepsis 27 35.06% 16 17.20% 0.040 poisoning 14 18.18% 10 10.75% >0.05 obstructive uropathy 4 5.19% 16 17.20% 0.030 burn 3 3.90% 8 8.60% >0.05 cellulitis 7 9.09% 4 4.30% >0.05 heart failure 5 6.49% 2 2.15% >0.05 acute pancreatitis 2 2.60% 2 2.15% >0.05 malaria 1 1.30% 1 1.08% >0.05 total 77 100% 93 100% aki patients no. of patients (n=77) % medical icu (n=117) 55 71.43 surgical icu (n=53) 22 28.57 total 77 100 aki patients no. of patients (n=77) % rrt done 21 27.27% rrt not done 56 72.73% total 77 100% aki patients no. of patients (n=21) % anuria 19 90.48% oliguria 2 9.52% acidosis 16 76.19% hyperkalemia 2 9.52% aki patients no. of patients (n=21) % improved 5 23.81% expired 12 57.14% lama 4 19.05% total 21 100% x 31gjra global journal for research analysis kidney injury from different poisonous substances. in our study we divided the whole study population on the basis of qsofa score. most of the patients with suspected aki had qsofa score less than 2(67.65%). the same trend continued in patients with conrmed aki also where more than half of the patients (51.94%) had qsofa score less than 2. protocol for a prospective observational study on the association of variables obtained by contrast-enhanced ultrasonography and sepsis-associated acute kidney injury [22]by ning liu et al., in 2017 . the importance of acute kidney injury in suspected community acquired infection by james tollitt et al., in 2019 also correlated q sofa score with acute kidney injury. in our study there were four outcomes of the patients. most of the patients who developed aki were improved (49.35%)and ndthe 2 most common outcome was death as 36.36% patients expired during the icu stay. outcome of critically ill patients with acute kidney injury using the akin criteria by tal [23]mandelbaum, et al in 2011 showed a clear and signicant increase in the risk for mortality in patients who developed acute kidney injury compared with patients who did not. the increased risk was found to be proportional to the stage of aki although there is no clear risk difference between the patients with aki 1 and aki 2 compared to a large increase in mortality risk in patients with aki 3. epidemiology and outcomes of acute kidney injury in critically ill: experience from a tertiary [24]care center by ps priyamvada et al 2018 showed that in the initial 48 h, 12 patients (5.08%) recovered from aki. of 126 patients with caaki, 26.98% (n = 34) showed complete recovery (cr) at the end of the 30 days, whereas 16.67% (n = 21) showed partial recovery (pr). among 110 patients with haaki, 32.73% (n = 36) had cr and 18.18% (n = 20) had pr. one patient continued to remain dialysis-dependent at the st [25]end of the 1 month. joaniddis et al in their study of icu patients showed that the mortality rate among patients classied to have aki by rifle criteria was 36.5%.] in the study by ali et al., involving 474 patients with aki, the in hospital mortality was found to be 32.7%. however, this study involved aki patients irrespective of the hospital setting. two indian studies, one using rifle criteria and other using akin criteria to diagnose aki patients in icu, found the mortality rate to be as high as 73.5% (n = 25) and 93.9% (n = 31) respectively. from the total study population 38.82% patients had hypoalbuminemia while the same trend continued for patients with aki where 45.15% patients had hypoalbuminemia. seventeen clinical studies with 3,917 total patients were included: 11 studies (6 in surgical or intensive care unit patients and 5 in other hospital settings) evaluating the inuence of serum albumin on aki incidence and 6 studies describing the relationship between serum albumin and mortality among patients who had developed aki. lower serum albumin was an independent predictor both of aki and of death after aki development. (christian j. wiedermann et [26]al , 2009) another study proved hypoalbuminemia as a predictor of acute kidney injury (daniele roberto giacobbe et [27]al 2018). in our study, majority of the patients did not require rrt and were treated conservatively. 72.72% of the total patients with aki didn't require any rrt while it was given in 27.28% patients. the patients who received rrt were mostly from medical icus among those who were put on rrt,57.14% expired while 23.81% patients improved. anuria was the commonest factor warranting need of rrt and it was present in 90.48% of those patients while acidosis was present in [2]76.19% patients. previous indian studies by j prakash et al and singh et al., reported that 34% (n = 28) and 20.58% (n = 7) of the cases respectively, required rrt. however, these studies did not specically evaluate aki patients in icu but studied them irrespective of the hospital setting. intermittent hemodialysis and slow low efciency dialysis were the most commonly used modalities of rrt in our hospital. mahajan et [28]al who evaluated arf in icu, reported that 71.1% required rrt and that intermittent rrt was the most common mode used. in our study, although the mortality rate was higher among [29]patients receiving rrt (57.14%). chertow et al previously demonstrated that among critically ill patients, acute renal failure requiring dialysis is an ominous condition with a high risk of in-hospital mortality. conclusions the present study was carried out on 170 cases in the department of medicine, m.l.b. medical college, jhansi (u.p.) from march. 2018 to oct. 2019.. in this study we studied 170 patients of suspected acute kidney injury and assessed the incidence of acute kidney injury in such patients and various factors related to this disorder. ÿ a total of 45.29% patients of the total critically ill patients developed aki in our study from akin criteria. in akin, 54.54% were grade-iii. ÿ most of the patients were from medical icu where akin grade iii was the most common grade of aki. ÿ age >60, male gender were prevalent in the majority of aki patients and represented 31.17% and 71.43% population respectively. male to female ratio was around 2.5:1. ÿ sepsis was the most common cause of aki in the critically ill patients of our study and it was found in 35.06% of the patients which was followed by acute gastroenteritis and various types of poisoning that constituted 18.18% of patients. ÿ of the 77 patients developing aki, 40(51.94%) were having qsofa score between 0 to 1 while rest 37 (48.06%) were having qsofa score of 2-3. ÿ crude mortality rate among patients with aki in our study group was 36.36%%. ÿ almost half of the patients having aki (49.35%) were improved. ÿ hyponatremia was the most common electrolyte abnor mality in aki in our study population with 32.47% develo ping it while 20 patients developed hypokalemia which was 25.97% ÿ majority of the patients did not require rrt and were treated conservatively. 72.72% of the total patients with aki didn't require any rrt while it was given in 27.28% patients.the patients who received rrt were mostly from medical icus among those who were put on rrt,57.14% expired while 23.81% patients improved. ÿ anuria was the commonest factor warranting need of rrt and it was present in 90.48% of those patients while acidosis was present in 76.19% patients. ÿ leucocytosis was found in around 84.42% patients while 44.15% patients had hypoalbunimeia and 72.73% patients had acidosis. limitations and the final words: our study has both strengths and weakness. a limitation of our study was that we could not nd the incidence of aki in the patients who have already developed chronic kidney disease. there were many patients in whom 48 hr creatinine level could not be obtained and they couldn't be categorized according to akin grading. few patients went against the medical advise and couldn't be studied till their nal outcome. our centre being a major tertiary care hospital in bunde lkh and region,it caters to a large population. with the help of our study we can focus on the major cause that predispose to a volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 32 x gjra global journal for research analysis patient to aki like sepsis, acute gastroenteritis, poisoning, cellulitis etc. and timely intervention in these causative factors can prevent the occurrence of aki. references: 1. sushrut s. waikar; joseph v. bonventre.334: acute kidney injury 2. t. b. singh, s. s. rathore, t. a. choudhury, v. k. shukla,1 d. k. singh,2 and j. prakash.hospital-acquired acute kidney injury in medical, surgical, and intensive care unit: a comparative study.indian j nephrol. 2013 jan-feb; 23(1): 24–29. 3. brivet fg, kleinknecht dj, loirat p, landais pj. acute renal failure in intensive care units–causes, outcome, and prognostic factors of hospital mortality; a prospective, multicenter study. french study group on acute renal failure. crit care med. 1996;24:192–8. 4. hou sh, bushinsky da, wish jb, cohen jj, harrington jt. hospital-acquired renal insufciency: a prospective study. am j med. 1983;74:243–8. 5. cruz dn, bolgan i, perazella ma, bonello m, de cal m, corradi v, et al. north east italian prospective hospital renal outcome survey on acute kidney injury (neiphros-aki): targeting the problem with the rifle criteria. clin j am soc nephrol. 2007;2:418–25. 6. bellomo r, ronco c, kellum ja, mehta rl, palevsky p, acute dialysis quality initiative workgroup acute renal failure denition, outcome measures, animal models, uid therapy and information technology needs: the second international consensus conference of the acute dialysis quality initiative (adqi) group. crit care. 2004;8:r204–12. 7. mehta rl, kellum ja, shah sv, molitoris ba, ronco c, warnock dg, et al. acute kidney injury network acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. crit care. 2007;11:r31. 8. hobson c, ozrazgat-baslanti t, kuxhausen a, et al. cost and morality associated with postoperative acute kidney injury. ann surg. 2014 9. bihorac a, delano mj, schold jd, et al. incidence, clinical predictors, genomics, and outcome of acute kidney injury among trauma patients. ann surg. 2010;252:158–65. 10. ansermino m, hemsley c. intensive care management and control of infection in burned patients. bmj. 2004;329:220–3. 11. robert w. schrier, wei wang, brian poole, and amit mitra.acute renal failure: denitions, diagnosis, pathogenesis, and therap.j clin invest. 2004 jul 1; 114(1): 5–14. 12. bagshaw sm, george c, bellomo r anzics database management committee. early acute kidney injury and sepsis: a multicentre evaluation. crit care. 2008;12:r47. 13. kellum ja, bellomo r, ronco c. denition and classication of acute kidney injury. nephron clin pract. 2008;109:c182–7. 14. sakhuja v, sud k. acute renal failure in the tropics. saudi j kidney dis transpl. 1998;9:247–60. 15. sakhuja v, sud k. acute renal failure in the tropics. saudi j kidney dis transpl. 1998;9:247–60. 16. gurcharan avasthi, m.d.,1 jasvinder singh sandhu, d.m.,2,* and kavita mohindra, m.d.1.acute renal failure in medical and surgical intensive care units—a one year prospective study.renal failure vol. 25, no. 1, pp. 105–113, 2003 17. hoste ea1, bagshaw sm, bellomo r, cely cm, colman r, cruz dn, edipidis k, forni lg, gomersall cd, govil d, honoré pm, joannes-boyau o, joannidis m, korhonen am, lavrentieva a, mehta rl, palevsky p, roessler e, ronco c, uchino s, vazquez ja, vidal andrade e, webb s, kellum ja..epidemiology of acute kidney injury in critically ill patients: the multinational aki-epi study.intensive care med. 2015 aug;41(8):1411-23. doi: 10.1007/s00134-0153934-7. epub 2015 jul 11. 18. zhi dy, lin j, zhuang hz, dong l, ji xj, guo dc, yang xw, liu s, yue z, yu sj, duan ml. acute kidney injury in critically ill patients with sepsis: clinical characteristics and outcomes. j invest surg. 2019 dec;32(8):689-696. doi: 10.1080/08941939.2018.1453891. epub 2018 apr 25. pubmed pmid: 29693474. 19. korula s, balakrishnan s, sundar s, paul v, balagopal a. acute kidney injuryincidence, prognostic factors, and outcome of patients in an intensive care unit in a tertiary center: a prospective observational study. indian j crit care med 2016;20:332-6. 20. koeze et al.,. incidence, timing and outcome of aki in critically ill patients varies with the denition used and the addition of urine output criteria. bmc nephrology (2017) 18:70 21. rubina naqvi.acute kidney injury from different poisonous substances.world j nephrol. 2017 may 6; 6(3): 162–167. 22. ning liu zhongheng zhang, yucai hong ,bing li.protocol for a prospective observational study on the association of variables obtained by contrastenhanced ultrasonography and sepsis-associated acute kidney injury.article (pdf available) in bmj open 9(7):e023981 • july 2019 23. tal mandelbaum, md,1,2 daniel j scott, phd,2 joon lee, phd,2 roger g. mark, md phd,2 atul malhotra, md,3 sushrut s. waikar, md mph,4 michael d. howell, md mph,5 and daniel talmor, md mph1.outcome of critically ill patients with acute kidney injury using the akin criteria.crit care med. author manuscript; available in pmc 2012 dec 1. 24. p. s. priyamvada, r. jayasurya, vijay shankar, and s. parameswaran. epide miology and outcomes of acute kidney injury in critically ill: experience from a tertiary care center.indian j nephrol. 2018 nov-dec; 28(6): 413–420. 25. joannidis m, metnitz b, bauer p, schusterschitz n, moreno r, druml w, metnitz pg. acute kidney injury in critically ill patients classied by akin versus rifle using the saps 3 database. intensive care med. 2009 oct;35(10):1692-702. doi: 10.1007/s00134-009-1530-4. epub 2009 jun 23. pubmed pmid: 19547955. 26. wiedermann cj, wiedermann w, joannidis m. causal relationship between hypoalbuminemia and acute kidney injury. world j nephrol. 2017 jul 6;6(4):176-187. doi: 10.5527/wjn.v6.i4.176. review. pubmed pmid: 28729966; pubmed central pmcid: pmc5500455. 27. daniele roberto giacobbe.hypoalbuminemia as a predictor of acute kidney injury during colistin treatment.article open access published: 10 august 2018. 28. mahajan s, tiwari s, bharani r, bhowmik d, ravi s, agarwal sk, et al. spectrum of acute renal failure and factors predicting its outcome in an intensive care unit in india. ren fail. 2006;28:119–24. 29. chertow gm, christiansen cl, cleary pd, munro c, lazarus jm. prognostic stratication in critically ill patients with acute renal failure requiring dialysis. arch intern med. 1995;155:1505–11. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 33gjra global journal for research analysis introductionthe incidence of post-operative pulmonary complications (ppc) in patients undergoing abdominal surgery is variable owing to the presence of different risk factors. it is reported to range from 5 to 30% (1,2). type of operation, type and duration of anaesthesia, age, pulmonary disease and smoking have been identied as main predictors of ppc. ppcs are the leading cause of postoperative morbidity and mortality and increase hospital length of stay, medical consumption, and hence costs. to counter the complications many interventions such as deep breathing exercises (dbe), incentive spirometry (is) and early ambulation have been considered, though the results of studies incorporating such techniques have been conicting. in the present medical scenario, there is a need for a uniform criteria for establishing the presence� of pulmonary complications and for describing postoperative therapeutic regimens. the objective of the present study was to elucidate the incidence of, risk factors for, and preventive measures for ppcs after emergency laparotomy. aims & objectives1. to determine incidence of ppc following emergency laparotomy 2. to determine methods to reduce the complications material & methodsa prospective hospital based study carried out over a period of 1yr (june 2018-june 2019) including 50 patients who underwent emergency exploratory laparotomy for various reasons. all patients were given general anaesthesia. duration of the hospital stay and of the post-operative hospital stay were recorded. all patients were followed up in the surgical ward. post-extubation, patients were ambulated within 24hours and chest physiotherapy, along with incentive spirometry was started within 12hrs. a daily assessment of the respiratory conditions was made until discharge according to a standardized protocol, which included clinical examination and oxy-haemoglobin saturation monitoring by a pulse oximeter. pneumonia, pneumothorax and pleural effusion were diagnosed on a clinical and radiological basis. respiratory failure was considered in the presence of abnormalities of pulmonary gas exchanges as reected by an increase higher than 4 kpa of pa–ao associated with a 2 persistent decrease, longer than 2 days, in oxyhaemoglobin saturation lower than 90% on room air. assisted ventilation via an endotracheal tube and monitoring in a high dependency area were needed when respiratory failure was not relieved by oxygen and medical therapy. resultsof the 50 patients, 28 (56%) were male and 22 (34% ) were female. mean age was 42 +/2.5 years. table 1 shows the frequency of complications in each agegroup. table 2 shows the various diagnosis at exploration and number of patients with ppc table 3 shows type of ppc and frequency post-operative pulmonary complications in cases of emergency exploratory laparotomy original research paper dr. apoorva sharma mbbs pg resident, dept of general surgery, smt kashibai navale medical college & general hospital, pune-411041, maharashtra, india general surgery the frequency of post-operative pulmonary complications (ppcs) after emergency laparotomies are incompletely understood. these are associated with increased morbidity and mortality, thereby leading to poorer outcomes. ppcs combine infectious causes like pneumonia, respiratory failure, along with acute exacerbations of pulmonary diseases. the commonest cause for development of ppcs is the length of the incision taken at time of surgery and the time lag between patient mobilization and extubation. abstract keywords : ppc, emergency, laparotomy, pneumonia volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. snehal nachiket purandare* mbbs, ms-general surgery professor, dept of general surgery, smt kashibai navale medical college & general hospital, pune-411041, maharashtra, india *corresponding author age group (in years) number of patients frequency of complications 20-30 6 1 31-40 14 8 41-50 14 7 51-60 10 7 61-70 6 4 diagnosis at surgery freque ncy frequency of patients with ppc hollow viscus perforation 29 16 bowel obstruction 15 8 solid organ injury 1 mesenteric ischemia 1 1 volvulus 4 3 pulmonary complications frequency notes basal atelectasis 10 1. most common 2. 48-72hrs post extubation pneumonia 2 pleural effusion 8 therapeutic tap, if symptomatic 60 x gjra global journal for research analysis discussionwe found an overall incidence of 53% ppc. upper abdominal incisions, old age, pre-existing cardiac or respiratory illnesses were independent risk factors for development of ppcs.smetana et al. [ 3 ] reviewed the literature on frequency and risk factors for ppcs after non cardiothoracic surgery spanning the years 1980–2005. nine papers focused on laparotomies [ 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12, 13 ],and ppcs ranged from 0.9 to 69.5%.a prospective cohort study published in 1997 not included in the review of smetana et al. [ 3 ] included 400 patients and reported a ppc frequency of 22.5%[ 4 ] laparotomy reduces diaphragmatic function via reex inhibition of phrenic nerve output, during the rst postoperative week [ 14 ]. atelectasis and pneumonia are promoted by rapid-shallow breathing due to the impairment of diaphragmatic function. the primary aim of respiratory exercises is to increase expiratory lung volume, particularly functional residual capacity. hence patients are asked to inate their lungs maximally to sustain that ination. this is achieved with incentive spirometrywhich has shown signicant results in reduction of ppc. there are many studies, like those by thorren et al, morran et al, and warren, have all shown a ppc rate of 12% , 27%, 12% in patients who were given postoperative chest physiotherapy, which is less than half, when compared with the patients who were not given chest physiotherapy following abdominal surgery. whether incentive spirometry or chest physiotherapy is better to prevent ppcis a topic for discussion. conclusionpost-operative pulmonary complications are common following emergency laparotomies, its incidence can be reduced by chest physiotherapy, incentive spirometry. references1. brooks brunn ja. postoperative atelectasis and pneumonia. heart lung 1995;24:94-115. 2. hayden sp, mayer me, stoller jk. postoperative pulmonary complications: risk assessment, prevention, and treatment. cleve clin j med 1995;62:401-7. 3. smetana gw, lawrence va, cornell je: preoperative pulmonary risk strati cation for noncardiothoracicsurgery:systematic review for the american college of physicians. ann intern med 2006;144:581–595 4. brooks-brunn ja: predictors of postoperative pulmonary complications following abdominal surgery. chest 1997;111:564–571. 5. fogh j, willie-jørgensen p, brynjolf i, et al: the predictive value of preoperative perfusion/ventilation scintigraphy, spirometry and x-ray of the lungs on postoperative pulmonary complications. a prospective study. acta anaesthesiolscand 1987;31:717–721. 6. jørgensen fs, sørensen cg, kjaergaard j: postoperative fever after major abdominal surgery. ann chirgynaecol 1988;77:47–50. 7. mellors jw, kelly jj, gusberg rj, et al: a simple index to estimate the likelihood of bacterial infection in patients developing fever after abdominal surgery. am surg 1988;54:558–564. 8. nielsen ph, jepsen sb, olsen ad: postoperative pleural e usion following upper abdominal surgery. chest 1989;96:1133–1135. 9. ejlertsen t, nielsen ph, jepsen s, et al: early diagnosis of postoperative pneumonia following upper abdominal surgery. a study in patients without cardiopulmonary disorder at operation. acta chirscand 1989;155:93–98. 10. hall jc, tarala ra, hall jl, et al: a multivariate analysis of the risk of pulmonary complications after laparotomy. chest 1991;99:923–927. 11. dilworth jp, white rj, brown em: oropharyngeal ora and chest infection after upper abdominal surgery. thorax 1991;46:165–167. 12. lawrence va, hilsenbeck sg, mulrow cd, et al: incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. j gen intern med 1995;10:671–678. 13. kocabas a, kara k, ozgur g, et al: value of preoperative spirometry to predict postoperative pulmonary complications. respir med 1996;90:25–33. 14. ford gt, rosenal tw, clergue f, et al: respiratory physiology in upper abdominal surgery. clin chest med 1993;14:237–252. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra ventilator associated pneumonia 4 1. old age 2. three patients of volvulus 3. one patient of prepyloric perforation acute respiratory distress syndrome 2 1. re-intubated 2. succumbed x 61gjra global journal for research analysis introduction: rhinitis caseosa is a chronic inammatory condition of the nose due to obstruction of nasal passage, all major sinuses due to stenosis or adhesions or synechiae leading to stagnation of secretions and constant exfoliation of nasal mucosa collected together to undergo chemical changes and putrefaction resulting in the formation of caseous material in nasal cavity. it is associated with sinusitis, foreign body , fungal infection , tb , syphillis, polyp degeneration. fungal sinusitis is a distinct clinical entity characterized by inammation of the sinus mucosa caused by fungal infection like aspergillus (fumigatus, niger, avus), mucormycosis, candida (albicans), scedosporium, pencillium. there are different types of fungal sinusitis: fungal mycetoma, allergic fungal, chronic indolent and fulminant sinusitis. allergic fungal rhinosinusitis is the most common entity. aspergillosis is the most common fungal infection. of these aspergillus fumigatus is the most common fungal pathogen. maxillary sinuses are commonly involved. case report: a 68 years old male presented to opd with left sided nasal obstruction, nasal discharge and anosmia, for 4 months. on examination: ÿ anterior rhinoscopy – dns-right, foul smelling cheesy material lling left nasal cavity associated with blood stained discharge. ÿ lt maxillary region – tenderness + diagnostic nasal endoscopy: right -dns with spur, accessory ostium leftfoul smelling cheesy material lling left nasal cavity associated with blood stained discharge, polypoidal middle turbinate and pale greyish glistening mass seen in middle meatus fig1: foul smelling cheesy material seen lling left nasal cavity ct pns: fig2: erosion of bony part of posterior nasal septum noted with atrophy of inferior turbinate fig3: soft tissue density lesion noted completely lling left maxillary , frontal and ethmoidal sinuses extending through left maxillary ostium into left nasal cavity with few air pockets.sclerosis of left maxillary sinus ÿ no evidence of intracranial / intraorbital extension. surgical management: ÿ the aim of surgery was to remove oedematous mucosa and caseous debris, establish sinus aeration ÿ patient underwent microdebrider assisted polypectomy with fess under ga. the maxillary sinus l was found to be lled with cheesy material which was removed after middle meatal antrostomy.the walls of the maxillary sinus was found to be intact. and specimen sent for histopathological examination , koh mount. a rare case of rhinitis caseosa and fungal sinusitis original research paper dr. m. k. rajasekar professor dept of ent, sree balaji medical college, chennai ent rhinitis caseosa also called as nasal cholesteastoma is a misnomer. the essential criteria for diagnosing rhinitis caseosa are -1) nasal polyp and offensive purulent discharge and cheesy material ; 2) clinical or radiological evidence of bony expansion of the sinus walls and 3) demonstration of heterogenous opacication of the paranasal sinuses with areas of hyper-attenuation. fungal sinusitis is a distinct clinical entity characterized by inammation of the sinus mucosa caused by fungal infection like aspergillus, mucormycosis, candida, scedosporium, pencillium. we hereby present a case of 68 years old male presented to opd with left sided nasal obstruction, nasal discharge and anosmia, for 4 months. patient was evaluated and underwent microdebrider assisted polypectomy with fess. early recognition and prompt initiation of combined medical treatment and surgical intervention done to prevent its aggressive nature and propensity for orbital and intracranial extension. abstract keywords : rhinitis caseosa,nasal cholesteastoma,fungal sinusitis dr. sridhara narayanan* professor dept of ent, sree balaji medical college, chennai *corresponding author dr. shaheera junior resident dept of ent, sree balaji medical college, chennai volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 108 x gjra global journal for research analysis disease was evident as hypertrophic mucosa or polyp in the sinonasal cavities surrounding necrotic avascular, caseous, greenish-green casts. the ethmoids and septum were involved in the caseous process. these caseous casts were removed fig.4.cheesy material taken for hp,koh fig.5.left middle meatal antrostomy done ÿ koh mount: fungal elements seen. ÿ hp report: multiple sections show oedematous respiratory epithelium.the underlying edematous tissue shows lobules of mucous glands and granulation tissue with foci showing fragments of fungal colonies enclosing dichotomously acute angle branching septate fungal laments .histologically squamous elements could not be identied in them – suggestive of aspergillus fungal lesion and nasal cholesteastoma. ÿ ct scan and nasal endoscopes increased the awareness to this disease spectrum. the diagnosis was based on an otolaryngological, imagistic but histopathological examination suggestive of fungal lesion make the certain diagnostic in this case. discussion: duplay coined the term rhinitis caseosa. a most exhaustive review is to be found by eggston and wolff (1947). they concluded rhinitis caseosa to be a secondary condition which could be consequent to any primary pathology causing an obstruction to the discharge of secretions from the para-nasal sinuses. their studies revealed that in patients with extensive bilateral ethmoidal polyposis this condition is more common. accumulation of secretions in the nasal cavity is due to the presence of polyp which causes obstruction to the normal drainage mechanism of paranasal sinuses. yellow-brown, cheesy, "caseous" material were found within the nasal cavities of these patients behind the nasal polypi. subsequent reports have since emphasized the bony expansion and erosion of the sinus walls (seeb, 1977), and also the extensions into the orbit and the cranial cavity (ladagao, 1979; wolfowitz, 1973).dne done to see the presence of cheesy foul smelling material in the nasal cavity . ct pns is indicated if there is suspected bony erosion in xray pns.if not treated it can lead to orbital and intracranial complications.removal of cheesy material and obstructed lesion is corrected surgically with alkaline douching for 3 weeks and oral penicillin antibiotic for one week. fungal sinusitis is classied into invasive and non invasive. invasive fungal sinusitis is classied into acute invasive fulminant fungal sinusitis and chronic or indolent invasive fungal sinusitis and are characterized by black necrotic turbinate, dark, thick, greasy material found in the sinuses. invasive infections can cause tissue invasion and destruction of adjacent structures (eg, orbit, cns).patient is immunoco mpromised in invasive fungal sinusitis. noninvasive fungal sinusitis is classied into sinus mycetoma, afrs and saprophytic colonization.most common fungus seen in non invasive (fungal ball) is aspergillus fumigatus, its otherwise known as aspergilloma. most common sinus invoved is maxillary sinus.patient is immunocompetent and there is no reaction to fungus..ct pns done reveals heterogenous opacication associated with bony thickening or sclerosis of sinus walls involved and its conrmed by hp.surgical removal of fungal ball is required and antifungal therapy is not required conclusion: our purpose was to emphasize the need of early recognition and prompt initiation of combined medical treatment and surgical intervention with the intent to preserve the involved vital structures its aggressive nature and and to prevent propensity for orbital and intracranial extension ÿ surgery aims at clearing the sinus and establishing aeration. the prognosis is excellent provided aeration and drainage of sinuses can be maintained ÿ adjuvant steroids local and systemic have been advocated for fungal sinusitis in order to reduce recurrences. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 109gjra global journal for research analysis aims and objectives the purpose of this study is to review the incidence of various orbital and ocular tumors, age and sex distribution, the speci�c imaging characteristics which aid in diagnosis and correlation with the histopathological diagnosis. 1. to identify the commonly occurring orbital and ocular tumors. 2. to formulate an appropriate imaging protocol for patients with orbital tumors. 3. to study the imaging characteristics of various tumors and delineation of tumor extent with respect to the surrounding structures. 4. to correlate the mri diagnosis with the histopathological diagnosis. pathophysiology of the orbit a variety of tumors are found in the tumors; however it is important to distinguish vascular lesions. vascular disorders of the orbit encompass vascular malformations and vascular tumors. capillary hemangioma veno-lymphatic malformations (lymphangiomas) choroidal hemangiomas cavernous hemangioma retinoblastoma hemangiopericytoma orbital schwannoma rhabdomyosarcoma optic nerve glioma optic nerve sheath meningioma orbital pseudo tumor lacrimal gland tumors benign mixed tumor of the lacrimal gland adenoid cystic carcinoma lymphoma leukemia metastasis materials and methods the present study included total 50 patients referred for orbital imaging. they underwent magnetic resonance imaging of the orbit in the department of radio diagnosis in a 2900 bed tertiary referral centre from december 2017 to september 2018. selection of patients: the patients selected were either upon having referred from the ophthalmology or neurosurgery out-patient departments or wards with strong clinical suspicion of orbital tumors or preliminary ct revealing a mass in the orbital region. among 72 patients with such a strong clinical suspicion, 50 patients turned out to have a diagnosis of orbital tumors and were included in the study. exclusion criteria: ÿ the patients who were already operated for orbital tumors and referred for follow up study. ÿ patients who are not willing to undergo mri examination. ÿ patients with general contraindications for mri, such as having any of the following: cardiac pacemakers, cochlear implants, aneurysm clips and mri incompatible orthopedic implants as well as claustrophobic patients. instrumentation: mr imaging was done on a 1.5 tesla, mr achieva , phillips. a standard head coil was used for the examination. patient preparation: ÿ no speci�c preparation was required before the scans. ÿ few uncooperative patients were sedated before the examination. ÿ all the patients were given instructions to remove all metallic belongings prior to the examination. mri protocol: precontrast mri evaluation of orbital tumours original research paper dr. prajwaleet gour (prof.) government medical college, nagpur , maharastra radiodiagnosis the orbit and the visual system form the most important sense organ in humans. multiple disease entities affect the orbit, viz. congenital, in�ammatory, infectious, vascular and traumatic. the clinical manifestations and �ndings are often non-speci�c, being protean and overlapping. of these various pathologies, tumors are an important cause of mortality and especially, morbidity. plain radiographs permit the separation of the two attenuation values as bone and soft tissue. sonography may be helpful in speci�c cases, but has many drawbacks and limitations with high operator dependence. computed tomography may allow separation of the air, fat, �uid, soft tissue and bone. direct axial and coronal imaging is also possible. in many cases, however it is limited by artifacts from bone. magnetic resonance imaging is non-ionizing, avoids harmful radiation to the lens. excellent soft tissue details and multi-planar imaging is feasible. bony artifacts are not seen and vessels can be identi�ed by the contained �ow void. in our present study, we have evaluated 50 patients with suspected orbital tumors. an attempt has been made to devise an optimum imaging protocol in a given group of disorders. it also compares the reliability of magnetic resonance imaging in diagnosis by comparing it with histopathological diagnosis. abstract keywords : dr. abhisek jaiswal* government medical college, nagpur, maharastra *corresponding author sequence slice thickness mm interslice gap(mm) no.of acquisitions fov (cm) matrix coronalt1 fat sat 3 0.1 3 17 256 x256 t1 axial 2 0.1 4 17 256 x256 pdt2 oblique sagittal 3 0.1 3 17 256 x256 coronal t2 stir 3 0.1 3 17 256 x256 coronal t2w* (gradient) 3 0.1 3 17 256 x256 postcontrast t1fs sagittal 3 0.1 3 17 256 x256 postcontrast t1fs coronal 3 0.1 3 17 256 x256 post contrast t1 fs axial 2 0.1 4 17 256 x256 40 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 first the standard axial flair brain screening with slice thickness 5mm was performed. after this, high resolution t1se and t2se sequences focussed on the orbital region are performed in all cases, using following parameters. routine t1fs post contrast axial sequence of the brain was also (slice thickness 5mm) performed in all cases. additional sequences: the gradient sequence was used for evaluation of foci of hemorrhage and calci�cation. additionally pd t2 axial sequence with a small fov was taken along with or instead pd t2 oblique sagittal wherever they would give a better anatomical delineation. clinical profile : symptoms of a space occupying lesions were noted such as proptosis, pain and reduced motility of the eye. visual symptoms like dimunition of vision, blurring of vision, transient loss of vision and �ashes of light. whether in�ammatory symptoms like fever, pain, chemosis and lacrimation of the eye were present. mri interpretation: mri was interpreted for the following: presence of a space occupying lesions: 1) size of lesion: ÿ small (largest diameter less than 2 cm) ÿ medium (largest diameter between 2 to 4cm) ÿ large (largest diameter more than 4 cm) 2) morphology and shape of lesion: ÿ well de�ned ÿ ill de�ned ÿ round, oval, fusiform, conical, dumb bell shaped or irregular. 3) location of the lesion ÿ intra conal ÿ extra conal ÿ both intra as well as extra conal ÿ intra ocular ÿ intra cranial extension ÿ quadrant of the lesion ÿ superior, lateral, inferior or medial 4) signal intensity characteristics: compared to the extra ocular muscles of the orbit on t1w, t2w, stir and t1w fat sat sequences. ÿ isointense. ÿ hypo intense. ÿ hyperintense. ÿ heterogeneous. 5) contrast enhancement: ÿ homogenous. ÿ inhomogeneous ÿ mild ÿ intense. 6) flow voids or septae in the lesion. 7) involvement of the extra ocular muscles. 8) hemorrhage/ calci�cation within the tumor. 9) intracranial extension 10) bony erosion or destruction. 11) mass effect and displacement / indentation on the globe 12) associated retinal detachment or optic atrophy mri diagnosis was correlated with histopathological diagnosis given from the pathology department in our hospital results age distribution: the youngest patient was a 4 months male child while the eldest was a 75 year old man. maximum no. of patients were in 41to 50 years age group (24%) table 1age distribution in orbital tumors. chart 1age distribution in orbital tumors sex distribution : table 2sex distribution in orbital tumors. chart 2sex distribution in orbital tumors. distribution of pathologies in orbital tumors table 3-distribution of orbital tumors age distribution(years) no. of cases(total no. 50) percentage 0-10 6 12 11-20 7 14 21-30 7 14 31-40 5 10 41-50 12 24 51-60 8 16 >60 5 10 sex no. of cases (n=50) percentage male 30 60 female 20 40 sr. no. pathology no. of cases(n=50) percentage 1 pseudotumor 10 20 2 cavernous hemangioma 8 16 3 lymphoma 11 22 4 retinoblastoma 4 8 5 optic nerve glioma 3 6 6 meningioma 4 8 7 dermoid 1 1 8 melanoma 2 4 9 lymphangioma 1 2 10 hemangiopericytoma 1 2 11 schwannoma 1 2 12 pleomorphic adenoma 1 2 13 metastases 2 4 14 others 1 2 x 41gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 chart 3-distribution of orbital tumors table 4 mri and histopathological correlation: table 5 sensitivity and speci�city for the commonest 5 pathologies table 6 common clinical symptoms in orbital tumors chart 4 common clinical symptoms in orbital tumors table 7 location of the lesions chart 5 location of the lesions chart 6 benign vs malignant table – 8 distribution of pediatric orbital tumors chart 7distribution of pediatric orbital tumors chart 8 sex distribution in pseudotumors sr. no. histopathological diagnosis no. mri diagnosis no. 1 pseudotumors 10 pseudotumor lymphoma 7 3 2 cavernous hemangioma 8 cavernous hemangioma lymphangioma 7 1 3 lymphoma 11 lymphoma pseudotumor 8 3 4 retinoblastoma 4 retinoblastoma dermoid cyst 3 1 5 meningioma 4 meningioma 4 6 optic nerve glioma 3 optic nerve glioma 3 7 melanoma 2 melanoma 2 8 metastasis 2 metastasis 2 9 pleomorphic adenoma 1 pleomorphic adenoma 1 10 schwannoma 1 schwannoma 1 11 dermoid 1 dermoid 1 12 lymphangioma 1 lymphangioma 1 13 hemangiopericytoma 1 meningioma 1 14 others adenosquamous ca 1 squamous cell carcinoma 1 tumor sensitivity speci�city pseudotumor 70% 92.5% lymphoma 72.7% 92.31% cavernous hemangioma 87.5% 100% retinoblastoma 75% 100% optic nerve sheath meningioma 100% 100% symptoms no. of cases percentage % visual disturbances 21 42 proptosis 19 38 in�ammatory symptoms 10 20 reduced extra ocular motility 10 20 pain 8 16 constitutional symptoms 7 14 location no. of cases percentage % intra conal 11 22 extra conal 18 36 both 14 28 intra ocular 7 14 intracranial extension 10 20 tumor no. of cases percentage retinoblastoma 4/9 44.4% optic nerve glioma 3/9 33.3% pseudotumor 1/9 11.1% hemangioma 1/9 11.1% 42 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 chart 9 sex distribution in lymphomas chart 10 age distribution in pseudo tumor and lymphoma patients table 9 incidence of in�ammatory symptoms in pseudotumors chart 11 location of pseudo tumors chart 12 location of lymphomas chart 13 – bilaterality of lymphomas table 10 t2 weighted signal intensity of pseudotumor and lymphoma table 11 sensitivity and speci�city of t2w hyperintensity to fat of lymphoma thus, sensitivity and speci�city of t2w hyperintensity in differentiating between lymphoma and pseudo tumor is 81.8% and 80% respectively. table 12 comparison of t1w and t2w signal intensity in lymphoma and pseudotumor cavernous hemangioma: table 13 -age distribution of cavernous hemangiomas: cavernous hemangiomas: male vs female distribution table 14 – gender distribution in cavernous hemangiomas chart 14 gender distribution in cavernous hemangiomas chart 15 location of cavernous hemangioma in�ammatory symptoms pseudo tumors other diagnoses sensitivity speci�city yes 6 4 60% 90% no 4 36 tumor t2w si compared to muscles t2w si compared to fat isointense hyperintense isointense hyperintense pseudo tumor (n = 10) 8 (80%) 2 (20%) 8 (80%) 2 (20%) lymphoma (n = 11) 10 (90.9%) 1 (9.1%) 2 (18.1%) 9 (81.9%) tumor t2w hyperintensity t2w isointensity lymphoma 9 2 pseudotumor 2 8 signal intensity t1wi > t2wi t1wi < t2wi lesion pseudotumor 2 9 lymphoma 1 9 age distribution(years) no. of cases(total no. 8) percentage 0-10 0 0 11-20 2 25 21-30 2 25 31-40 1 12.5 41-50 3 37.5 51-60 0 0 >60y 0 0 sex no. of cases(total no. 8) percentage male 5 62.5 female 3 375 x 43gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 table 15 characteristics of hemangioma chart 16 characteristics of hemangioma chart 17 bilaterality of retinoblastomas table 16 growth pattern of retinoblastoma table 17 other characteristics of retinoblastoma table 18 t2w signal intensity of the most common orbital tumors discussion the present study was undertaken with the aim of evaluating mri �ndings in orbital tumors and the diagnostic accuracy of mri in characterization and diagnosis of the same. this was done by correlating mri �ndings with histopathological diagnosis. 72 patients who were having strong clinical complaints and preliminary ct was showing abnormality were evaluated. of these 4 patients turned out to have non-neoplastic lesions and were excluded from the study. of the remaining 68 patients, histopathological con�rmations were not obtained in 18 patients and were hence excluded from the study. data from the remaining 50 patients was obtained and used for the study. the patients belonged to all age groups ranging from 4 months to 75 years. however, the majority of the patients (about 40 %) belonged to the �fth and sixth decade of life. the sex ratio in our 5study was 1:1.5 with a male preponderance. ohtsuka et al (1981) in, their retrospective study of 244 orbital tumors encountered the mean age of patients to be 48.7 years. they however found a female preponderance of 0.8:1. this could be possibly due to a larger sample size or epidemiological differences. among the clinical symptoms, visual disturbances (42%) and proptosis (38%) were most common, followed by reduced motility (20%), in�ammatory symptoms (acute pain and chemosis) (20%), pain (16%) and constitutional symptoms (weight loss, cachexia) (14%). regarding location of the lesions in the orbit, purely intra conal lesions were limited to 11 accounting for 22% while extra conal or mixed extra conal and intra conal lesions accounted for 64% with 514% being intra ocular. ohtsuka et al , also found majority of lesions to be extra conal with 85% being extraconal and 15% intraconal. in our study, 34% of the lesions were malignant while 66% were benign whereas in the study of 1264 by shields consecutive patients 4et al , the percentage of benign lesions was 36% and malignant 64%. however their study included all consecutive patients referred over the course of 3 decades to an ocular oncology service; hence there is some amount of referral bias in their study. the sample size of their study was also much larger. the most common diagnoses in their study were: lymphoid tumor (11%), idiopathic orbital in�ammation (11%), cavernous hemangioma (6%), lymphangioma (4%), meningioma (4%), optic nerve glioma (4%), metastatic breast cancer (4%) and uveal melanoma (3%). in our study the most common diagnoses were lymphoma (22%), pseudotumor (20%), hemangioma (16%), meningioma (8%), retinoblastoma (8%), optic nerve sheath (6%), metastases (4%) and uveal melanoma (4%). among the intra ocular lesions, retinoblastoma was the commonest 4 cases (59%) followed by uveal melanoma 2 cases (28.5%) and metastasis 1 case (14.2%). in the paediatric age group out of 9 cases, there were 4 patients with retinoblastoma (44.4%), 3 patients with optic nerve glioma (33.3%), 1 hemangioma (11.1 %) and 1 pseudo tumor (11.1%). benign lesions (55.6%) were thus more common than malignant (44.4%). johnson 125et al in a study of 141 children with orbital tumors also found retinoblastoma (32%) to be the commonest tumor in children followed by vasculogenic tumors (22%) there were a few shortcomings in our study. the sample size of 50 cases might be a small size for comparing the incidence of various tumors in the general population. a single case of lacrimal gland pleomorphic adenoma and orbital schwannoma may not represent the true incidence of these cases. similarly there was a single case of dermoid, lymphangioma, and no case of capillary hemangioma and rhabdomyosarcoma. this could be explained partly by the problems with sedation of pediatric patients. in addition to this ct is advised rather than mri for cases like rhabdomyosarcoma and orbital metastases in neuroblastoma and hence these cases do not �gure in our study. finally in a number of cases histopathological diagnosis could not be obtained as surgery or biopsy was not considered necessary and follow up of the patients was advised. hence some cases of capillary and cavernous hemangioma could not be histopathologically proven and were not included in the study. in some cases of pseudo tumor where biopsy was not performed, regression of the tumor on steroids was considered to be diagnostic and these lesions were included. orbital pseudo tumors and lymphoproliferative disorders in our study of the 50 cases, 10 cases were diagnosed histopathological ly as pseudotumors and 11 cases as lymphoproliferative disorders. although pseudotumors usually present with proptosis and in�ammatory symptoms, in�ammatory characteristics no. of lesions percentage t2w hyperintensity 6 75% internal septations 4 50% blooming on gradient (calci�cation) 5 62.5% growth pattern no. of cases percentage exophytic 2 40% endophytic 0 0 both 2 40% indeterminate 1 20% characteristic no. of cases percentage retinal detachment 2 40% vitreous hemorrhage 1 20% optic nerve involved 3 60% pineal lesion 1 20% tumor t2w si compared to muscles isointense hyperintense pseudo tumor (n = 10) 8 (80%) 2 (20%) lymphoma (n = 11) 10 (90.9%) 1 (9.1%) hemangioma (n = 8) 2 (25%) 6 (75%) meningioma (n = 4) 0 4 (100%) 44 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 symptoms may be absent in some cases. clinical and imaging features show overlap with orbital lymphoproliferative disorders, hence it has been included in our study of orbital tumors. of the 10 patients with pseudo tumors, 7 (70%) were male and 3 (30%) were female. only 1 patient (10%) was in the pediatric age group, while majority of the patients were between third and sixth decade (70%). all the cases were unilateral. these results are similar 6to studies performed by j yan et al . clinical symptoms were classi�ed into those due to mass effect including proptosis, blurring of vision and restriction of extra ocular movements and those suggestive of in�ammation which included pain, chemosis and watering of eye. 6 (60%) out of the 10 patients showed signs of in�ammation along with proptosis, while 4 (40%) patients showed only signs of mass effect with no signs of in�ammation. proptosis and motility restriction were the symptoms 6 in majority of the cases in studies conducted by j yan et al and 7gunalp et al . the location of the tumors was as follows: 4 (40%) affected only the extra ocular muscles (�gure 6) i.e. myositis, 3 (30%) diffusely involved the orbit including retro orbital fat, extra and intra conal compartment and prebulbar portions (�gure 5), 2 (20%) presented as focal masses involving both intra conal and extraconal compartments, 2 involved the lacrimal gland (�gure 6) with only 1(10%) affecting purely the lacrimal glands, 1(10%) involved only 6the prebulbar portion. in study by j yan et al , however, focal mass within the orbit was the most frequent subtype (43%), followed by lacrimal in�ammatory pseudotumor (32%), diffuse orbital in�ammation (10%), and myositis (8%). all the tumors appeared isointense with muscles on t1w imaging, while 8 out of 10 (80%) were isointense to fat and muscles on t2w imaging. the intensity of 1(10%) tumor decreased on t2w compared to t1w imaging, rest all were iso-hyper on t2w compared with t1w imaging. enhancement was seen in all the lesions and 80 % enhanced intensely on post contrast fat saturated t1w images. none of the lesions showed bone destruction or intracranial 8extension. in study by cytryn et al , all pseudo tumors were isointense to muscles on t1w imaging, approx 84% of the lesions were isointense to fat on t2w images. only 15% lesions appeared brighter on t1w images than t2w images. all the lesions in their study showed enhancement on post contrast study. similar results 6 were also obtained by j yan et al in their study. of the 11 patients with lymphoma, 6 (54.5%) were male and 5 (45.5%) were female. age of the patients ranged from 30 to 75 years with majority of the patients (8 out of 11 patients i.e. 72.7%) aged thabove the 4 decade (70%) with none of the patients below 30 years. 6j yan et al found a strong male preponderance in their study with 70% of the patients being males. 4 of the 11 cases (32.7%) were bilateral and all the 4 lesions were associated with systemic disease. 617 % of the cases were bilateral in study by j yan et al . 4 (36.3%) out of the 11 patients showed signs of in�ammation along with proptosis, while 7 (73.7%) patients presented with proptosis and diminished vision. thus patients with pseudo tumors are more likely to present with in�ammatory symptoms than patients with lymphoma which is consistent with their �ndings. the location of the tumors was as follows: 4 (36.3%) affected only the extra ocular muscles , 3 (27.2 %) diffusely involved the orbit including retro orbital fat, extra and intra conal compartment and prebulbar portions (�gures 3 & 4), 3 (27.2 %) showed involvement of both intra conal and extraconal compartments, 3 involved the lacrimal gland with only 1(0.9%) affecting only the lacrimal glands. the signal intensities were nonspeci�c with all the tumors appeared isointense with muscles on t1w imaging, while 10 out of 11 (90%) were isointense to muscle on t2w imaging and 9 (81.1%) were hyperintense to fat on t2w imaging. the intensity of 2 (18.1%) tumor decreased on t2w compared to t1w imaging, rest all were iso-hyper on t2w compared with t1w imaging. these �ndings are 6 8similar to those of j yan et al and cytryn et al . enhancement was seen in all the lesions and 6 of the 11 tumors (54.5%) enhanced intensely on post contrast fat saturated t1w images. the histopathological characterization of the lymphoproliferative lesions showed 8 (72.7%) lesions to be malignant and 3 (27.3%) lesions to be benign. of the 8, 5 (45.5%) were b cell lymphomas, 1 (0.9%) was a t cell lymphoma, 2 (18.1%) were plasmacytomas in seropositive patients and 3 (27.3%) were reactive lymphoid proliferation. the distribution is similar to that seen in study by j yan 6et al . intracranial extension and bony changes were seen in 4 out of the 11 patients (i.e. 36.3%). cavernous hemangioma : in the present study, there were 8 cases of cavernous hemangioma constituting about 16% of total tumors in the orbit. out of 8 cases 5 were males and 3 were females so the gender ratio 11was 1.6:1. however data collected by harris gj et al shows that females are more frequently affected than males. this could be due to a small sample size of 8 cases against data collected by them from 66 patients. in our study 4 of the 8 cases were intra conal (�gure 11), while 3 were extra conal (�gure 7); 1 case with a predominantly intra conal lesion with extra conal extension. 7 of the 8 lesions were well-de�ned oval 9to round. in a study of 8 cases by thorn kany et al 7 were well de�ned intra conal lesions. multiple small internal septations were seen in 4 out of the 8 lesions; while foci of blooming were seen on gradient imaging in 5 out of the 8 lesions which were con�rmed as calci�cations on ct (�gure 7). one of the lesions showed multiple t1 hyper intense lesions suggestive of hemorrhage, which prompted a diagnosis of lymphangioma, but histopathological diagnosis was cavernous hemangioma. of the 8 cases, 6 were isointense on t1 weighted images and hyper intense on t2 weighted images with mild to moderate contrast enhancement in all cases. hemangioma was diagnosed in 7 out of 8 cases without dynamic contrast study. retinoblastoma in our study out of 50 cases, there were four cases of retinoblastoma. all were in the �rst decade youngest of age 4 months and oldest of age 6 years. there were three males and one female patient. thus we 12found a sex ratio of 3:1, but in study by graaf et al , they have found a ratio of 1:1; however theirs was a much larger sample of 58 retinoblastomas in 56 eyes. three cases were unilateral while 1 was bilateral i.e. 5 eyes with retinoblastoma were found. 25 % bilateralism was thus found as compared to 32 % in their study. out of the 5, one was an atypical case. of the other 4 cases, 2 showed an exophytic growth pattern and 2 showed both endophytic as well as exophytic growth pattern, a purely endophytic growth pattern was 12not found. graaf et al found 46% to be exophytic, 42% endophytic and 12% to be combined. retinal detachment was seen in 2 out of 5 cases (40%); vitreous hemorrhage was seen only in 1 case (20%). their results showed retinal detachment in 69% and vitreous hemorrhage in 4%. optic nerve involvement was seen in 3 cases out of 5 (60%) comparable to their results (64%). one patient with unilateral retinoblastoma also had a supra sellar mass. signal intensities in 4 out of the 5 cases were typical with t1 hyper intensity and t2 hypo intensity as compared to vitreous (�gure 10). all the lesions showed enhancement on post gadolinium study. in 12study by graaf et al all the cases had typical signal intensity as described above. 1 case was atypical of that of a 4 year female with a large mass in the left eye (�gure 12); the eye globe could not be identi�ed separately. optic nerve involvement was seen. the growth pattern, involvement of choroid, retinal detachment, vitreous hemorrhage x 45gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 could not be therefore commented on. signal intensity was also atypical with isointense on t1 and hyperintense on t2 with hypointense area within with a �uid �uid level was seen. enhancement was seen on post contrast study. such signal 12 14intensities are not seen in studies by graaf et al , scheuler et al and 13barkhof et al . optic nerve sheath meningioma: out of 50 cases, there were 4 optic nerve sheath meningiomas. two of the patients were in their fourth decade, one in third decade and one in seventh decade. there were 3 females and 1 male. the mean age of the patients in a series of 6 patients by castel and de potter et 15 16al was 40 years and in a series of 25 patients by karp et al was 31 years; whereas the sex ratios were 1.2:1 and 5:1 in favor of females respectively. intracranial/ intracanalicular extension was seen in 2 out of 4 patients in our study accounting for 50% and in study by 15castel et al the percentage was same. also all the cases were unilateral. among the symptoms, pain was complained by 3 patients (75 %), decreased vision (100%), proptosis (75 %) and motility loss in 1 patient (25%). disc edema was seen in 2 patients (50%) and disc 15atrophy in 2 patients (50%). in study by castel et al , 50% of the patients presented with pain, 100% with diminished vision and none with proptosis or loss of motility. 50% of the patients had disc edema and 50% had disc pallor. these differences are probably due to larger size of lesions in our cases. all the tumors were isointense on tw1, iso-hyper intense on t2w and showed intense enhancement on post contrast study with the tram track type of enhancement seen in all the patients (�gure 8). 15the �ndings of castel et al were identical. optic nerve glioma: in our study, there were three patients with optic nerve glioma. there were two males and one female. all patients were within the second decade and 2 out of the three patients were under 8 years. 17according to alvord et al , 90% of patients are within the second decade and 50% of the tumors are intra orbital and the rest are intracranial and intra canalicular. in our study, however, all the cases were intra orbital. all the cases presented with changes in visual acuity and proptosis which is again consistent with the �ndings of 17alvord et al . mri �ndings in all the cases were buckling and enlargement of the optic nerve and the tumor appeared isointense on t1w and isohyperintense on t2w images. these �ndings are consistent with 18�ndings of hendrix et al . however in their study, the cases did not show any enhancement on post gadolinium study, while 2 out of the 3 optic gliomas showed enhancement in our study . uveal melanoma we found 2 cases of melanoma, a 55 year old female and a 70 year 19old male. lemke et al in their study of 42 patients with melanoma found a sex ratio of 1.2:1 and mean age 62 years. the typical signal intensities of the melanoma i.e. hyper intense on t1w and hypo intense on t2w images were found in both the patients (figure 13). 19 20these �ndings were endorsed by lemke et al and mafee et al . both the melanomas were seen to be arising posterior to the equator and retinal detachment was seen in both the patients. 19retinal detachment was seen in 93% of cases of lemke et al and 62% melanomas were posterior to the equator. a mushroom shaped mass was seen in 50% of their cases, while 31% had a mound shaped and 19% lesions were �at. both the cases in our study had a mushroom shaped mass. metastases: there were two cases of metastases; one a 60 year old female and other 54 year old female. both were known cases of ca breast. one patient showed diffuse enlargement of the medial rectus muscle which showed typical signal intensity of t1 isointense and t2 hyperintense and intense enhancement on post contrast study 120(�gure 18). holland d et al in their study of 20 patients with metastases to the orbit found mean age of presentation to be 64 years and extra ocular muscle involvement was seen in 35% of their patients with medial and lateral rectus being the most common muscles to be involved. breast was the most common site of primary neoplasm in their study. the other patient had a uveal metastasis with a small lesion in the choroid posteriorly. it appeared isointense to vitreous on t1w and t2w images and showed enhancement on 126post contrast study. jooyong lee et al in their study found lung and breast as the most common site of primary neoplasm in case of uveal metastases. majority of their patients had sub retinal �uid accumulation and location of the lesion in choroid was posterior to the equator in 57% patients. dermoid: we found 1 case of dermoid in the study. it was a 27 year old male patient with extra conal mass anteriorly in the superolateral quadrant. i t was a well de�ned rounded lesion. i t was heterogeneous in signal intensity with a hyper intense area on t1w images which was suppressed on fat saturated t1 and stir images representing fat.mild scalloping of the adjacent bone was seen. this typical location and signal intensity of dermoid have been 127described by kaufman et al in their article. pleomorphic adenoma of the lacrimal gland 1 case of pleomorphic adenoma of lacrimal gland was found. a 52 year old male patient came with history of painless proptosis lobulated extra conal lesion in the lateral quadrant. the lacrimal gland was not seen separately. the lesion was predominantly isointense on t1w and hyper intense on t2w images with intense inhomogeneous enhancement on post contrast study. no bony 128destruction was seen. mafee et al also found that pleomorphic th thadenoma are seen in 4 to 5 decade, are usually painless extraconal lesions which appear iso-hypointense on t1w and hyperintense on t2w images with heterogeneous enhancement and are usually well circumscribed lobulated lesions. hemangiopericytoma: 1 case of hemangiopericytoma was found. a 47 year old male came with a large lesion in the superiolateral quadrant intra conal with extra conal extension. it was isointense on t1w images and isohyper on t2w images with intense enhancement on post contrast study. linear �ow voids were seen in the lesion and adjacent bony destruction with intra cranial extension was also noted (figure 15). these �ndings draw resemblance to the typical features described 129by wendy r. k. smoker et al in their article. lymphangioma: 1 case of lymphangioma was found in the study. an 18 year male came with a large mass lesion occupying the orbit and a large intra 22cranial component. according to kalisa p et al , usually patients are within the second decade of life. it was heterogeneous in signal intensity with areas of hemorrhage and �uid-�uid levels and intense heterogeneous enhancement on post contrast study .bony destruction and extension into the sinonasal cavity was also seen. 21linear �ow voids were also seen. bond jb et al , in a study of 12 patients, found that magnetic resonance imaging delineated clearly the internal structure of subacute and chronic hemorrhagic cysts, and differentiated between these tumors because of the different paramagnetic qualities of subacute hemorrhage compared to chronic hemorrhage. in two patients, mri detected large tumor feeding vessels by the �ow void phenomenon. orbital schwannoma: a 17 year old male patient with history of seizures and headache came for mri. an extra axial dumb bell shaped lesion in the temporal region with an extension into the orbital apex was seen. it was isointense on t1 with a hypo intense area in its center and central hyper intense area on t2 with heterogeneous enhancement on post 23contrast study. wang et al in a study of 62 patients found majority 46 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 of lesions conical in shape (26%) followed by dumb bell shaped lesions (16%). similar signal intensity �ndings were also seen with a central hypo intense area on t1w imaging. adenosquamous carcinoma : a case of 40 year old male with painful proptosis and loss of vision was seen. a large heterogeneous lesion occupying the intraconal and extra conal compartments of the orbit with intracranial extension, involvement of the ipsilateral ethmoid sinuses, bony destruction involving the roof and medial wall and displacement of the globe was seen. extreme stretching of the optic nerve was also seen. calvarial destruction was seen with enhancing soft tissue. the lesion appeared isointense on t1w and t2w images with intense enhancement on post contrast study (figure 16). an area of hemorrhage was also seen within. the histopathological diagnosis came to be adenosquamous carcinoma. a similar aggressive lesion 24was reported by som p et al . a 62-year-old woman had proptosis of the right eye, decreased visual acuity of the left eye and grand mal seizure showed extensive bone destruction of the margins of the right orbit, the �oor of the middle cranial fossa, the right cavernous sinus, and much of the calvaria. there was considerable dural disease and tumor in the right orbit, paranasal sinuses, and scalp, as well as mucoceles of the left ethmoidal sinus with desiccated s e c re t i o n s. th e s i gn a l i nte n s i t y wa s a l s o s i m i l a r. th e histopathological diagnosis in this case was also given as adenosquamous carcinoma. summary and conclusions the present study was aimed at evaluating mri �ndings in orbital tumors and to assess the diagnostic accuracy of mri in the characterization of the orbital tumors. this was done by correlating the mri and histopathological features. total 50 patients referred to radiology department in a tertiary care hospital were evaluated for the study. the patients were referred with strong clinical suspicion and prior ct scan showing orbital mass. following is the summary of our study: ÿ orbital tumors are more common in the �fth and sixth decade of life. males were more commonly affected than females with male: female ratio being 3:2 ÿ proptosis and diminution of vision were most common clinical complaints followed by pain and decreased motility. in�ammatory symptoms are seen in cases of pseudotumor and lymphoma. ÿ good correlation was obtained for clinical complaints and size and extent of the lesions in orbital tumors. ÿ gadolinium enhanced scans were used to delineate the extent of the lesion accurately and pattern of enhancement of lesions. ÿ the most common orbital tumor detected was lymphoma followed by pseudo tumor comprising of 21(42%) out of 50 th thcases. lymphoma was more common in 5 to 7 decade and there was a slight male preponderance. pseudo tumors occurred mainly in the fourth to sixth decade and were more common in males with sex ratio 2.3:1. extra ocular muscle involvement (myositis) was most common in pseudotumors followed by diffuse orbital involvement in our study lymphomas are more likely to be bilateral than pseudotumors. the t2w signal intensity with respect to orbital fat combined with in�ammatory symptoms can be used to differentiate between pseudo tumors and lymphoma tumors in most cases. ÿ the next most common abnormality detected was cavernous hemangioma (8 cases -16%). most common occurrence was noted in �fth decade of life and we found a slight male preponderance with a ratio of 1.6:1. intraconal hemangiomas were more common than extraconal. calci�cation could be seen as blooming on gradient imaging and internal septations were seen in half of the lesions. majority of the lesions were isointense on t1w and hyperintense on t2w images. typical pattern of delayed enhancement was seen on post contrast study. ÿ third most common were retinoblastoma and meningioma (4 cases-8%). all the patients of retinoblastoma were under the age of 6 years with 3 of the patients being male. an exophytic or endophytic growth pattern, optic nerve involvement, associated retinal detachment and vitreous hemorrhage could be identi�ed. typical signal intensity pattern was t1 hyperintense and t2 hypointense with respect to vitreous. ÿ meningiomas were commonly seen in middle aged to old females . half of the lesions showed intracanalicular or intracranial extension. pain, proptosis and diminished vision were chief symptoms. optic atrophy or papilledema may be present. the lesions were isointense on t1w and isohyperintense on t2w imaging and typical tram track type of enhancement was seen. ÿ next most common pathology was optic nerve glioma (3 cases6%). all the patients were within second decade, with 2 out of 3 males. all the cases were intraorbital and buckling and enlargement of the optic nerve was seen. typical signal intensities are isointense on t1w and iso-hyperintense on t2w images. contrast enhancement may be seen. ÿ two cases of uveal melanoma were seen. intra ocular mushroom shaped lesions with retinal detachment were seen in old aged male patients which were hyperintense on t1w and hypointense on t2w images. ÿ a variety of other tumors may be seen including orbital schwannoma, pleomorphic adenoma of lacrimal gland, dermoid, lymphangioma, hemangiopericytoma, and secondary tumors like orbital metastases and extension of adenoid and squamous carcinomas. but in a sample size of 50 patients, adequate number of cases of each tumor were not found to draw de�nitive conclusions. thus we assessed the mr imaging characteristics of 50 histopathologically proved orbital tumors. lymphoma, pseudotumor and hemangioma, retinoblastoma and optic nerve sheath meningioma constituted 74% of the lesions in our series. in our study, mri was precise in histopathological typing of orbital tumors in 84% cases. most of the ambiguity was in distinguishing between pseudo tumor and lymphoma. hence, �nally to conclude: ÿ a wide variety of tumors is seen in the orbital and ocular region in all age groups with various clinical and imaging characteristics. ÿ an appropriate imaging protocol is necessary with both plain and fat saturated t1w imaging as it is necessary for proper anatomical delineation of tumors. though gradient sequences detect calci�cation and hemorrhage as blooming, mr is not a very sensitive modality for detection of calci�cation. ÿ mr imaging characteristics and signal intensities allow distinction between most of the orbital tumors. however pseudo tumor and lymphoma cannot be adequately differentiated on the basis of imaging alone. clinical correlation and trial of corticosteroid can be used to further distinguish between them accurately. ÿ other characteristics such as intra conal versus extra conal location, intra cranial or extra orbital extension, nature of contrast material enhancement and clinical �ndings permit further differentiation among the various other abnormalities. the superior resolution and multiplanar capacity of mr imaging best depicts the extent of orbital tumors. references 1. jong han, jane benson et al: magnetic resonance imaging of the orbit: a preliminary experience. radiology 1984; 150:755-759 2. david daniels, robert herfkins et al: magnetic resonance imaging of the optic nerve and chiasma. radiology 1984; 152: 79-83 3. bilaniuk and schenk et al: ocular and orbital lesions: surface coil mr imaging. radiology 1985; 156:669-674 4. shields ja, shields cl, scartozzi r. survey of 1264 patients with orbital tumors and simulating lesions: the 2002 montgomery lecture, part 1. ophthalmology 2004;111:997– 1008 5. kenji ohtsuka, masato hashimoto, and yasuo suzuki a review of 244 orbital tumors x 47gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 in japanese patients during a 21-year period: origins and locations jpn j ophthalmol 2005;49:49–55 6. jianhua yan, zhongyao wu, yongping li. the differentiation of idiopathic in�ammatory pseudotumor from lymphoid tumors of orbit: analysis of 319 cases. orbit – 2004, vol. 23 no. 4, pp. 245–254 7. günalp i, gunduz k,yazar z. idiopathic orbital in�ammatory disease. acta ophthalmol scand.1996; 74:191–193. 8. cytryn, albert s. m.d.; putterman, allen m. m.d.; schneck, gideon l. m.d.; beckman, enrico m.d.; valvassori, galdino e. m.d. predictability of magnetic resonance imaging in differentiation of orbital lymphoma from orbital in�ammatory syndrome ophthalmic plastic & reconstructive surgery: 1997;13-2 9. thorn-kany m, arrue p, delisle mb, et al. cavernous hemangiomas of the orbit: mr imaging. j neuroradiol 1999;26(2):79 –86. 10. atsuo tanaka, takashi yoshiura et al:differentiation of cavernous hemangioma from schwannoma of the orbit: a dynamic mr study ajr 2004;183:1799–1804 11. harris gj, jakobiec fa. cavernous hemangioma of the orbit. j neurosurg 1979; 51(2):219– 28. 12. de graaf p, barkhof f, moll ac, et al. retinoblastoma: mr imaging parameters in detection of tumor extent. radiology 2005;235:197-207 13. f. barkhof, m. smeets, p. van der valk, k. e. w. p. tan, f. hoogenraad, j. peeters and j. valk mr imaging in retinoblastoma european journal of radiology vol 7 no. 5 june 1997 14. a o schueler, n hosten, n e bechrakis, a j lemke, p foerster, r felix, m h foerster, and n bornfeld: high resolution magnetic resonance imaging of retinoblastoma br j ophthalmol. 2003 march; 87(3): 330–335 15. castel a., boschi a., renard l., de potter. optic nerve sheath meningiomas:clinical features, functional prognosis and controversial treatment p.1 bull. soc. belge ophtalmol. 2000; 275, 73-78. 16. karp la, zimmerman le, borita a, spencer w primary intraorbital meningiomas. arch ophthalmol 1974; 91: 24, 17. alvord ec, lofton s gliomas of the optic nerve or chiasm: outcome by patients’ age, tumor site and treatment. j neurosurg 68:85-98, 1988 18. hendrix le, kneeland jb, haughton vm, et al. mr imaging of optic nerve lesions: value of gadopentetate dimeglumine and fat-suppression technique. ajnr am j neuroradiol. jul-aug 1990; 11(4):749-54. 19. lemke aj, hosten n, bornfeld n, et al. uveal melanoma: correlation of histopathologic and radiologic findings by using thin-section mr imaging with a surface coil. radiology 1999; 210:775–783. 20. mafee mf, peyman ga, peace jh.magnetic resonance imaging in the evaluation and differentiation of uveal melanoma. ophthalmology 1987; 94:341–348. 21. bond jb, haik bg, taveras jl, francis ba, numaguchi y, mihara f, gupta kl magnetic resonance imaging of orbital lymphangioma with and without gadolinium contrast enhancement. ophthalmology. 1992 aug;99(8):1318-24 22. kalisa p, van zieleghem b,roux p, meire f: orbital lymphangioma: clinical features and management bull. soc. belge ophtalmol., 282, 59-68, 2001. 59 23. y wang and l h xiao. orbital schwannomas: �ndings from magnetic resonance imaging in 62 cases. eye (2008) 22, 1034–1039 24. peter m. som, adam r. silvers, peter j. catalano, margaret brandwein, and azita s. khorsandi. adenosquamous carcinoma of the facial bones, skull base, and calvaria: ct and mr manifestations. ajnr jan 1997 18:173–175. 25. shields ja, bakewell b, augsburger jj, et al. classi�cation and incidence of spaceoccupying lesions of the orbit. a survey of 645 biopsies. arch ophthalmol 1984; 102(11):1606–11. 26. kopelow sm, foos ry, straatsma br, et al. cavernous hemangioma of the orbit. int ophthalmol clin 1971;11(3):113– 24. 27. mcnab aa, wright je. cavernous haemangiomas of the orbit. aust nz j ophthalmol 1989;17(4):337– 45. 48 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 introduction : the sensory neuropathies are still prevalent as the most frequent neurological disorder associated with hiv infection and its treatment with art [1-3]. ellis et al. [4] reports that distal sensory polyneuropathy is prevalent (57%) in the cart era. there are two major types of hiv-associated distal sensory peripheral neuropathies: primary hiv-associated distal sensory polyneuropathy (hiv-dsp) and art toxic neuropathy (atn), together which affect approximately 30–67% of patients with advanced hiv disease [5,6]. the pathology of hiv-dsp involves a length-dependent degeneration of both small and large peripheral nerve bers but the pathogenesis is unknown [6,7,8]. the pathogenesis of atn is believed to reect inhibition of gamma dna polymerase by narts leading to reduced mitochondrial dna content and therefore to mitochondrial dysfunction [9]. reduced mitochondrial dna levels in subcutaneous fat obtained by punch skin biopsies have been associated with atn [10,11]. the signs/symptoms of hiv-dsp and atn resemble common neuropathies encountered in clinical practice including diabetic and alcohol-associated neuropathy. diabetes mellitus is a common cause of sensory neuropathy, and art therapy, especially protease inhibitors, is associated with diabetes mellitus [12]. the interaction between metabolic syndrome and hiv is unclear. aims : association of hiv neuropathy & its correlation with glycemic status . material & methods after obtaining prior ethical clearance, treatment naïve plha (person living with hiv/acquired immunodeciency syndrome (aids)) patients were included in the study and we carried out a cross-sectional study of the hiv seropositive patients in inpatient and outpatient clinic of the gandhi medical college, bhopal, from december 2011 to december 2012. patients on antitubercular therapy, on antiretroviral therapy, alcoholic, vitamin b-12 deciency, leprosy, chronic kidney disease, and with hereditary neuropathy were excluded from the study. the diagnosis of hiv was made according to national aids control program guidelines.[13] consecutively, each patient underwent a bpns using the bpns tool.[14] history and lower extremity examination was done to evaluate patient perception of vibrations for over 10 s using a 128 hz tuning fork on the big toe. ankle reexes were also tested using a reex hammer. sociodemographic and anthropometric information relevant to the study were also obtained from each patient. fasting blood glucose obtained after 8 hour fast in the morning and postprandial plasma glucose was obtained 2 hour after 82.5 g oral glucose load. statistical analysis: unpaired t-test & chi-square test was used to compare the quantitative variables of interest under study namely; mean hemoglobin, mean body mass index (bmi), mean serum albumin, and mean cd4 t-cell count between clinically evident neuropathy and non-neuropathy group. hiv-sn was dened as the presence of symptoms and at least abnormal perception of vibration or ankle reex or both. evidence of association was considered for a two-sided p value of less than 0.05. results : total number of patients were 75 in number and had mean age , mean weight mean bmi were 33.11±10.45 year , 50.69±9.14 and 18.51±2.71 respectively (table 1). mean fasting blood glucose was 98.16±14.794 and post 75 g ogtt value were 138.52±19.63.(table1). hiv neuropathy drug naive plha patients and it's correlation with glycemic status in central india. original research paper somnath singh raghuvanshi exsenior resident depart. of endocrinoloy medical collage & hospital kolkata. x 33gjra global journal for research analysis endocrinoloy the sensory neuropathies are still prevalent as the most frequent neurological disorder associated with hiv infection and its treatment with art. there are two major types of hiv-associated distal sensory peripheral neuropathies: primary hiv-associated distal sensory polyneuropathy (hiv-dsp) and art toxic neuropathy (atn), together which affect approximately 30–67% of patients with advanced hiv disease. aim: association of hiv neuropathy & its correlation with glycemic status. material & methods: after obtaining prior ethical clearance, treatment naïve plha (person living with hiv/acquired immunodeciency syndrome (aids)) patients were included in the study and we carried out a cross-sectional study of the hiv seropositive patients in inpatient and outpatient clinic of the gandhi medical college, bhopal, from december 2011 to december 2012. results: impaired fasting glucose was signicantly higher in neuropathy group by ncs examination (61.9%) than nonneuropathy group (31.2%), p=0.009 . impaired glucose tolerance is signicantly higher in clinical neuropathy group (75.9%) than non-neuropathy group (28.3%), p=0.009. conclusion : the dysglycemia is more common in the hiv patients and both dysglycemia and hiv associated with neuropathy or hiv patients are more prone to dysglycemia. abstract keywords : human immunodefeciency virus , plha , nerve conduction study . dysglycemia. tribhuvan nath dubey* dean & ex hod depart. of medicene, gandhi medical collage bhopal *corresponding author himanshu sharma assistant professor depart. of medicine , gandhi medical college bhopal rita saxena assistant professor depart. of medicine gandhi medical college bhopal volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table : 1 baseline characteristics n minimum maximum mean std. deviation age 75 18 60 33.11 10.454 34 x gjra global journal for research analysis the neuropathy was present with both impaired fasting glucose and impaired postprandial glucose load and thre was signicant difference among fasting (p<0.001) in patient with neuropathy with similar signicance level in the post prandial glucose.(table02). : both fbs and 75 ogtt were signicantly higher in neuropathy present group than non-neuropathy group as determined by unpaired t-test. both fbs and 75 ogtt were signicantly higher in clinical neuropathy present group than non-neuropathy group as determined by unpaired t-test.(table03) impaired fasting glucose is signicantly higher in neuropathy group by ncs examination (61.9%) than non-neuropathy group (31.2%), p=0.009 as determined by chi-square test.(table:04) impaired glucose tolerance is signicantly higher in neuropathy group (61.9%) than non-neuropathy group (25%), p=0.009 as determined by chi-square test.(table05) impaired glucose tolerance is signicantly higher in clinical neuropathy group (75.9%) than non-neuropathy group (28.3%), p=0.009 as determined by chi-square test. discussion : in the our study 56.7 % patients had abnormal nerve conduction study with both impaire fasting plasma glucose as well as with impaired glucose tolerance . impaired fasting glucose was signicantly higher in neuropathy group by ncs examination (61.9%) than non-neuropathy group (31.2%). the clinical neuropathy was present in the 38.8% of the patient with dysglycemia. diabetes reected by insulin use also predicts less chance for reversal of symptomatic neuropathy, suggesting that combining the diabetic risk with nart-induced mitochondrial decits may be a particularly troublesome neurotoxic situation. early studies emphasized cd4 and viral load as risk factors, but with successful therapy these associations have become less important. specically viral suppression did not decrease the odds of peripheral neuropathy. although neuropathy was more common in the plha patient with dysglycemia but it is difcult to comment on the etiology of neuropthy because both hiv and dysglycemia causes neuropthy & also plha patient are prone to dysglycemia . conclusion : the dysglycemia is more common in the hiv patients and both dysglycemia and hiv associated with neuropathy or hiv patients are more prone to dysglycemia. acknowledgement : thank to my respected teachers and artplus center gmc bhopal. conflict of interest : none . reference : 1. keswani sc, pardo ca, cherry cl, hoke a, mcarthur jc. hiv-associated sensory neuropathies. aids. 2002; 16:2105–2117. [pubmed: 12409731] 2. bacellar h, munoz a, miller en, cohen ba, besley d, selnes oa, et al. temporal trends in the incidence of hiv-1-related neurologic diseases: multicenter aids cohort study, 1985–1992. neurology. 1994; 44:1892–1900. [pubmed: 7936243] 3. mcarthur jc, brew bj, nath a. neurological complications of hiv infection. lancet neurol. 2005; 4:543–555. [pubmed: 16109361] 4. ellis, r.; rosario, d.; clifford, d.; mcarthur, j.; simpson, d.; alexander, t., et al. croi. montreal, canada: 2009. persisting high prevalence of hiv distal sensory peripheral neuropathy in the era of cart: correlates in the charter study. [paper #461] 5. wulff ea, wang ak, simpson dm. hiv-associated peripheral neuropathy: epidemiology, pathophysiology and treatment. drugs. 2000; 59:1251–1260. [pubmed: 10882161] 6. cornblath dr, mcarthur jc. predominantly sensory neuropathy in patients with aids and aidsrelated complex. neurology. 1988; 38:794–796. [pubmed: 2834669] 7. barohn rj, gronseth gs, leforce br, mcvey al, mcguire sa, butzin ca. peripheral nervous system involvement in a large cohort of human immunodeciency virus-infected individuals. arch neurol. 1993; 50:167–171. [pubmed: 8381649] 8. grifn, jw.; crawford, to.; mcarthur, jc. peripheral neuropathies associated with hiv infection. in: gendelman, he.; epstein, e.; lipton, sa.; swindells, s., editors. the neurology of aids. new york: chapman & hall; 1998. p. 275-291. 9. brinkman k, hofstede j, burger d, smeitink j, koopmans p. adverse effects of reverse transcriptase inhibitors: mitochondrial toxicity as common pathway. aids. 1998; 12:1735–1744. [pubmed: 9792373] 10. brew bj, tisch s, law m. lactate concentrations distinguish between nucleoside neuropathy and hiv neuropathy. aids. 2003; 17:1094–1096. [pubmed: 12700465] 11. cherry cl, gahan me, mcarthur j, lwein sr, hoy jf, wesselingh sl. exposure to dideoxynucleosides is reected in lowered mitochondrial dna in subcutaneous fat. j acquirimmune dec syndr. 2002; 30:271–277. [pubmed: 12131563] 12. banerjee s, mccutchan ja, ances bm, deutsch r, riggs pk, way l, ellis rj. hypertriglyceridemia in combination antiretroviral-treated hiv-positive individuals: potential impact on hiv sensory polyneuropathy. aids. 2011; 25:f1–f6. [pubmed: 21150557] 13. guidelines for hiv testing-national aids control organisation.national hiv testing network operational guidelines naco document.operational characteristics of commercially available assays to determine antibodies to hiv-1 and/or hiv-2 in human sera.14. 14. cherry cl, affandi js, imran d, yunihastuti e, smyth k, vanar s,et al. age and height predict neuropathy risk in patients with hiv prescribed stavudine. neurology 2009;73:315-20. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra weight 75 34 82 50.69 9.143 fbs 75 67 124 98.16 14.794 75 ogtt 75 102 188 138.52 19.634 height 75 145 178 165.29 8.160 bmi 75 13 27 18.51 2.713 table:02 neuropathy(ncs) and dysglycemia study variable neuropathy by ncs examination n mean std. deviation p fbs present 42 103.74 13.520 <0.001 absent 32 90.69 13.422 75 ogtt present 42 146.45 20.502 <0.001 absent 32 128.03 12.855 table :03 clinical neuropathy clinical neuropathy n mean std. deviation p fbs present 29 106.83 11.793 <0.001 absent 46 92.70 13.944 75 ogtt present 29 149.41 19.778 <0.001 absent 46 131.65 16.304 table 04 :neuropathy by ncs examination * ifg crosstabulation ifg total p absent present neuropathy by ncs examination present count 16 26 42 0.009 % 38.1% 61.9% 100.0% absent count 22 10 32 % 68.8% 31.2% 100.0% total count 38 36 74 % 51.4% 48.6% 100.0% table:05 neuropathy by ncs examination * igt crosstabulation igt total p absent present neuropathy by ncs examination present count 16 26 42 0.002 % 38.1% 61.9% 100.0% absent count 24 8 32 % 75.0% 25.0% 100.0% total count 40 34 74 % 54.1% 45.9% 100.0% 30.dr. nadia az zahra.cdr introduction self-care has been dened by world health organization (who) as activities undertaken by individuals, families & communities for managing health and health related 1 problems. an essential component of self-care is 'selfmedication'. self-medication (sm) is an age old practice and has gained tremendous global importance in the recent past, due to its rising prevalence and because it not only reduces the burden on health services effectively, but also improves compliance of patients and consequently the disease 2 outcome. it can be dened as the use of drugs to treat selfdiagnosed disorders or symptoms, or the intermittent/ continued use of a prescribed drug for chronic or recurrent 3disease or symptoms. promoting a sense of responsibility in an individual about their own health through health education and making them aware that professional care is not necessary for minor illness 4 are the keys that lead to this concept. in 1978, the declaration of alma-ata recognized the involvement of individuals in achieving the optimum health. also, in 1986, the ottawa declaration emphasized the central role of individuals and 5communities in contributing to health. self-medication is a tool to accomplish this. unfortunately, now-a-days, health is being commoditized and pharmaceuticalized. health is being treated as a state which can be maintained by consumption of medicines, if one has the capital to invest. people conveniently “reach for the pill” at the rst sign of ill health. it has become a common practice for patients to use medicines without the supervision of healthcare professionals. this limits the opportunity for ongoing patient follow-up & safety monitoring, thereby increasing the risk of premature abandonment of treatment, up-titration leading to potentially dangerous dosing, and wastage of medication. conversely, incomplete information by the patient about the self-administered drugs during reconciliation can cause unintended drug interactions, failure to apprehend adverse drug events and redundant therapy. 6 this consequently increases the health-care costs. furthermore, drug resistance has become a worldwide concern. irrational use of antibiotics has resulted in the spread of resistant pathogens, termed as “nightmare bacteria” which pose a “catastrophic threat” across the 7,8 continents. great english philosopher-physician sir william osler has rightly said that “one of the rst duties of the physician is to educate the masses when not to take the medicines”. ironically, the concept of 'rational' and 'responsible' self-medication is drifting towards an 'irrational' and 'indiscriminate' use of drugs. evaluation of the practice of self medication among outpatients at nalanda medical college, a tertiary care teaching hospital of patna original research paper dr. nadia az zahra junior resident, department of pharmacology, nalanda medical college & hospital, patna. pharmacology background: there is no separate over the counter (otc) category in india. drugs that are not included in the list for prescription-only drugs are pictured as non-prescription drugs. prescription-only drugs are those that fall under schedule h, h1 & schedule x of drugs and cosmetics rules 1945.the otc drug market is thincreasing internationally and india ranks 11 in the global otc market. in spite of the existing rules & regulations, in the absence of a clear denition & legal recognition to otc products & ease of access to various medications, it seems difcult to curb the rising tendency towards self-medication which is highly prevalent in india. objective: to evaluate the practice of self-medication and nd out the indications, reasons, category of drugs used, source of information for self-medication, knowledge about the purchased medicine and public opinion regarding self-medication practice in a tertiary care hospital of patna. materials and methods: a questionnaire based cross sectional observational study was carried out at nalanda medical college & hospital, patna among 602 patients for a period of 4 months from april 2019 to july 2019. descriptive data analysis was done and reported in frequencies and percentage. results: prevalence of self-medication in our study was found to be 55%. frequency of self-medication was found to be once in 39% of the patients. main reason for self-medication was cost effectiveness(25%) followed by previous experience(24%), the indications most commonly being pain(32%) followed by respiratory infections(17%). we found analgesics (34%) to be the most commonly used drug for self-medication. around 30% of the patients had some knowledge about the medicines purchased. most of them(61%) believed that it is an acceptable practice in case of minor illness. conclusion: self-medication appears to be a double-edged sword. our study reects the prevalence and practice of selfmedication in this area. imparting knowledge about frequently used medications, conditions to be considered as a minor illness, the upsurge of antibiotic resistance, importance of package inserts & expiry dates, advantage of consulting a medical practitioner in contrast to a pharmacist at medical stores and pros & cons of self-medication as a whole, would denitely help balance this concept. abstract keywords : self-medication, prescription-only drugs, over the counter(otc) drugs volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. sanjay kumar* professor & head of the department of pharmacology, nalanda medical college & hospital, patna. * corresponding author dr. afzal ahmad assistant professor, department of biochemistry, gs medical college & hospital, hapur, u.p. dr. jwala kumar junior resident, department of pharmacology, nalanda medical college & hospital, patna. dr. shubhra bishwas junior resident, department of pharmacology, nalanda medical college & hospital, patna. 26 x gjra global journal for research analysis focusing on india, we see that there is no separate over the counter (otc) category. in spite of the existing rules & regulations, in the absence of a clear denition & legal recognition to otc products & ease of access to various medications, it seems difcult to curb the rising tendency towards self-medication. various community-based studies have determined the prevalence of self-medication in india 9,10 ranging from 12% to as high as 73%. recently, the drugs consultative committee (dcc) has decided to dene, classify and lay down specic provisions for the regulation for approval, distribution & sale of otc drugs in the country. various studies are being conducted targeting selfmedication. the objectives of this study were to evaluate the practice of self-medication in the patients attending the opd of nalanda medical college & hospital, patna. an attempt was made to nd out the indications, reasons, category of drugs used, source of information for self-medication, knowledge about the purchased medicine and public opinion regarding self-medication practice was also examined. materials and methods a questionnaire based cross-sectional study was conducted involving face to face interviews amongst the patients attending outpatient department of nalanda medical college & hospital, patna. it was a 4 month study from april 2019 to july 2019. the purpose and details of the study were explained to the patients prior to the initiation of data collection. those who were willing to participate in the study and gave informed consent, with address proof of residency in bihar, who understood hindi or english were eligible to participate in the study. those having communication problem, severe illness or mentally challenged were excluded from the study. on behalf of children below 12 years of age, response to the questionnaire was obtained from their parents. self-medication for this study was considered as the use of medicines in the last 4 months for which a doctor was not consulted. a total of 1150 patients were approached and out of them 602 (52.3%) were found to be practicing self-medication and were included in our study. descriptive data analysis was done & reported in frequencies and percentage. results among 602 participants, the frequency of self-medication was found to be once in 39% (234/602) of the patients, twice in 26.4% (159/602), more than twice in 22% (133/602) of the patients while 76 (12.6%) of them were not sure. paracetamol(19%) was the most common self-medicated analgesic antipyretic, amoxycillin(16%) was the most common antibiotic while cetirizine(10%) was most common antihistaminics (12%). consumption of ors was more common for diarrhoea as compared to vomiting. ors power was not even dissolved in 1litre of water by 18.6%(112/602) of the patients. opinion about the practice of sm was also sought and we found that 61.5%(370/602) of the participants believed that it is an acceptable practice in case of minor illness, 61 of them considered it a good practice and should be encouraged while 122 participants thought it should be avoided. 49 participants did not have any view about this. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 1. demographic characteristics of the study group(n=602) demographic factors categories frequency(%) gender male female 387(64.3) 215(35.7) age <20 years 20-35 years 36-60 years >60 years 48(7.9) 191(31.7) 296(49.2) 67(11.1) employment status employed unemployed student farmer 294(48.8) 198(32.8) 67(11) 43(7) educational level illiterate primary high school intermediate graduate post graduate 83(13.7) 82(13.6) 165(27.4) 133(22) 115(19) 24(4) table 2.indications for self-medication (n=776) indications frequency(%) pain (headache,musculoskeletal etc.) 248(31.9) fever 96(12.3) vomiting 61(7.9) loose motions 90(11.6) cough/cold/urti 130(16.8) constipation 19(2.4) weakness 27(3.5) acidity 94(12.1) others(eye/ent/skin problems) 11(1.4) table 3. drug classes used for self-medication (n=1043) drug class frequency(%) analgesic & antipyretics 360(34.5) antacids & other gastrointestinal drugs 268(25.7) antibiotics 220(21) antihistaminics 128(12.3) multivitamins 35(3.3) others (ors, probiotics, corticosteroids, lozenges etc.) 32(3) x 27gjra global journal for research analysis discussion the prevalence of self-medication in our study was found to be 52.3% (602/1150). a study done by saharan in mumbai reported self-medication prevalence of 85% which is higher than present study while in a study by saba et al at bengaluru, prevalence rate of self-medication was found to be 11,1240.5%. our study showed that cost (25%), past experience with similar illness (24%) were the main reasons for sm. our result is similar to studies done in bangladesh which reported cost saving as reason other than minor illness for practicing self13medication. this nding is in contrast with another recent survey that revealed common reasons for self-medication as 14,15ailments being minor (85.2%). the indications for which majority of the individuals selfmedicated was pain (32%) followed by cough and respiratory infections (17%). similar to our result, pain & respiratory infections were the top symptoms in a study from urban and rural population of islamabad and another study conducted 15,16in mumbai. while in a study from urban & rural areas of bangladesh, western nepal and mumbai, pain (17%) and 11,13,17fever (15%) were the main symptoms. our study revealed that pharmacy shop (39%) was the main source of obtaining drugs for self-medication followed by old prescriptions (18%), 16,18similar to other studies from rural tamil nadu & pune. we found analgesics (34%) to be the most commonly used drug for self-medication similar to ndings in other 14,16,17,19 studies. in contrast to our study, the next commonly prescribed medication was vitamins & minerals in a study 16 conducted in pune. our study found that consumption of ors was more common for diarrhoea than vomiting and 18% of the respondents did not follow proper directions to dissolve and use the ors powder. therefore, awareness about proper ors usage is necessary. conclusion in order to address the disadvantages of self-medication and to understand the public perspective and increase their knowledge about responsible self-medication, we need to have a clear picture of the factors inuencing self-medication. we found that more than one-third of the individuals practiced self-medication. integrated efforts on the part of the individuals and communities as well as health care facilities and regulatory bodies are crucial steps towards attainment of rational & responsible self-medication. references 1. global status report on noncommunicable diseases 2014. world health organization; 2014. 2. patient self-management of chronic disease in primary care. bodenheimer t, lorig k, holman h, grumbach k jama. 2002 nov 20; 288(19):2469-75. 3. world health organization; 2000. guidelines for the regulatory assessment of medicinal products for use in self-medication 4. world health organization. guidelines for the regulatory assessment of medicinal products for use in self-medication. geneva, switzerland: who, 2000. 5. park k. park’s textbook of preventive and social medicine, 22nd edn. jabalpur, india: m/s banarasidas bhanot publishers, 2013. 6. monte aa, heard kj, hoppe ja, vasiliou v, gonzalez fj. the accuracy of selfreported drug ingestion histories in emergency department patients [online]. jcph 2014; 55(1) 33–8. available from: http://onlinelibrary.wiley.com 7. khan sj, amanullah ks, shah n. self-medication with antibiotics in urban areas of peshawar. gomal j med sci. 2011;9(1):1–4. 8. centers for disease control and prevention (cdc): antibiotic resistance threats in the united states. 2013. http://www.cdc.gov/drugresistance/threatreport-2013/pdf/ar-threats-2013-508. 9. selvaraj k, kumar sg, ramalingam a. prevalence of self-medication practices and its associated factors in urban puducherry, india. perspect clin res 2014;5(1):32–6. 10. kaushal j, gupta mc, jindal p, verma s. self-medication patterns and drug use behavior in housewives belonging to the middle income group in a city in northern india. indian j community med 2012;37(1):16–9 11. saharan v, pandey m. a study of prevalence of self-medication practice among people of mumbai. int j pharm pharm sci. 2015;7(7):253-6. 12. prevalence of self-medication practices and its associated factors in rural bengaluru, karnataka, india,saba hi et al. int j community med public health. 2016jun;3(6):1481-1486 13. a comparative study on self-medication practice between some urban & rural areas of bangladesh. shahjalal b. a dissertation submitted to the department of pharmacy, east west university, 2016. available at: http://dspace.ewubd.edu/bitstream/handle/123456789/1729/binder1.pdf?se quence=1&isallowed=y. 14. al-ramahi r. patterns and attitudes of self-medication practices and pos¬sible role of community pharmacists in palestine. int j clin pharmacol ther. 2013;51(7):562-7. 15. aqeel t, shabbir a, basharat h, bukhari m, mobin s, shahid h, et al. prevalence of self-medication among urban and rural population of islamabad, pakistan. trop j pharm res. 2014;13(4):627-33. 16. keche y, yegnanarayan r, bhoyar s, agrawal r, chavan r, mahendrakar p, et al. self-medication pattern in rural areas in pune, india. int j med public health. 2012;2(4):7-11. 17. shankar p, partha p, shenoy n. self-medication and non-doctor prescription practices in pokhara valley, western nepal: a questionnaire-based study. bmc family pract. 2002;3:17. 18. annadurai k, selvasri s, ramasamy j. self medication: predictors and practices among rural population of nellikuppam village, kancheepuram district, tamil nadu. jkimsu. 2017;6(1):90-8. 19. keche y,pati l d. self medication use in nagpur ci ty, central india.inventiimpact: pharmacy practice 2010;1(1):22-4 volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 28 x gjra global journal for research analysis 80.afshan perveen online.cdr introduction being one of the gulf cooperation council (gcc) countries oman is dependent on migrant labor to bolster and stimulate economic growth and development. although indian migration to oman is apparently for the purpose of spreading their commercial activities and mutually sharing the prots, their mutual good relations are believed to have existed as 1early as the 7th century. the indian community in oman is regarded to be among the prosperous communities in the country. indians have now become the largest expatriate community in oman, according to the national centre for statistics and information. there are 6,64,227 indians living and working in the sultanate as of october 2018. among the indian population, 4,8,115 are female, while the vast majority 2 6,16,112 are male. the indian migrants in oman have come from all states of india. they are skilled workers and professionals, such as technicians, doctors, engineers, bankers, nance experts, managers who are on many senior and middle management positions in the cooperate division, a number of indians are working on chief posts in government sector and there are approximately 2000 indian doctors providing services in the country. the role of indians in the development of commerce, healthcare, education, horticulture, nance, construction and communications in the country is recommendable. materials and methods study design: a cross sectional survey location: sultanate of oman and india community population: indian sample size: 200 (ofce workers in india-52, ofce workers in oman-52, labors in india-48, labors in oman-48) sampling: convenient population: inclusion criteria: males (in the age group of 35-55years) working in ofce, construction sites, shops, etc. exclusion criteria: ÿ female workers ÿ men who are mentally and physically challenged ÿ men who were unable to respond to questions(due to hearing problem or any other reason) ÿ men who were not willing to participate. procedure the purpose of the study was explained to all the eligible participants in the language (english/hindi/arabic) understandable by them. verbal and written consent were obtained from all participants. data was collected by face to face interview method using different questionnaires. questionnaires were lled by the participants at the time of interview. following that all the participants were explained about different problems related to physical health, mental stress and life satisfaction. data collected was analyzed. an 'occupational therapy awareness' program was also conducted in which the attendees were given an occupational therapy education booklet. the booklet explained a comparative analysis of life satisfaction, physical and mental stress in indians versus indian expatriates working in oman original research paper afshan perveen bachelor of occupational therapy intern, department of rehabilitation sciences, jamia hamdard, new delhi. rehabilitation objective: over the years, there has been a signicant increase in the number of indian migrants in the country of oman. the indians working and living there are diverse in terms of the economic strata; therefore, the living and working conditions are also very different. there is a lack of studies focusing on the indian population, working in abroad more specically on their lifestyle and its impact on mental and physical health. hence a need was felt to understand the mental and physical aspect and life satisfaction of the indian population working and living in oman. methodology: 200 (ofce workers in india-52, ofce workers in oman-52, labors in india-48, labors in oman-48) 1. perceived stress scale 2. satisfaction with life scale (swls) 3. musculoskeletal discomfort form 4. researcher's assisted questionnaire results: the ndings of present study show that among the total 104 ofce workers, 66% of ofce workers in india had higher stress level as compared to 34% of indian ofce workers in oman, in case of life satisfaction, 62% of indian ofce workers in oman were better satised with life as compared to 38% of ofce workers in india. considering the labor population, among the total 96 labors 53% of indian labor in oman had high stress level as compared to 47% of labors in india, in case of life satisfaction, 57% of labors in india were better satised with life as compared to 43% of indian labors in oman. ofce workers reported discomfort in the neck and back region whereas the labor population reported discomfort in knee, shoulder and ankle regions. providing support to family, dissatisfaction with the job and heavy workload are some of the reasons that the indian population recognized as factors contributing to their stress and level of life satisfaction. the non-resident population acknowledged facts such as having family support, good living conditions and job satisfaction as factors contributing to their stress and satisfaction with life. conclusion: considering mental stress, the ofce workers in india have high stress level as compared to the ofce workers in oman. on the other hand, the labors working both in india and oman are facing high stress levels. it was found that in case of life satisfaction, the ofce workers in oman are more satised with life than the ofce workers in india whereas, the labors working in oman are less satised with life as compared to the labors working in india. it was found that the neck and lower back areas are more affected among the ofce workers and the knees, shoulders and ankles are the areas of discomfort among the labors. abstract keywords : ofce workers, labors, life satisfaction, stress dr. swati srivastava* mot (musculoskeletal), jamia hamdard, new delhi assistant professor, department of rehabilitation science, jamia hamdard, new delhi. *corresponding author 22 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra occupational therapy program for safe, healthy and efcient lifestyle. outcome measures / scales ÿ perceived stress scale (pss) ÿ satisfaction with life scale (swls) ÿ musculoskeletal discomfort form ÿ researcher's assisted questionnaire the questionnaire was a set of 5 questions each for the resident and non-resident indian population which had to be answered in simply yes or no. the questions comprised of the factors affecting mental stress and satisfaction from the life. data analysis a paired-samples t-test was conducted to compare the effect of quality of life and stress level among indian ofce workers in oman and india; and indian labors working in oman and india. descriptive analysis included percentages, means and sd. findings t-test value for different factors table 1: t-test value for different factors (*signicant at 0.00 level: ns: not signicant) percentage analysis 1.life satisfaction and stress level in ofce workers in oman and india table 2 2.life satisfaction and stress level in labors in oman and india table 3 3.factors considered by indians table 4 4. factors considered by non-resident indians (nris) table 5 distribution of areas of musculoskeletal discomfort graph 1 discussion this study was set out to investigate and compare life satisfaction, mental stress and physical stress among the indian population of ofce workers and labors working in india and the indian population of ofce workers and labors working in the sultanate of oman. a total sample of 200 indian men was taken which were divided in 52 ofce workers from oman and india respectively and 48 labors from oman and india respectively. the satisfaction from life was analyzed using the satisfaction with life scale (swls). upon doing the analysis, it was found that the indian ofce workers in oman are more satised with life than the ofce workers in india. the percentage analysis shows that 62% of ofce workers in oman are satised with life as compared to 38% of ofce workers in india. in case of the labor community the results are opposite; the labors working in india have a higher life satisfaction than the labors working in oman. it was seen that 57% of labors working in india are better satised with life as compared to 43% of labors working in oman. a similar study titled 'for better, for worse: life satisfaction consequences of migration' was conducted by gordon f.de jong et al. the results showed considerable similarity between the theoretical predictors of increased and decreased post15move satisfaction by migration type. the mental stress was analyzed using the perceived stress scale (pss). the comparative analysis between the ofce workers showed that 66% of ofce workers in india have higher stress level as compared to the 34% of ofce workers in oman. on the other hand, the labors working in india and oman have almost the same level of mental stress with 47% of labors in india and 53% of labors in oman having high stress level. shotaro doki et al conducted a similar study on stress of working abroad: a systematic review. it concludes that foreign-born workers are suffering from acculturation and 13occupational stress. the musculoskeletal discomfort form was used to determine the physical stress and the work related discomfort and pain among the two groups of ofce workers and labors. both groups marked the areas of distribution of discomfort. it was investigated that the ofce workers reported discomfort in the neck and the back region. the labors' group reported discomfort in the knee, shoulder and the ankle region. vari able ofce workers in oman n=52 ofce workers in india n=52 mean standard deviation mean standard deviation tvalue signica nce level pss 12.7307 4.343 30.5576 4.1746 -20.61* 0.000 lss 30.2692 2.9777 19.7115 3.189 -16.54* 0.000 vari able labours working in oman n=48 labours working in india n=48 mean standard deviation mean standard deviation tvalue signica nce level pss 16.5416 3.6739 19.25 6.6795 -2.57 0.0667 lss 12.6041 1.932 25.593 2.7586 -27.70* 0.000 office worker in oman office worker in india a)life satisfaction 62% 38% b)high stress level 34% 66% labors in oman labors in india a)life satisfaction 43% 57% b)high stress level 53% 47% indians job satisfaction 23% support family 30% work in abroad 16% mental stress 15% physical stress 16% job satisfaction 28% family support 19% living conditions 20% continue working in oman 24% return to india 9% nris x 23gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra the study also carried a research assisted questionnaire to better understand the factors involved and contributing to the aspects of stress and satisfaction with life. the questionnaire consisted of 5 questions each for the indian population, which are ofce workers and labors working in india; and the nonresident indian population, which are the ofce workers and labors working in oman respectively. the questions had to be answered in 'yes' or 'no'. considering the indian population rst, this was a total of 100 participants, 52 ofce workers and 48 labors. out of the total population 30% agree on having a family to support, 23% are satised with their current job, 16% agree that their workload gives them physical stress, 15% agree that their workload gives them mental stress and 16% wish to work in abroad. coming on to the non-resident indian population, this was also a total of 100 participants, 52 ofce workers and 48 labors. out of the total population 26% wish to continue working in oman, 28% are satised with their job, 22% are satised with their living conditions in the country, 20% have their family living with them in oman and 9% wish to permanently return to india. p.kameswara et al conducted a similar study on perceptual factors in quality of work life of indian employees. results from the factor analysis suggest four dimensions of qwl labeled favorable work environment, personal growth and autonomy, nature of job and stimulating opportunities and co21workers. conclusion in our comparative study on physical stress, mental stress and life satisfaction among the indians working in india and the indian expatriates working in oman, the data analysis was done by dividing the population into four groups, viz. ofce workers in india, ofce workers in oman, labors in india and labors in oman. results were obtained by comparing the two groups of ofce workers and the two groups of labors. considering mental stress, the ofce workers in india have high stress level as compared to the ofce workers in oman. on the other hand, the labors working both in india and oman are facing high stress levels. it was found that in case of life satisfaction, the ofce workers in oman are more satised with life than the ofce workers in india whereas, the labors working in oman are less satised with life as compared to the labors working in india. it was found that the neck and lower back areas are more affected among the ofce workers and the knees, shoulders and ankles are the areas of discomfort among the labors. it is evident that more and more indians are migrating to foreign countries for better job opportunities and a better lifestyle. for the well educated population the quest to work abroad seems to be achievable and in most cases turns out in their favor. but the skilled and the unskilled labor population of india who dream of working abroad need not necessarily end up with the expected results. therefore it is important to identify the different factors that act as a barrier for both population and the problems that they face in different working conditions in order to resolve them. conicts of interest: the authors report no conicts of interest in this work. findings sources: self ethical clearance: necessary permission was obtained from the head of superintendent to conduct the study. verbal consent and written consent were obtained from all the men who elected to participate in the survey. references 1. amboss prepare and succeed on your medical exams. https:// www. amboss.com/us/knowledge/ airway_management. 2. h jarineshin,* a abdolahzade baghaei,* f fekrat,* a kargar,* n abdi,* s navabipour,** a zare,*** and h akhlagh.comparison of two different doses of dexmedetomidine in attenuating cardiovascular responses during laryngoscopy and endotracheal intubation: a double blind, randomized, clinical trial study.j med life. 2015; 8(spec iss 4): 45–51. 3. priyamvada gupta, durga jethava, ruchika choudhary, and dharam das jethava.role of melatonin in attenuation of haemodynamic responses to laryngoscopy and intubation.indian j anaesth. 2016 oct; 60(10): 712–718. 4. priyamvada gupta, durga jethava, ruchika choudhary, dharam das jethava.role of melatonin in attenuation of haemodynamic responses to laryngoscopy and intubation.original article year : 2016 | volume : 60 | issue : 10 | page : 712-718. 5. premraj nagarwal1 , swapnil modi2 gaurav goyal3.effect of preoperative oral melatonin on attenuating haemodynamic responses of laryngoscopy, intubation and sternotomy in patients undergoing cabg..iosr journal of dental and medical sciences (iosr-jdms) e-issn: 2279-0853, p-issn: 22790861.volume 18, issue 8 ser. 12 (august. 2019), pp 07-11. 6. adithi devi e1, w r pathanjali rao2*, pavani kalyanam3.a prospective study on role of melatonin in attenuation of haemodynamic responses to laryngoscopy intubation and extubation.table of content volume 8 issue 2 november 2018. 7. bon sebastian, anand t talikoti, dinesh krishnamurthy.attenuation of haemodynamic responses to laryngoscopy and endotracheal intubation with intravenous dexmedetomidine: a comparison between two doses.original article year : 2017 | volume : 61 | issue : 1 | page : 48-54 24 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 17.dr. nidhi dubey.cdr introduction pregnancy is a vital part of a woman's life but it is period of greater risks of different complications for mother and fetus. one of the most prevalent complication is anemia, which is being faced throughout the world. it is more common in developing countries due to poor nutritional status. the average prevalence rate of anemia is 56% in developing countries with a range of 35% to 100%. according to who denition the women having hemoglobin level of 11 gm/dl or less is considered as anemic during pregnancy. the frequency of maternal complications is very high among sever anemic pregnant women in comparison with normal pregnant women. aims and objectives ÿ to determine the frequency of women having pregnancy with severe anemia, its maternal complications and fetomaternal outcome. materials and methods a total of 186 pregnant women was included from obstetrics and gynecology department of m.l.b. medical college jhansi. the study was conducted from march 2019 to august 2019 to all the women admitted for delivery with gestational age ≥ 34 weeks. the who's anaemia classication was adopted for functional denition of haemoglobin conditions; anaemic (serum hb 511g/dl), and nonanaemic (serum hb>11g/dl) the anemic group was further divided into mild (9-10.9 g/dl), moderate (7 8.9 g/dl) and severe anemia (< 7 g/dl). results distribution of different categories of anemia showing distribution of patients with different categories of anemia maternal complications & fetal outcome there were 29(16%) women with pregnancy induced hypertension. post-partum heamorrhage was seen in 17(9%) women. there were 62(33%) fetus who had low birth weight. apgar score <7 was observed in 84(45%) babies. maternal complications in the cases of pregnancy with anemia a statistically signicant (p value= 0.000) association was present between anemia and pregnancy induced hypertension and insignicant association between anemia and post-partum hemorrhage (p-value=0.068). perinatal complications in pregnancy with anemia no statistically signicant (p-value=0.05) association fetomaternal outcome of anemia in pregnancy original research paper dr. sanjaya sharma professor department of obstetrics and gynaecology of m.l.b. medical college, jhansi obstetrics & gynaecology objective: to determine the frequency of women having pregnancy with severe anemia, its maternal complications and feto-maternal outcome. study design: d a total of 186 pregnant women was included from obstetrics and gynecology department of m.l.b. medical college jhansi. the study was conducted from march 2019 to august 2019 to all the women admitted for delivery with gestational age ≥ 34 weeks. results: thirty-ve (19%) women were diagnosed with anemia among which 12(6.5%) women had severe anemia, 4(2.2%) had mild, and 19(10.2%) had moderate anemia. the frequency of pih (37.14%), pph (17.14%), low birth weight (62.68%) and apgar score<7 (60%) was noted higher in anemic patients. conclusion: there were signicantly higher maternal complications among anemic women as compared with non-anemic women. the fetal complications that is low birth weight and apgar <7 at 5 minute has also been found signicantly associated with maternal anemia. abstract keywords : apgar score, fetomaternal outcome, induced hypertension, low birth weight., pregnancy, postpartum heamorrahge, severe anemia volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. nidhi dubey* junior resident, department of obstetrics and gynaecology of m.l.b. medical college, jhansi *corresponding author complications anemia p value pregnancy with anemia (n=35) pregnancy with normal hb (n=151) pregnancy induced hypertension (n=29) 13 (37.14%) 16 (10.60%) 0.000 post partum hemorrhage (n=17) 6 (17.14%) 11 (7.28%) 0.068 complications anemia p value pregnancy with anemia (n=35) pregnancy with normal hb (n=151) low birth weight (n=62) 22 (62.86%) 40 (26.49%) 0.000 apgar score (<7) (n= 84) 21 (60%) 63 (41.72%) 0.050 46 x gjra global journal for research analysis between anemia and apgar score <7 at 5 minutes. conclusion there were signicantly higher maternal complications among anemic women as compared with non-anemic women. the fetal complications that is low birth weight and apgar <7 at 5 minute has also been found signicantly associated with maternal anemia. references: 1. ravishankar suryanarayana, muninarayana chandrappa, [...], and s. r. sheela.prospective study on prevalence of anemia of pregnant women and its outcome: a community based study.j family med prim care. 2017 oct-dec; 6(4): 739–743. 2. tandon r, jain a, malhotra p. management of iron deciency anemia in pregnancy in india. indian j hematol blood transfus. 2018;34(2):204–215. doi:10.1007/s12288-018-0949-6 3. shweta kumari, neelima garg, [...], and mohammad sohail.maternal and severe anaemia in delivering women is associated with risk of preterm and low birth weight: a cross sectional study from jharkhand, india.received 2019 feb 21; revised 2019 jul 23; accepted 2019 jul 23. 4. who. haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. vitamin and mineral nutrition information system. geneva, world health organization, 2011 (who/nmh/nhd/mnm/11.1) 5. grace stephen,1 melina mgongo , 2,3 tamara hussein hashim,2,4 johnson ka tanga ,1 ,5 bab i l l s t ray-pedersen ,3 ,6 and s ia emmanue l i msuya1,2,7.anaemia in pregnancy: prevalence, risk factors, and adverse perinatal outcomes in northern tanzania.hindawi anemia volume 2018, article id 1846280, 9 pages https://doi.org/10.1155/2018/1846280 6. dr ashram khatana, dr kanti yadav.study of fetomaternal outcome in patients of moderate and severe anaemia in > 28 week pregnancy.category: volume 05 issue 07 july 2017 hits: 791 volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 47gjra global journal for research analysis introductionendometrial diseases are prevalent across all age group and to a great extent are a leading cause of increases mortility and morbidity.the majority of females with endometrial diseases present with abnormal uterine bleeding(aub).(1,2) abnormal uterine bleeding (aub) is dened as any departure from normal menstruation or from a normal menstrual cycle pattern.(3) bleeding is considered abnormal when the pattern is irregular, abnormal duration , or menorrhagia or abnormal ammount.(4) causes include functional causes like normal cyclical endometrium abnormal physiological changes of endometrium (atrophic endometrium, weakly proliferative endometrium, disordered proliferative) and organic lesions like chronic endometritis, hyperplasia, polyp, carcinomas and pregnancy related complications. histopathological examination of endometrial biopsy is a major diagnostic tool in evaluation of abnormal uterine bleeding.(5) the underlying disaese can be detected by histological variations of endometrium taking into account the age of woman, the phase of her menstrual cycle and use of exogenous hormones. the aim of the study was to analyze the histomorphological patterns of endometrium in various age group of patients presenting with aub and their frequencies. material & methodthe study conducted in the histopathological section of department of pathology, ssmc, sgmh/gmh, rewa, mp. specimen of endometrial tissue received in the duration of 6 month from january 2019 to june 2019 were included in the study. a total of 87 specimen were received in 10% buffered neut ra l fo rmal in and were sub jec ted to rou t ine histopathological processing. section of 5 micron thickness were taken and stained with h& e stain. the nal diagnosis was given after detailed study of these sections under the light microscope.specimens where there is no endometrial tissue or no only minimal stromal elements or couldn't be concluded, in spite of the presence of some tissue, a diagnosis of inadequate for evaluation were given. resultsthe present study received 87 endometrial biopsy during 6 month of study period, of which 5 excluded from study due to inadequate sampling. the patient age ranges from from 20 years to 60 years . maximum cases were in the age group of 3150 accounting for 86.5% of total cases. table 1:cases in different age groups: table 2:-organic lesions of abnormal uterine bleeding study of histopathological lesion of endometrial biopsy in women presenting with abnormal uterine bleeding: a retrospective study original research paper dr. yogita singh tomar pg resident & room no. g-9 sumati pg girls hostel, shyam shah medical college, sanjay gandhi hospital rewa, mp, india, (486001) pathology introduction: abnormal uterine bleeding is a common symptom of the patients in all age group. aub is caused by a wide variety of causes in different age.histopathological examination of endometrial biopsy is a major diagnostic tool in evaluation of aub. aim:to study the endometrial lesion in all age group presenting with aub. methodology:-a retrospective study was designed to study of various d& c and endometrial biopsies sent for histopathological examination at department of pathology, shyam shah medical college, rewa, m.p. from 1st january 2019 to 30th june 2019.the study is based on the histopathological evaluation of endometrial biopsies received during the 6 month of study period. result: total 87 specimen of endometrial biopsies were collected in 6 month of study period, of which 5 cases excluded from study due to inadequate sampling and 82 cases were analyzed. we found that all age group was presented with aub but women with age group 36-50 years were more common. 53.7% cases were the organic cause and in which endometrial hyperplasia was most common. 46.3% cases were the functional causes in which proliferative phase was most common. 2 cases of endometrial carcinoma found. conclusion: histopathological evaluation of endometrial samples can be used as rst step for diagnosis of abnormal uterine bleeding. abstract keywords : endometrial biopsy, functional, organic. dr. kalpit agarwal pg resident & f-3/4, new doctors colony, near pts chauraha, shyam shah medical college, sanjay gandhi hospital rewa, mp, india(486001) *corresponding author dr. santosh singh associate professor, dept of pathology, shyam shah medical college & sgmh, rewa. mp volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. u. r. singh professor and head, dept of pathology, shyam shah medical college & sgmh, rewa. mp age group no. of patients % of patients 20-30 yrs 06 7.31% 31-40 yrs 33 40.24% 41-50 yrs 38 46.34% 51-60 yrs 05 6.09% total 82 100% causes no. of cases % of cases retained product of conception 06 13.6% h. mole 01 2.27% 84 x gjra global journal for research analysis table 3:-functional causes of abnormal uterine bleeding table 4:distribution of study subjects (n=82) according to histological diagnosis in different age group discussionthe present study shows that maximum number of cases were from 41-50 age group (46.3%) which is comparable with the different study. in the present study, most common histopathological ndings was proliferative endometrium(25.6%) followed by endometrial hyperplasia without atypia(19.5%) which was comparable with the bhatta s et al(8) study in which 26.23% was proliferative endometrium and 18.03% was endometrial hyperplasia without atypia. proliferative endometrium as a leading cause of aub also seen in deka r.r.et al(9) study(24.2%), salvi a et al(10) study(37.2%), khare et al(11)study(26.8%). in our study most common organic cause of aub was due to endometrial hyperplasia (40.9%),which is consistent with other studies conducted by anwar m et al(12) study (62.8%) and mirza t et al(13) study(30%). in reproductive age group, pregnancy related complications were the most common nding below 30 years of age and in 31-40 yrs of age cyclical endometrial change was predominant nding which is comparable to the study deka rr et al (9) . in perimenopausal age,prol i ferat ive endometrium(32%) was the major cause which is comparable to the ndings in daka r r et al(9) study(35.6%), salvi et al (10) study (53%), bhatta s et al(8) study(29.8%. table 5:-comparison of causes of aub with different study conclusionendometrial causes of aub are age related pathology. histopathological examination of endometrium is the gold standard to evaluate aub.accurate analysis of endometrial s a m p l i n g i s t h e k e y t o e f f e c t i v e t h e r a p y. t h u s histopathological evaluation of endometrium is, especially, indicated in women over the age of 35 years presenting with aub to rule out preneoplastic lesions and malignancies. references1. sarwar a, haque a. types and frequencies of pathologies in endometrial curretings of abnormal uterine bleeding.int j pathol. 2005;365-70. 2. crum cp, hornstein md, nucci mr, mutter gl. hertig and beyond: a systematic and practical approach to the endometrial biopsy.adv anat pathol. 2003;10(6):301-18. 3. ian s. fraser, m.d., hilary o.d. critchley, m.d., michael broder, m.d. and malcolm g. munro, m.d.the figo recommendations on terminologies and denitions for abnormal uterine blrrding, seminars in reproductive medicine 2011; vol 29(5)383-390 4. speroff l, fritz ma. in: clinical gynecologic endocrinology and infertility. 7th edition. jaypee brothers med publishers (p) ltd; 2005. menopause and the perimenopausal transition;621-88. 5. critchley hod, maybin ja. molecular and cellular causes of abnormal uterine bleeding of endometrial origin. semin rerod med 2011;29(5):400-409. 6. elavarasan t, puthiva rd, shruthi ms , shylaja s.histopathological study of endometrium in abnormal uterine bleedding an experience in a tertiary care centre of rural south india, njbms 2017; 8(1)32-38. 7. rajagopal i, thomas bm, rao vnkr. endometrial pathology in abnormal uterine bleeding,ijrms,oct 2019;7(10)3762-3766. 8. bhatta s, sinha ak. histopathological study of endometrium in abnormal uterine bleeding, journal of pathology of nepal 2012;2,297-300. 9. deka rr, saikia t, handique a, sonowali b. histopathological spectrum of endometrial changes in women presenting with abnormal uterine bleeding with special reference to endometrial malignancies: a two years hospital based study.aabs 2016; 3(2):152-157. 10. salvi a, mital p, hooja n, batar alka, soni p, beniwal r. spectrum of endometrial histopathology in women presenting with abnormal uterine bleeding sch. app med sci,2015;3(1a):1-4. 11. khare a, bansal r., sharma s, elhence p. makkar n, tyagi y. morphological spectrum of endometrium in patients presenting with dyfunctional uterine bleeding. people’s journal of scientic research.2012;5(2):13-16. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra endometrial polyp 07 15.9% leiomyoma 06 13.6% chronic endometritis 04 9.1% endometrial hyperplasia without atypia 16 36.4% endometrial hyperplasia without atypia 02 4.5% endometrial carcinoma 02 4.5% total 44 100% causes no. of cases % of cases proliferative phase 21 55.3% secretory phase 06 15.8% proliferative anovulatory phase 04 10.5% disorderd proliferative endometrium 03 7.9% hormaonal changes/decidualization 04 10.5% total 38 100% histopathological diagnosis5 20-30yrs 31-40yrs 41-50yrs 51-60yrs rpocs 5(83.3%) 1 h.mole 1(16.6%) endo. polyp 5 2 leiomyoma 2 4 chronic endometritis 1 2 1 eh without atypia 5 9(23.6%) 3 eh with atypia 1 1 endo. carcnoma 2 proliferative phase 9(27.27%) 12(34.2%) secretory phase 4 2 anovulatory phase 2 2 disorderd proliferative endometrium 2 1 hormonal changes/pseudodeci dualization 2 3 total 6 33 38 5 study elavarasan. t et al study(6) rajgopal i et al study(7) bhatta s et al study(8) present study cases 111(48.7%) 81(48.5% 48(39.3%0 57(46.3%) study/ causes eh pp sp rpoc endo. carcinoma deka r.r. et al study(9) 15 (11.3%) 32 (24.2%) 16 (12.1%) 25 (18.9%) 01 (0.75%) chhatrasal et al study(14) 395 (25.5%) 117 (7.6%) 372 (24.1%) 28 (1.8%) rajgopal i et al study(7) 38 (22.6%) 15 (8.9%) 40 (23.9%) 6( 3.5%) 3 (1.7%) bhatta s et al study(8) 22 (18.03%) 32 (26.23%) 20 (16.39%0 7 (5.74%) present study 18 (21.9%) 21 (25.6%) 06 (7.3%) 06 (7.35%) 02 (2.4%) x 85gjra global journal for research analysis background: glomus tumours are benign perivascular neoplasms that originate from glomus bodies and comprise just 1% of tumours arising in the hand, with fewer than 10% involve the volar pulp [1,2,3]of digits . in the hand they are often found in the subungual regions, as well as in the nail matrix, nail bed and involvement of pulp of a nger is very rare. an exophytic glomus tumour on the pulp of nger in pregnant women has been reported in literature. the period of evolution of glomus tumour ranges from 1 to 7 years. glomus body is an innervated coiled arteriovenous dermal shunt that normally control blood pressure and skin temperature through arterio-venous shunting of blood. glomus tumour arises from the arterial end of the glomus body. they are relatively uncommon and usually less than one centimetre in size. patients typically present with a triad of symptoms including excruciating paroxysmal pain that is worse at night, out of proportion to [4].tumour size, cold sensitivity and severe point tenderness glomus tumours are benign lesions arising from modied smooth muscle cells of neuromyo-arterial component of glomus body. histologically they resemble glomus bodies. they are found more in subungual regions of digits, in the subcutis and supercial soft tissues deep dermis of the palm, [5]wrist, and forearm . glomus tumour appear as small (less than 1cm) blue-red nodule and may occur in different viscera including the lung, liver stomach, pancreas, gastrointestinal, [6]and genitourinary tract . subungual presentation has a female preponderance and there is no sex predilection evident for presentation in other locations. glomus tumours are typically composed of 3 components: glomus cells, smooth muscle cells, and vasculature. the classical histological features of the glomus tumour include angiocentric uniform sheets of cells with oval nuclei, forming a perivascular “collar” [7]around vessels . atypical or frankly malignant glomus tumours are exceedingly rare and more frequently are deepseated large tumours in the gastro-intestinal system. glomangioma and glomangio-myoma are classic variants of the common form of glomus tumours. case presentation: a 73 years old right handed male working as a security guard presented to hand surgery outpatient department with history of pain in the pulp of his right mid nger of 6 years duration. there is no history of trauma. he is not diabetic, not hypertensive and does not have any other medical condition. initially the patient noticed cold intolerance and then developed lancinating type of pain in the digit. on clinical examination of right middle nger there is no visible swelling. palpation elicited severe tenderness on the pulp of the terminal phalanx, slightly ulnar to midline and on deep palpation a tender, diffuse, palpable mass measuring 0.5 centimeter was identied. figure 1: there was no obvious swelling in the pulp of middle nger. clinical diagnosis and differential diagnosis: a clinical diagnosis of glomus tumour was considered along with other differential diagnosis including the possibility of vascular or melanocytic lesions and lipoma. investigations: laboratory diagnosis for screening tests were all negative. plain x-ray of the right hand was taken. figure 2: plain radiography ndings were unremarkable. treatment: with a clinical diagnosis of glomus tumour the patient was taken up for excision biopsy of the lesion. the surgery was done under loupe magnication, under digital block anaesthesia and tourniquet control using a tourniquet. a curvilinear incision with convexity to ulnar side of terminal phalanx of right middle nger was made to avoid scar on the contact radial border of nger. glomus tumor in the pulp of finger – a rare presentation and diagnostic pearls original research paper dr. m srivignesh* department of hand surgery sri ramachandra institute of higher education and research, porur, chennai-600116 *corresponding author x 53gjra global journal for research analysis plastic surgery summary: glomus tumors are rare and occur typically in the subungual region of the digits of extremities. they present with severe pain out of proportion to the size of the tumor and are associated with severe cold intolerance. possibility of glomus tumour must be considered in the differential diagnosis for evaluation of unexplained nocturnal or rest hand pain. we present a unique case of 73-year-old male patient treated for rare presentation of the tumor at the pulp of nger. we also discuss clinical, histopathological and immunohistochemistry diagnosis and management of glomus tumors of hand. abstract keywords : glomus tumour, glomangioma, glomangiomatosis, perivascular neoplasm, sub-ungual glomangiomyoma, sucquet-hoyer canal. dr. n. mariappan department of hand surgery sri ramachandra institute of higher education and research, porur, chennai-600116 dr sandhya sundaram department of pathology sri ramachandra institute of higher education and research, porur, chennai-600116 volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 54 x gjra global journal for research analysis figure 3: a nger tourniquet was used at the base of the middle nger. the tumour was found to be deep in the pulp of terminal phalanx of mid nger slightly to the ulnar side of midline.tumour was excised in toto and skin wound was closed primarily using 4-0 ethilon sutures. post-operative period was uneventful. the wound healed well and sutures were removed on seventh post-operative day. he was adviced to follow scar care treatment protocol. figure 4: the tumour was deep in the pulp just above terminal phalanx. the excised specimen measured 1 x 0.5 cm. pathological diagnosis: histopathological study conrmed diagnosis of glomus tumour. multiple fragments of bro-adipose and brocollagenous tissue shows well circumscribed tumour composed of predominantly glomus cells, blood vessels and smooth muscle cells. the glomus cells are arranged in sheets interspersed with myxoid stroma showing round sharply punched out nucleus with indistinct border, eosinophilic cytoplasm and homogenous nuclear chromatin and few of them showing prominent nucleoli. no nuclear atypia or mitosis seen. it was recommended immunohistochemistry conrmation with vimentin, sma and ki67. ihc was positive for sma and vimentin and the ki67 labelling index was 1%. based on h & e and ihc studies, diagnosis of glomus tumour was conrmed. analysis: the following validated outcome questionnaires were completed prior to treatment and prospectively posttreatment. numeric pain rating scale: the patient rated his pain over the previous week on a scale of 0–10. quick disability of arm, shoulder and hand (quickdash): the dash outcome measure is a validated quality of life measure used to assess disability secondary to upper limb complaints. in this case study, the quickdash is used for assessment consisting of a disability score. the score ranges from 0 (no disability) to 100 (most severe disability). an improvement of 10 points is considered a minimal clinically important difference. outcome and follow-up: the patient was followed in the out-patient department. the patient experienced signicant relief from symptoms of local and paroxysmal pain. the scar settled well without any pain sensation. he has returned to his job and has not experienced intolerance to cold. discussion: glomus tumours, also known as barre–́ masson syndrome, are rare benign hamartomas that arise from the normal glomus apparatus, located in subcutaneous tissue. wood was the rst to describe the condition in 1812 as a painful subcutaneous tubercle. masson in 1924 coined the descriptive term “glomus” (latin for “ball”) and with histopatho-logical study he recognised their neuromyoarterial origin. touraine in 1936 rst described multiple hereditary glomangiomas. glomus body consists of an afferent arteriole, an anastomotic sucquet–hoyer canal, an efferent venule, the intraglomerular reticulum and its capsule. the sucquet–hoyer canals are lined by endothelial cells which are surrounded by smooth muscle cells and large cuboid glomus cells are interspersed in [8]the smooth muscle . with application of tourniquet to the nger, glomus tumours are characterized by a capsule surrounded by dark red, beige-pink colour. they are either solitary or multiple. solitary glomus tumours are far more common than the multiple variant. according to rettig and strickland, the solitary variant is mostly found in the hand, with 25%–75% occurring in the subungual region and are [9]more frequent in women in the age group of 2540 . multiple glomus tumours are most often are painless, pink or purple [10,11]appearance with a nodal shape . they develop in young children or in males in an autosomal dominant fashion. glomus tumour is also classied as digital and extra-digital. figure 5: incidence of glomus tumour in different body parts. clinical tests: (1) love test: apply pressure on the tumour with a blunt object to localize the tumour. positive love's pin test means patient experience severe pain when skin overlying the tumour is pressed with ballpoint pen or a pinhead. (2) hildreth's test: elevate patients' arm, exsanguinate it and a tourniquet is inated to 250 mm hg. pain and tenderness are reduced on palpation of the tumour. positive test is sudden onset of severe pain and tender-ness in the area of tumour when the cuff is [12]released . (3)provocation test shows cold impact on pain. the cold-sensitivity test is positive when hand immersion in cold water elicits severe pain in and around the lesion. these clinical diagnostic tests are helpful, but still have limitations in accurate diagnosis. love's test has a sensitivity of 100% and 78% accuracy. hildreth's test has a sensitivity of 71.4%, a specicity of 100% and accuracy of 78% and the coldsensitivity test has a sensitivity, specicity and accuracy each o f 100%. (4 ) recen t l y, ek in e t a l in t roduced a transillumination test useful in the diagnosis and location of sub-ungual tumours. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra differential diagnosis include vascular or melanocytic lesions and lipoma. there may be confusion and difculty in differentiating cyst, angioma, broma, neuroma, melanoma,nevus, leiomyoma, pyogenic granuloma and spiradenoma. mechanism of pain in glomus tumour: hypertrophy of glomus body is the feature of glomus tumour. glomus cells are specialized perivascular muscle cells that are round or oval and have a dense, granular cytoplasm. the causes of pain are due to ÿ the capsule of the tumours are more sensitive to pressure. temperature changes cause contraction of myolaments as a response with increase in intracapsular pressure with resultant severe pain. ÿ abundant mast cells in glomus tumours release substances such as heparin, 5-hydroxytryptamin, and histamine. this results in receptors to pressure or cold [13]stimulation to be sensitive and ÿ lancinating type of pain is due to non-myelinated nerve bres, intermixed with thick-walled capillaries. numerous non-myelinated nerve bers penetrate into glomus tumours. typical histological features: glomus tumours are typically composed of 3 components: glomus cells, smooth muscle cells and vasculature. the classical histological features of the glomus tumour include angiocentric uniform sheets of cells with oval nuclei, forming a peri-vascular “collar” around vessels. three different tumour variants are differentiated by [14,15]their histological characteristics . ÿ solid form(more common) ÿ glomangioma and glomangiomyoma(classic variants) ÿ malignant form: glomangiosarcoma figure 6: section showing a well circumscribed lesion with thin walled blood vessels surrounded by uniform cells (100 x h&e). glomus cells have both smooth cell and pericyte phenotype as conrmed by immunohisto-chemical and electron microscopic analyses.glomus tumours are characteristically and diffusely immune-reactive for �smooth muscle actin (�sma), muscle specic actin(msa), and h-caldesmon. vimentin and collagen type iv are also expressed, although they are non-specic. variable expression of cd34, and to a lesser extent desmin, has also been reported. pathology of glomus tumour is conrmed from hematoxylin and eosin stains and are positive for actin, cd31, cd34, sma, ets[16]related gene and vimentin . they are negative for s100 and desmin usu. the following guidelines are helpful in immunohistochemical and electron microscopy studies. figure7: high power showing glomus cells with uniform round to oval cells, moderate amount of eosinophilic cytoplasm and homogenous chromatin 200 x h&e positive stains: vimentin (100%), smooth muscle actin (99%), muscle specic actin (95%), calponin (80%), cd34 (32 53%; typically focal); collagen type iv, laminin (91%; pericellular), h-caldesmon (87%). figure 8: ihc for smooth muscle actin (sma) showing strong postivity in the glomus cells x100. negative stains include cytokeratin, cd31, s100, hmb45; cd117, desmin, chromogranin, synaptophysin, cd20, cd45 [17,18]and wt1 . electron microscopy shows thick basal lamina surrounds individual glomus cells except at cellular junctions. pinocytic vesicles and myobrils with dense bodies in the [19]cytoplasm are characteristic features . conclusion: glomus tumour is a rare perivascular benign tumour arising from the sucquet-hoyer canal of the normal glomus body, most commonly in the digits. we report a rare case of glomus tumour at pulp of the nger, with long-term severe pain, cold sensitivity, and point tenderness. glomus tumours are diagnostic challenge as they are small and situated deep in the ngertip. awareness regarding the unusual locations of tumours such as the pulp of the ngers is important for early treatment. patients presenting with a typical triad of symptoms should be evaluated for glomus tumour. ultrasonography or mri scan should be performed to ensure proper diagnosis [20,21]and treatment . histopathology revealed a wellcircumscribed tumour composed of clusters of monotonous polygonal cells surrounding capillary-sized blood vessels. tumour cells also showed immunopositivity for smooth muscle antigen and vimentin. finally, complete surgical excision must be meticulously planned for permanent cure and recurrence rate can be anywhere from 5% to 50% due to incomplete excision. learning points: ÿ a high index of suspicion of glomus tumour is essential for clinical diagnosis. ÿ glomus tumour should not be confused with hemangioma or para-ganglioma. patients with unexplained paroxysmal shooting pain , nocturnal or rest hand pain sensitivity to cold, and localized tenderness in the nger must be investigated to rule out glomus tumour. ÿ various presentations of glomus tumours and occurrence at rare locations must always be kept in mind. ÿ imaging studies like ultrasonography and magnetic resonance imaging are needed for conrmation. ÿ incision should be planned to avoid scars on the contact areas of the ngers. ÿ immunohistochemistry(ihc) studies are essential to conrm diagnosis and also to rule out the possibility of malignant transformation, which is extremely rare. ÿ the standard treatment of choice is surgical removal. recurrence of glomus tumour generally resulted from incomplete excision. funding: the authors have not declared a specic grant for this research from any funding agency in the public, commercial or not-for-prot sectors. competing interests: none declared. patient consent for publication: obtained. x 55gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra provenance and peer review: not commissioned; externally peer reviewed. references 1. kim dh. glomus tumour of the ngertip and mri appearance. iowa orthop j 1999;19:136-8. 2. shin dk, kim ms, kim sw, et al. a painful glomus tumor on the pulp of the distal phalanx. j korean neurosurg soc 2010;48:185-7. 3. lin yc, hsiao pf, wu yh, et al. recurrent digital glomus tumor: analysis of 75 cases. dermatol surg 2010;36:1396-400. 4. van geertruyden j, lorea p, goldschmidt d, de fontaine s, schuind f, kinnen l, et al. : glomus tumours of the hand. a retrospective study of 51 cases. j hand surg br 21 : 257-260, 1996 5. venkatachalam ma, greally jg. fine structure of glomus tumor: similarity of glomus cells to smooth muscle. cancer 1969;23:1176-84. 6. takei tr, nalebuff ea. extradigital glomus tumour. j hand surg br 1995;20:409-12. 7. lee, dw.; yang, jh.; chang, s.; won, ch.; lee, mw.; choi, jh.; moon, kc. (dec 2011). "clinical and pathological characteristics of extradigital and digital glomus tumours: a retrospective comparative study.". j eur acad dermatol venereol 25 (12): 1392-7. doi:10.1111/j .1468-3083.2011.03979.x (http://dx.doi.org/10.1111%2fj.1468-3083.2011.03 979.x). pmid 21371130 (http://www.ncbi.nlm.nih.gov/ pubmed /21371130). 8. gombos z, zhang pj. glomus tumor. arch pathol lab med 2008; 132: 1448-52. 9. rettig ac, strickland jw.glomus tumor of the digits. j hand surg am 1977;2:261-5. 10. rudolph r. familial multiple glomangiomas. ann plast surg. 1993;30:183–185. 11. parsons me, russo g, fucich l. multiple glomus tumors. int j dermatol. 1997; 36:894–900. 12. giele h (2002) hildreth’s test is a reliable clinical sign for the diagnosis of glomus tu-mours. j hand surg br 27(2):157–158. 13. rodriguez jm, idoate ma, pardo-mindan fj. the role of mast cells in glomus tu-mours: report of a case of an intramuscular glomus tumour with a prominent masto-cytic component. histopathology 2003;42:307-8. 14. gombos z, zhang pj (september 2008). "glomus tumor". arch. pathol. lab. med. 132 (9): 1448–52. doi:10.1043/1543-2165(2008)132[1448:gt]2.0.co;2 (http://dx.doi.org/10.1043%2f1543-2165%282008%29132%5 b1448%3agt% 5d2.0.co%3b2). pmid 18788860 (http://www.ncbi.nlm.nih.gov/ pubmed/ 18788860). 15. tuncali d, yilmaz ac, terzioglu a, aslan g. multiple occurrences of different histo-logic types of the glomus tumor. j hand surg 2005;30a:161–164. 16. mentzel, t. , h. kutzner , a. rutten , and h. hugel . cd34-positive glomus tumor: clinicopathologic and immunohistochemical analysis of six cases with myxoid stromal changes. j cutan pathol 2002. 29:421–425 17. int j surg pathol 2015;23:181 18. am j surg pathol 2002;26:301 19. cancer 1969;23:1176 20. vandenberghe l, de smet l (2010) subungual glomus tumours: a technical tip to-wards diagnosis on plain radiographs. acta orthop belg 76(3):396–397 21. hou sm, shih tt, lin mc (1993) magnetic resonance imaging of an obscure glomus tumour in the ngertip. j hand surg br 18(4):482–483. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 56 x gjra global journal for research analysis introduction there has been a constant association of adverse clinical outcome in myocardial infarction (mi) patients with acute kidney injury (aki). aki often complicates the hospital stay 1and is prevalent in about 30% of cases admitted to icu. the incidence of aki has surpassed the incidence of stroke and has increased by fourfolds in the u.s. since 1988 and is in a rising trend and will probably continue to do so in future as 1well if proper measures are not taken. due to advancement in the eld of medical sciences in both, pharmacological as well as revascularization therapy, the overall survival of st-elevation myocardial infarction (stemi) patients has considerably improved in the last two 10decades. presently the physician's focus is shifting on the subsets whose outcome after mi is still disappointing and mortality rate remains high. poor prognosis is associated in patients who develop aki after mi. however, management guideline of stemi currently does not focus much attention on 11aki. therefore, this study was planned in view of providing a framework of reference to raise the awareness of aki post mi to physicians, so as to improve the outcome of stemi patients with aki. even though aki is a frequent complication seen in the hospitals and is known to have a marked impact on morbidity and mortality, many important questions remain unanswered like whether aki contributes to a high risk of cardiovascular events. as very few studies are conducted in this context and a lesser amount of knowledge regarding aki's short-term effects after its occurrences as a complication of ami.thus, this study was performed to nd out the incidence of aki in post mi patients and to study their clinical prole and the outcome of aki in post mi. materials and method: prospective observational study was undertaken in saraswathi medical college and hospital, bareilly including 100 patients admitted in the medical icu,emergency and st stward from 1 may 2019 to 31 nov 2019. detailed history taking and clinical examination was performed and laboratoryinvestigations were done after explaining the nature of study and informed written consent taken from the patients. the following investigations were done: ÿ blood glucose: fbs, ppbs ÿ renal function tests ÿ electrolytes ÿ urine routine and microscopy ÿ electrocardiography(ecg) ÿ chest x-ray ÿ echocardiography ÿ cardiac enzymes like troponin, cpk-mb the data was collected, computed and statistically analyzed. results: out of 100, 36 patients had aki. mean age of these patients was 53±5.9 years in patients with aki and those without aki were 50± 6.1years. out of 100, 44 had inferior wall mi, 36 had anterior wall mi and 20 had nstemi. fig. 1. showing incidence of inferior wall , anterior wall mi and nstemi aki in post mi: a killer in disguise original research paper abhishek kumar verma assistant professor, md medicine, saraswathi medical college and hospital, hapur general medicine introduction: there has been a constant association of adverse clinical outcome in myocardial infarction (mi) patients with acute kidney injury (aki). however, whether aki contributes to an excess risk of cardiovascular events is still controversial, as very few studies are conducted in this context and less amount of knowledge regarding aki's short-term effects after its occurrence as a complication of ami, so this study was performed. aim: to nd the incidence of aki in post mi patients, study their clinical prole and outcome of aki in post mi patients. material and method: prospective observational study was undertaken in saraswathi medical college and hospital, bareilly including 100 patients admitted in the icu, emergency and ward from 1stmay 2019 to 31stnov 2019. they were subjected to careful history taking and detailed clinical examination; routine investigations were done. the data was computed and was statistically analyzed. results: out of 100, 36 patients had aki. mean age of the patients with aki was 50± 6.1years and those without aki was 53±5.9 years. out of 100, 44 had inferior wall mi, 36 had anterior wall mi and 20 had nstemi. mean fasting blood glucose (mg/dl) in patients without aki was 94.7±32 and in those with aki was 145±40. mean troponin i(ng/ml) was 2.4±3.4 in patients without aki and 5.29±7.1in those with aki which was found statistically signicant (p value=0.015). mean urea (mg/dl) and creatinine (mg/dl) was 33.9±11.9 and 0.74±0.11 respectively in patients without aki and with aki was 70±48.9 and 2±1.45 respectively. patients with aki after mi had a more number of complications like arrhythmia, heart failure, hypotension, lvef (<30%), rupture (free wall or septum or papillary muscle) as compared to patients without aki. mortality in patients without aki was 4 and in patients with aki was 6 . conclusion: high troponin i and older age are the most important risk factors for aki in patients with acute mi. post-mi complications and mortality in patients with aki was more than that in patients without aki. careful monitoring of susceptible patients in icu is recommended for early detection and management of aki in patients with mi. abstract keywords : kamlesh taori* junior resident, md medicine, rohilkhand medical college, bareilly *corresponding author hetal boricha mbbs, k.j. somaiya medical college, mumbai volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 16 x gjra global journal for research analysis incidence of aki in acute mi is 36. mean fasting blood glucose (mg/dl) was 94.7±32.1 in patients without aki and with that of aki was 145±40. mean troponin i(ng/ml) was 2.4±3.4 in patients without aki and with that of aki was 5.29±7.1 which was found statistically signicant (p value=0.015). mean urea (mg/dl) and creatinine (mg/dl) was 33.9±11.9 and 0.74±0.11 respectively in patients without aki and with that of aki was 70±48.9 and 2±1.45 respectively. table 1. clinical and laboratory prole of patients with aki and without aki *is statistically signicant using chi square test patients with aki after mi had a more number of complications like arrhythmia, heart failure, hypotension, lvef (<30%), rupture (free wall or septum or papillary muscle) as compared to patients without aki as shown in the table below. table 2. complication in post-mi patients with aki and without aki *is statistically signicant using chi square test mortality in patients with aki was 6 and in patients without aki was 4, which was found to be statistically signicant. discussion: the incidence of aki increased by fourfolds in the united states since 1988 and is projected to have incidence of 500 per 100,000 population annually, which is more than incidence of stroke annually. aki is related to markedly increased risk of mortality in hospitalized patients, predominantly in those who were admitted to the icu wherein mortality rates could be more than 50%.[1] acute kidney injury (aki) is dened by the impairment of kidney ltration and excretory function over days to weeks, resulting in retention of nitrogenous and other waste products 1normally cleared by the kidneys. by this denition the presence of aki is dened by an elevation in the serum creatinine concentration or reduction in urine output. aki is currently dened by a rise in serum creatinine from baseline of at least 0.3 mg/dl within 48 h or at least 50% higher than baseline within 1 week or a reduction in urine output to <0.5 7ml/kg per h for longer than 6 h. 2aki leads to an increase in cardiac biomarkers of ischemia ; 3also there is an increase in cytokines (inammatory) , 4endothelial dysfunction and dysregulation in mineral 5, 6metabolism . in post mi patients, the complication of aki, for example, dyselectrolytemia , hypervolumia, acidosis and others leads to increase in mortality and adverse outcome after mi. in a study by , fox cs et al found that kirsten e. fleischmann clinical factors,for example heart failure, hypotension, and the majority cardiac risk factors; and the procedures such as coronary artery catheterization and coronary artery bypass grafting,were found associated with increasedrisk for aki. they found that mortality was 2.1% in patients without aki, as compared to patients with mild, moderate and severe aki was 6.6%, 14.2%, and 31.8% respectively. aki was found to be associated with an increased risk of bleeding, i.e. 8.4% in patients without aki and 32.7% in patients with severe aki. [8] parikh rp, steven g, coca do yongfei ms; , et al found that aki has a graded and independent association with long-term mortality. they concluded that mild, moderate and severe aki was associated with a 15%, 23% and 33% increased risk of death respectively at 10 years. [9] thus, we conclude that aki is a frequent complication in ami that is associated with notable shortand long-term mortality. post-mi complication and mortality in patients with aki was more than that in patients without aki. careful monitoring of susceptible patients in icu is recommended for early detection and management of aki in those patients. conclusion: high troponin i and older age are the most important risk factors for aki in patients with acute mi. post-mi complication and mortality in patients with aki was more than that in patients without aki. careful monitoring of susceptible patients in icu is recommended for early detection and management of aki in those patients. references 1. kasper dl, fauci as, hauser sl, longo dl, jamesone jl,loscalzo j. harrison ‘s principles of internal medicine (20th edition ) new york : mcgraw hill education 2018;2: 2099 2. song d, de zoysa jr, ng a, chiu w: troponins in acute kidney injury. ren fail 34: 35–39, 2012 3. hoke ts, douglas is, klein cl,he z, fang w, thurman jm, tao y, dursun b, voelkel nf, edelstein cl, faubel s: acute renal failure after bilateral nephrectomy is associated with cytokine-mediated pulmonary injury. j am soc nephrol 18: 155–164, 2007 4. ko gj, grigoryev dn, linfert d, jang hr,watkins t, cheadle c,racusen l, rabb h: transcriptional analysis of kidneys duringrepair from aki reveals possible roles for ngal and kim-1 asbiomarkers of aki-to-ckd transition. am j physiol renal physiol298: f1472–f1483, 2010 5. christov m,waikar ss, pereira rc, havasi a, leaf de, goltzman d, pajevic pd,wolf m, ju¨ppner h: plasma fgf23 levels increaserapidly after acute kidney injury. kidney int 84: 776–785, 2013 6. leaf de, waikar ss, wolf m, cremers s, bhan i, stern l:dysregulated mineral metabolism in patients with acute kidneyinjury and risk of adverse outcomes. clin endocrinol (oxf) 79:491–498, 2013 7. kasper dl, fauci as, hauser sl, longo dl, jamesone jl, loscalzo j. harrison ‘s principles of internal medicine (20th edition ) new york : mcgraw hill education 2018;2: 2104 8. kirsten e. fleischmann, fox cs et al. acute kidney injury in myocardial infarction. massachusetts. nejm journal watch.2012 9. chirag r. parikh, steven g, coca do; yongfei ms,long-term prognosis of acute kidney injury after acute myocardial infarction. arch intern med. 2008;168(9):987-995. 10. meier p, lansky aj, baumbach a. almanac 2013: acute coronary syndromes. heart. 2013; 99: 1488-1493. 11. task force on the management of st-segment elevation acute myocardial infarction of the european society of cardiology (esc). steg pg, james sk, atar d, badano lp, blömstrom-lundqvist c, borger ma, et al. esc guidelines for the management of acute myocardial infarction in patients presenting with st-segment elevation. eur heart j. 2012;33:2569-619. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra no aki aki p value age 50± 6.1 53±5.9 0.004* troponin i(ng/ml) 2.4±3.4 5.29±7.1 0.015* cpk-mb (ng/ml) 65.3±84.9 44.1±76.5 0.19 urea (mg/dl) 33.9±11.9 70±48.9 0.00002* creatinine (mg/dl) 0.74±0.11 2±1.45 0.000003* albumin (g/dl) 3.7±0.6 3.5±0.4 0.086 a/c ratio (mg/g) 84±58 99±86 0.16 fasting blood glucose (mg/dl) 94.7±32.1 145±40 0.013* complications post-mi with aki post mi without aki pvalue arrhythmia 5 (13.9%) 3 (4.7%) 0.048* heart failure 6 (16.7%) 4 (6.3%) 0.046* hypotension 21 (58.3%) 19 (29.7%) <0.001* lvef (<30%) 11 (30.6%) 8 (12.5%) <0.001* rupture (free wall or septum or papillary muscle) 1 (2.8%) 0 (0%) 0.477 death 6 (16.7%) 4( 6.3%) 0.0238* x 17gjra global journal for research analysis introduction while most of the urethrocutaneous stulae are acquired as a complication of hypospadias repair surgery, congenital urethrocutaneous stulae (cucf) are extremely rare with only 64 reported cases since 1962. penoscrotal position is rare among the reported cases. [1,2] the cause is unclear. however, it may be due to a focal defect in the urethral plate that prevents fusion of urethral folds. [3] in this study, we describe a case of a congenital penoscrotal urethrocutaneous stula that was managed by primary tubularisation of exposed urethral plate with tunica vaginalis reinforcement. post-operatively, the child recovered well without any complications and is comfortable on follow-up. case presentation a 10-year-old uncircumcised boy presented to our outpatient clinic with complaints of passing urine through an opening located on the ventral aspect of his penis. there was no history of poor stream of urine or pain during micturition. he had neither history of trauma nor surgical intervention. there was no family history of genitourinary tract malformations. on local examination, a stula was seen on the ventral aspect of the shaft of the penis at penoscrotal junction, with exposed urethral plate measuring 7 x 3 mm. distal to the stula, the spongiosum, preputial skin, and the glans were intact with normal external urethral meatus. the distal and proximal urethra could be negotiated with an 8 french silicon tube without difculty (figure1). there were no associated genitourinary or anorectal anomalies. ultrasound abdomen and cystourethrogram were normal. the child was managed by a circum-stulous incision, mobilization of the splayed out spongiosa in that region, primary surgical tubularisation of exposed urethral plate over an 8 french silicon catheter, spongiosal repair (figure2), and reinforcement with tunica thvaginalis (figure3). catheter was removed on 7 postoperative day, and he had uneventful recovery. on follow up after 6 months, the boy had a good stream of urine through the external urethral meatus (figure4). discussion congenital urethrocutaneous stula is a rare anomaly which can either be isolated or in conjunction with other genitourinary or anorectal anomalies with a few reported cases. as in a meta-analysis study by lin y et al of 63 cases, the least common site of cucf was at the penoscrotal junction (5/63) while sub-coronal position was most common (33/63) [1]. with extensive review of english language literature, we could not nd any report of any isolated penoscrotal cucf without associated anomalies, making our case, a rst reported case of such nature. until 8 weeks of gestation, the male and female external genitalia are identical. the male external genitalia develops under the inuence of testosterone. in a growing phallus, the urethral folds coalesce in the midline from base to tip, forming a tubularised penile urethra and median scrotal raphe. at the 11th week, when leydig cells increase in number and size, urethral folds begin to fuse ventrally in the midline to form urethra. failure of fusion gives rise to the formation of cucf. [4] the etiology however remains unclear and several theories have been stated previously to explain its causes. olbourne stated that stulae located in the shaft of the penis is probably due to a focal defect in urethral plate function which may result in a complete defect or a partial deciency of urethral fold fusion. [3] as theorized by goldstein, a transient deciency in testicular evocator substance may lead to a cucf with chordee. [5] another theory by duckett suggested formation of a cucf by rupture of small diverticulum from the peni le ure thra . [4 ] karnak regarded congeni ta l urethrocutaneous stulae (excluding those associated with anorectal anomalies) as a separate set of anomalies. [6] congenital urethrocutaneous stulae may be secondary to embryonic urethral blowouts behind a distal congenital obstruction as suggested by campbell. [7] as stated by cook and stephens in their study, pressure atrophy from the heel of the baby's foot was a potential cause for cucf. [8] caldamone et al noted a ventral penile cyst before the spontaneous development of urethral stula, which was also seen by knapp who noticed six cases of cysts along the mediogenital raphe at the frenulum. [9,10] similarly, there was a case report of a baby with postnatal anterior urethrocuteous stula with prenatally identied penile cystic structure. [10] surgical approach to repair cucf depends on the type of stula. it is of paramount importance to rule out urethral duplication (y type urethral stula) which may be associated with anorectal anomalies. surgical repair follows the principles of hypospadias repair. these include local skin ap, preputial skin ap, thiersch-duplay urethroplasty, denis brown urethroplasty, buccal mucosal graft and tubularised incised plate urethroplasty with dartos ap and primary closure. [2] the choice of the method of repair is based on the size and the location of the stula as well as existing other anomalies and the condition of the distal urethra. if there are congenital penoscrotal urethrocutaneous fistula: a rare presentation original research paper ranjith kumar sridhar post graduate, m.s. general surgery, sri ramachandra institute of higher education and research, chennai, tamil nadu. surgery congenital urethrocutaneous stula is an extremely rare but easily manageable anomaly that can either be present in an isolated fashion or in association with other abnormalities of the genitourinary tract like hypospadias or chordee or anorectal malformations. a case of isolated congenital urethrocutaneous stula at the penoscrotal junction which was managed surgically by primary tubularisation of exposed urethral plate with tunica vaginalis reinforcement has been reported along with review of literature. surgical principles will be similar to any hypospadias repair. treatment of this rare condition is decided according to the site of the stula, associated anomalies and condition of the distal urethra. a meticulous clinical examination will yield the diagnosis and to rule out other associated anomalies. abstract keywords : congenital, urethrocutaneous, hypospadias, anorectal volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra jegadeesh sundaram* m. ch paediatric surgery, assistant professor, department of paediatric surgery, sri ramachandra institute of higher education and research, chennai, tamil nadu. *corresponding author 36 x gjra global journal for research analysis associated anomalies like decient distal urethra or spongiosum, associated chordee or hypospadias, a formal hypospadias repair is recommended. conclusion a cucf is an extremely rare anomaly which is easily manageable and needs meticulous examination to rule other associated anomalies. the type of surgery is based on the patency of the distal urethra, intactness of the distal spongiosum, size of stula, and the width of exposed urethral plate. following the principles of hypospadias repair, with proper mobilization and tubularisation, this condition is manageable with high success rate without recurrence. figures figure 1 figure 2 figure 3 figure 4 references 1. lin y, deng c, peng q. congenital anterior urethrocutaneous fistula: a systematic review. afr j paediatr surg 2018;15:63–8. 2. hassan a, kotb m, shehata s. congenital anterior urethrocutaneous stula: a case report and review of literature. urology case reports 2019;27. 3. olbourne na. congenital urethral stula. case reports. plast reconstr surg. 1976;57:237–9. 4. kale sm, mody nb, patil sb, sadawarte p. congenital urethrocutaneous stula in an adolescent male. indian j plast surg 2015;48:204-7. 5. goldstein m. congenital urethral stula with chordee. j urol. 1975;113:138–40. 6. karnak i, tanyel fc, hiçsönmez a. congenital urethrocutaneous stula: a case report and literature review, with a nomenclature proposal. j pediatr surg 1995;30:1504–5. 7. campbell m: clinical pediatric urology. philadelphia:w. b. saunders co.1951:531-3. 8. cook wa, stephens fs. pathoembryology of the urinary tract. in: urological surgery in neonates and young infants, l. r. king, ed. saunders, philadelphia, usa, 1988. 9. caldamone aa, chen sc, elder js, ritchey ml, diamond da, koyle ma, et al. congenital anterior urethrocutaneous stula. j urol 1999;162:1430–2. 10. biswas s, ghosh d, das s. congenital urethrocutaneous fistula—our experience with nine cases. indian j surg 2014;76:156–8. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 37gjra global journal for research analysis 1. introduction bacterial infection is an important problem in a world where mortality in developed countries is 20% with the largest number in children aged 1-4 years. early and accurate diagnosis of infection in children is very important to reduce mortality. [1] the human body is at risk of infection by various types of pathogenic microorganisms. before causing an infection, microorganisms must come into contact with the host and then form the focus of infection. [2] bacterial infections that reach blood are called bacterteremia.[3] cases of bacteremia can be established through culture testing and drug sensitivity which is the gold standard examination.[4] bacteremia can cause death with a mortality of 30% where high mortality is associated with the establishment of inaccurate and late diagnoses. [4-5] bacterial infections causing leukocytes are widely circulated and are characterized by increased neutrophils and lower lymphocytes, this is caused by an inammatory process. [6] the neutrophil lymphocyte ratio (nlr) is one of the infection markers currently being investigated and from the results of previous studies in the netherlands in 2001 stated that rnl was better as a predictor of bacteremia compared to creactive protein (crp), total leukocytes, and neutrophils. [7] the same was stated in turkey in 2015 where the neutrophil lymphocyte ratio could be used as an inammatory biomarker in acute exacerbation of bronchiectasis in children due to the physiological response of leukocyte circulation in the human body due to increased neutrophils and decreased lymphocytes. [8] increased neutrophils occur during systemic inammation caused by delayed apoptosis and stem cell stimulation by growth hormone and decreased lymphocytes due to redistribution of lymphocytes to the lymphatic system accompanied by accelerated apoptosis.[7,9-10] research that assesses nlr begins in adults but still few in children where several studies report that an increase in nlr is associated with poor prognosis and ideal cut-off still varies with grades 3 to 5.4. therefore, research is needed to assess nlr in children because nlr is easy, simple with a relatively low cost so that it can be used in daily practice. [5,11-12] this study aims to determine whether nlr can be used as a predictor of bacteremia. 2. methods research with a cross-sectional retrospective design on children performed blood culture at h. adam malik hospital in 2017. sampling was done in total population and a sample of 506 children who met the inclusion and exclusion criteria was obtained. data analysis used the chai squared test (p <0.05). inclusion criteria: 1. patients aged 0 days 18 years (before the 18th birthday), 2. patients treated in january 2017 to december 2017, 3. blood cultures are examined, 4. there are data on neutrophils and lymphocytes. exclusion criteria: secondary data from medical records are incomplete (examination of blood culture and complete blood, especially neutrophils and lymphocytes is not available). this research was conducted 6 months after obtaining approval from the health ethics committee from the faculty of medicine, universitas north sumatra/rsup.h. adam malik. 3. result this research was conducted at h. adam malik general hospital medan in 2018. samples were taken from the medical records of pediatric patients who carried out blood culture examinations in 2017. the total sample was 511 people but 6 people did not meet the inclusion criteria totaling 505 people. the ow of research results can be seen in gure 1. neutrophil lymphocytes ratio as a predictor of bacteremia in children original research paper nurhasanah lubis* department of child health, faculty of medicine, universitas sumatera utara, haji adam malik general hospital, medan, indonesia *corresponding author medicine bacterial infections are an important problem in the world. early and accurate diagnosis to detect infection is very important in order to reduce mortality. many bacterial infections that cause leukocytes are circulating and are characterized by increased neutrophils and decreased lymphocytes, this is caused by the inammatory process. the neutrophil lymphocyte ratio (nlr) is one of the infection markers currently being investigated because it is easy to do, simple with relatively low cost so that it can be used in daily practice. research with a cross-sectional retrospective design on children performed blood culture at h. adam malik hospital in 2017. sampling was done in total population and a sample of 506 children who met the inclusion and exclusion criteria was obtained. data analysis used the chai squared test (p <0.05). this study looked at the 5 most bacteria, namely klebsiella pneumonia, acinetobacter baumanii, staphylococcus aureus, escherichia coli, staphylococcus haemolyticus. the neutrophil lymphocyte ratio is better for determining bacteremia with sensitivity of 80.5%, specicity of 26.9%, positive predictive value of 33% and negative predictive value of 74% and cut off 1.3 but cannot be used as a guide because the relationship between blood culture and nlr is not signicant with (p=0.1) and (or=1.4) abstract keywords : bacterial infection; blood culture; marker of infection; neutrophil lymphocyte ratio; predictor. bugis mardina lubis department of child health, faculty of medicine, universitas sumatera utara, haji adam malik general hospital, medan, indonesia syahril pasaribu department of child health, faculty of medicine, universitas sumatera utara, haji adam malik general hospital, medan, indonesia volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra ayodhia pitaloka pasaribu department of child health, faculty of medicine, universitas sumatera utara, haji adam malik general hospital, medan, indonesia 86 x gjra global journal for research analysis fig 1. flow of research results characteristic data 4. discussion this study found the types of bacteria that appeared in blood cultures and found 5 most types of bacteria, namely klebsiella pneumonia, acinetobacter baumanii, staphylococcus aureus, escherichia coli and staphylococcus haemolyticus. this is different from the ndings of a retrospective study in the united kingdom in 2014 in 1954 of patients with bacteremia with age> 17 years with the discovery of escherichia coli as the most bacteria followed by streptococcus spp and staphylococcus spp. [13] this difference was inuenced by different germ patterns in each hospital. in australia, haemophilus inuenza was found as the most bacteria found in 2001 to 2010. [14] this is different from this study where haemophilus inuenza was fastidius and thus was not detected in this study.[15] research in africa said that the most bacteria found in the study were staphylococcus aureus, escherichia coli, klebsiella pneumonia and acinetobacter baumanii. [16] the bacteria found in this study were in line with the ve largest bacteria in our study, the 5 most germs only had a sequence different. possibly caused by the two studies carried out in developing countries, with the type of bacteria that circulates similarly. the neutrophil lymphocyte ratio is one of the infection markers that can be used as a predictor of bacterial infection. this occurs because delayed apoptosis and growth hormones are stimulated by stem cells resulting in an increase in neutrophils and accelerated apoptosis accompanied by redistribution of lymphocytes so that neutrophils increase. [7,9-10] retrospective studies in spain obtained nlr results >7 and eosinopenia as markers of mortality in bacteremia and prospective studies in the czech republic obtained nlr >6.2 as a diagnostic bacteremia. while in this study the cut-off of nlr ≥1.3.[17-18] this difference in nlr cut-off may be due to the different ages in each of these studies. our study is a retrospective cross sectional study with the results of the study found nlr sensitivity of 80.5% with specicity of 26.9%, positive predictive value of 33% and negative predictive value of 74%. in a retrospective study in england in 2014 in 1954 patients with bacteremia with age were found starting 17 years with results of sensitivity and specicity of 70%, positive predictive value of 20% and negative predictive value of 92% and prospective studies in czech 2012 in 87 adult bacterial infections with 91% sensitivity 13,18and 96% specicity. if the three studies are compared then we can see that these three studies have high sensitivity but our study has low specicity. high sensitivity and specicity produce low levels of diagnostic errors. [19] sensitivity and specicity and cut-off are related to the number of patients. in this study, we analyzed the cut-off of nlr with gram-positive and gram-negative bacteria. gram positive bacteria have a cut off of 1.4 with a sensitivity of 81.1% and specicity of 26.3%. gram negative bacteria have a cut off of 1.3 with a sensitivity of 80.2% and specicity of 24.8%. the purpose of this analysis is to predict what bacteria will appear when a blood culture examination is carried out so that we can provide antibiotics that might be suitable for the bacteria. in this study, it was found that nlr was better for determining bacterial infections than procalcitonin, crp and it ratio but could not be used as a guide because the relationship between nlr and blood culture was not signicant. this is in line with zahorec's research, et al., who said that nlr compared to crp, total leukocytes and neutrophils had better results for determining bacteremia.[7] the study by holub, et al. stated that nlr is a good parameter for predicting bacterial infections compared to wbc, crp and the number of neutrophils. [19] other researchers, kristiani, et al., stated that nlr is associated with inammation so that it can be used as a parameter to diagnose neonatal infection.[20] research by mentis found results of nlr and csf neutrophil count useful for distinguishing bacterial infections from viruses. [21] several other studies that obtained different results, namely the study by hamiel u, et al., obtained crp results as the best single marker for acute infection in febrile infants, absolute neutrophil count best for invasive bacterial infections and nlr and absolute neutrophils play a role in evaluating bacterial infections.[22] our research has benets and advantages because we can use nlr as a predictor of bacterial infections as an alternative examination, especially on health facilities that are limited to cheap and simple costs and we can give antibiotics immediately while waiting for the results of blood cultures so that patients can be treated more fast and on target. the limitation of our study is that this study was conducted volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra characteristic data, n (%) n= 505 gender, n(%) ÿ boys 293 (58) ÿ girls 212 (42) age, n (%) ÿ < 1 year 174 (34,4) ÿ 1-4 year 107 (21,2) ÿ 5-10 year 103 (20,4) ÿ > 10 year 121 (24,0) neutrol, mean (sd) ÿ < 1 year 62,9 (17,7) ÿ 1-4 year 57,6 (25,1) ÿ 5-10 year 57,5 (27,7) ÿ > 10 year 70,6 (24,3) limfosit, mean (sd) ÿ < 1 year 25,4 (15,2) ÿ 1-4 year 31,0 (22,9) ÿ 5-10 year 29,3 (23,9) ÿ > 10 year 18,5 (18,6) leukosit, mean (sd) ÿ < 1 year 14.583 (9.319) ÿ 1-4 year 19.456 (28.948) ÿ 5-10 year 12.288 (9.416) ÿ > 10 year 20.760 (52.457) c-reactive protein ÿ positif 159 (31,4) ÿ negatif 70 (13,9) ÿ not inspected 276 (54,7) procalcitonin ÿ positif 134 (26,5) ÿ negatif 136 (26,9) ÿ not inspected 235 (46,5) it ratio ÿ positif 1 (2) ÿ negatif 43 (8,5) ÿ not inspected 461 (91,3) x 87gjra global journal for research analysis using a retrospective cross-sectional design, incomplete data, medical records so that it can cause information bias so that further prospective research is needed to ascertain whether this nlr can properly be a predictor of bacterial infections so that it can be applied daily . the absence of fastidious bacteria is likely due to non-existent inspection facilities. 5. conclusion the ratio of neutrophil lymphocytes not yet used as a predictor of bacteremia in children. references [1] bruel av, haj-hassan t, thompson m, buntinx f, mant d. diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: a systematic review. lancet. 2010; 834-45. [2] soedarmo ssp, garna h, hadinegoro srs, satari hi. buku ajar infeksi dan pediatri tropis. jakarta. ikatan dokter anak indonesia; 2002. h.13. [3] kim yk, jeng td, lee w, chun s, min wk. procalcitonin in the assessment of bacteraemia in emergency department patients: results of a large retrospective study. ann clin biochem. 2015; 1-6. [4] gurol g, ciftci ih, terzi ha, atasoy ar, ozbek a, koroglu m. are there standardized cutoff values for neutrophil-lymphocyte ratios in bacteremia or sepsis?. j. mikrobiol. biotechnol. 2015; 521-5. [5] de jager cpc, van wijk pt, mathoera rb, de jongh jl, van der poll t. lymphocytopenia and neutrophil-lymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit. crit care. 2010; 14:192. [6] bozdemir se, altintop ya, uytun s, aslaner h, torun ya. diagnostic role of mean platelet volume and neutrophil to lymphocyte ratio in childhood brucellosis. korean j intern med. 2017; 32:1075-81. [7] zahorec r. ratio of neutrophil to lymphocyte counts rapid and simple parameter of systemic inammation and stress in critically ill. bratisl lek listy. 2001; 102(1):5-14. [8] nacaroglu ht, erdem sb, karaman s, yazici s, can d. can mean platelet volume and neutrophil-to-lymphocyte ratio be biomarkers of acute exacerbation of bronchiectasis in children?. cent eur j immunol. 2017; 42(4):358-62. [9] duksal f, alaygut d, guven as, ekici m, oaz mb, tuncer r, dkk. neutrophillymphocyte ratio in children with familial mediterranean fever: original article. eur j rheumatol. 2015; 1:20-3. [10] de jager cpc, wever pc, gemen efa, kuster r, van gageldonk-lafeber ab, van der poll t, dkk. the neutrophil-lymphocyte count ratio in patients with community-acquired pneumonia. plos one. 2012; 7(10):1-8. [11] yigit y, yilmaz s, akdogan a, halhalli hc, ozbek ae, gencer eg. the role of neutrophil-lymphocyte ratio and red blood cell distribution width in the classication of febrile seizures. eur rev med pharmacol sci. 2017; 21:554-9. [12] imtiaz f, shaque k, mirza ss, ayoob z, vart p, rao s. neutrophil lymphocyte ratio as a measure of systemic inammation in prevalent chronic diseases in asian population. int arch med. 2012; 5:2. [13] okashah as, el-sawy m, beshay bn, el raouf a. ratio neutrophil to lymphocyte counts as a simple marker for sepsis and severe sepsis in intensive care unit. res anesth. 2014; 2:39-45. [14] jensen us, knudsen jd, wehberg s, gregson db, laupland kb. risk factors for recurrence and death after bacteraemia: a population-based study. clin microbiol infect. 2011; 17:1148-54. [15] abdou ma, stockel h. unsuitability of blood culture media containing sodium polyanetholesulfonate for the detection of fastidious microorganism in csf and other blood-free body fluids. depart mikrobiol. 1982. 109-117. [16] lochan h, pillay v, bamford c, nuttall j, eley b. bloodstream infections at a tertiary level paediatric hospital in south africa. bmc infect dis. 2017; 17:750. [17] terradas r, grau s, blanch j, riu m, saballs p, castells x, et al. eosinophil count and neutrophil-lymphocyte count ratio as prognostic markers in patients with bacteremia: a retrospective cohort study. plos one. 2012; 7:8. [18] holub m, beran o, kasprikova n, chalupa p. neutrophil to lymphocyte count ratio as a biomarker of bacterial infections. cent eur j med. 2012; 258-61. [19] yusa t, tateda k, ohara a, miyazaki s. new possible biomarkers for diagnosis of infections and diagnostic distinction between bacterial and viral infections in children. j infect chemother. 2016; 1-5. [20] kristiani s, hendrianingtyas m. hubungan neutrophils/lymphocytes ratio dan c-reactive protein pada infeksi neonatal. jnh. 2017; 5(3):187-94. [21] mentis ae, kyprianou ma, tzanakaki g. age-spesic application of neutrophil-to-lymphocyte ratio in meningitis: a nationwide study. eur j clin mikrobiol infect dis. 2017; 1-5. [22] hamiel u, bahat h, kozer e, hamiel y, ziv-baran t, goldman m. diagnostic markers of acute infections in infants aged 1 week to 3 months: a retrospective cohort study. bmj open. 2017;8:1-9. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 88 x gjra global journal for research analysis introduction oligohydramnios is a serious complication of pregnancy, that is integrated with a poor perinatal outcome. it complicates 15%of term pregnancies (1). over all incidence is 3.9% of all pregnancies. oligohydramnios is dened as amniotic uid th index less than 5 percentile for the gestational age (moore and cayle) or afi less than or equal to 5cm regardless of gestational age. (phelan) it can be classied as mild, moderate & severe oligohyd ramnios when deepest pocket devoid of cord /fetal limbs measuring < 3, 2, or 1cm, respectively. (1) normal amniotic uid index is between 8.1-20cm.(2) bord erline oligohydramnios is dened as amniotic uid index between 5.1-8cm. manning et al dened oligohydramnios when largest pocket on ultrasound in its broadest diameter measured < 1cm. they revised the criteria to a single pocket measuring 2cm in both vertical/horizontal plane.(3) amniotic uid is an important part of pregnancy sac and helps in fetal development(4). it surrounds the foetus and provides protective low resistance environment suitable for fetal growth and development (5). it also protects fetus from trauma, maintains body temperature and it has bacteriostatic properties. its pressure helps in reducing the loss of lung uid and assist in pulmonary development(6). it supports development of musculoskeletal system by permitting foetal movements in addition to the growth and development of gastrointestinal system by swallowing amniotic uid(7). oligohydramnios is found to be associated with increased frequency of maternal & fetal complications.(8) it may be associated with uteroplacental insufciency, preeclampsia, hypertension, diabetes, cardiac disease, congenital anomalies, idiopathic fetal growth restriction, fetal hypoxia etc. oligohydramnios, in a pregnancy without fetal renal abnormality or genitourinary obstruction is thought to represent chronic in utero stress the impact of oligohy dramnios on maternal & fetal outcome can be signicant.(9) complication of oligohydramnios a)maternalprolonged labour, malpresentation , caesarean delivery, instrumental delivery, protracted labour, premature rupture of membrane b)fetalmeconium aspiration syndrome, septicaemia, fetal pulmonary hypoplasia, cord compression, deformity, perin atal mortality, nicu admission low apgar, abortion by diagnosing such cases early & timely intervention can prevent most of the complications. in case of irreversible complications having occurred, termination of pregnancy can be considered. objective of the study to assess the fetal and maternal outcome at term in low risk pregnancy with afi ≤5. materials and methods the prospective, case and control study conducted at government medical college, nagpur, maharashtra from dec 2017 to nov 2019.in study 102 pregnant women with oligohydramnios (afi ≤5) as case group and 102 pregnant women with afi >5 as control group. all the low risk cases that are available up to the study period is taken for the purpose of the study. consent from the patient is taken and ethical clearance taken from the ethical committee. this study includes an analysis of mode of delivery, meconium passage, birth weight, apgar score, neonatal intensive care unit admissions and neonatal deaths. inculsion criteria: 1. afi ≤5 2. single live intrauterine gestation with cephalic presentation 3. 37 completed weeks of gestation 4. intact membrane. 5. low risk pregnancy exclusion criteria 1. afi more than 5 2. gestational age <37 completed weeks 3. post-term (more than 42weeks) 4. associated fetal malformations 5. ruptured membranes 6. malpresentation and multiple gestation 7. pregnancy with maternal diseases like hypertension in pregnancy, diabetes, chronic renal disease, connective tissue disorders. 8. any other obstetric complications. the patients is selected after detail clinical history and exami pregnancy outcome in amniotic fluid index less than 5 at term low risk pregnancy original research paper dr mansi shrigiriwar department of obstetrics & gynaecology, government medical college, nagpur, maharashtra-440009 x 29gjra global journal for research analysis obstetrics & gynaecology background: to study the maternal and perinatal outcome in oligohydramnios of afi(amniotic uid index) ≤ 5 cm at term in low risk pregnancy methods: a prospective case control study consists of an analysis of pregnancy outcome in 102 cases with diagnosis of oligohydramnios (≤5) after 37 to 41weeks6days completed is compared with 102 controls with pregnant women afi>5. results: there is increased chances of oligohydramnios with primigravida. the selected outcomes showed signicant variations in both groups with increase rate of caesarean section, fetal distress, and nicu admission. conclusions: an amniotic uid index of ≤ 5 cm detected after 37 completed weeks of gestation is an indicator of maternal and poor perinatal outcome. in method of fetal surveillance determination of afi can be important. abstract keywords : perinatal outcome, oligohydramnios, a < 5 cm, maternal outcome dr shrikant khandekar* department of obstetrics & gynaecology, government medical college, nagpur, maharashtra-440009 *corresponding author volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 30 x gjra global journal for research analysis nation such as age, height, weight, bmi, weight gain, marital status, duration of amenorrhea, booked/referral ,number visits, detail obstetric history, menstrual history, regarding previous congenital abnormalities, oligohydramnios or major medical disorders complicating pregnancy like diabetes, cardiac disease, hypertensive disorders, anaemia, chronic renal diseases, etc. all patient the low risk pregnancy included having afi≤5 on sonography and completed 37 weeks of gestation. besides baseline characteristics, indication for induction and the method of induction is noted. methodology for induction-augmentation in our study: bishop score <6 pge1 2550μg vaginally/orally repeated after 2-4hours if necessary (10) or foleys induction. & bishop score >7 -arm(articial rupture of membrane) titrated oxytocin infusion: dose dependant on uterine response study conducted on women with uncomplicated oligohydramnios at term with amniotic uid index 5 cm and a low bishop score <-6 who underwent induction of labor with prostaglandin e2. indication for caesarean section in our study are:-fetal distress, failed induction, meconium stained liquor with fetal distress, obstetric indication (failure to progress) observations this study was conducted in department of obstetrics & gynaecology at tertiary care hospital from dec 2017 to nov 19. the observation & results of this study are shown below in form of tables and graphs. case group patient with afi ≤ 5. control group -patient with afi >5. table no 1: -inter group comparison of mean age in case and control group table no 2: -age distribution of patients table no 3-description of patient according to gravida. table no 4-nst (non stress test) in groups nrnon-reactive r-reactive table no 5-mode of induction in study various methods table no 6-mode of delivery in study table no7outcome of pregnancy in case and control groups ftnd-full term normal delivery, fd-fetal distress, mslmeconium stained with liquor, vf-variable fetal heart rate, cpd-cephalopelvic disproportion, dta-deep transverse arrest, fi-failure of induction, fp-failure to progress table no 8-apgar at 5min in groups of study. table no 9-nicu admission of neonates table no 10-mortality of neonates in study discussion accurate antepartum estimation of amniotic uid volume by clinical means alone is difcult, but it is easily diagnosed by current ultrasound methods. identication of oligohydr amnios women with sonography not difcult in modern era. this helps us to be more cautious and anticipate problems especially during labor. reduced amniotic uid at term is generally considered to have increased risk of intrapartum complications. the risk is volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra groups n mean std. deviation age case 102 24.96 ±4.275 control 102 25.62 ±4.450 groups age (years) cases control total chi square value p value of chi square test <20 4 7 11 21-25 59 48 107 26-30 23 30 53 2.904 0.407# >30 16 17 33 total 102 102 204 groups cases controls total chi square value p value of chi square test gravida 1 64(62.74) 54(52.94) 118 2 33(32.35) 41(40.19 74 2.046 0.360# 3 5(4.91) 7(6.87) 12 total 102 102 204 groups cases controls total chi square value p value of chi square test nst nr 11(10.78%) 8(7.84%) 19 r 91(89.22%) 94(92.16%) 185 0.522 0.470# total 102 102 204 case control misoprostol 12 59 foley's 90 74 arm 95 85 oxytocin 87 84 mode of delivery normal lscs case 23(22.54%) 79(77.46) control 71(69.60%) 31(30.40%) groups cases controls maternal outcome of study and indications of lscs ftnd 23(22.54) 71(69.6) fd 40(39.21) 15(14.70) msl fd 15(14.70) 7(6.86) vf 13(12.74) 3(2.94) cpd 3 2 dta 1 1 fi 1 2 fp 6 1 total 102 102 groups cases controls total 5'' apgar <7 12(11.76) 6(5.88) 18 ≥7 90(88.24) 96(94.12) 176 total 102 102 204 case control mother side 90(88.24) 96(94.12) nicu admission 12(11.76) 6(5.88) total 102 102 case control no 102 102 yes 0 0 most of patients in study is between 21 to 25 years of age group in both case (57.84%) and control (47.05%) and least number of patients were ≤20 years (i.e3.92% and 6.86%). and mean age in case group-24.96±4.275 and control group25.62±4.450. among study primigravida is 62.74% in case group and rd52.94% in control group and patient with 3 gravida was less. in study booked and referral patients number was almost same. the non-reactive nst high rates in women with afi <5 cm. the rate of non-reactive nst is 10.78% in present study and is less compared to that in similar study by purvi p.et al ,chandra et al. (24), sriya and singhai, , & sowmya.k et al with 68% ,69.23%, 41.55% & 12% respectively. various studies show different rate of caesarean section in pregnant women with amniotic uid index of <5 cm. the lscs rate in case group was 77.48% and in control group 30.40% with compare to other studies casey et at, mangal puri et al, purvi k. patel et al, maha al. bayatti et al,t. minwuye. et al, p.gaikwad et al, sowmya .k et al and ghosh et al was 32%,76%,81.25%,70%,80.3%,73.4%,68% and 49.10% respectively. in our study mode of delivery was compared between the two groups and it was found that in group with oligohydramnios normal delivery was 22.54% and with non-oligohydramnios was 69.40%. and this comparable to other studies of mangal puri et al-24%,purvi k. patel et al-18.25%,maha al. bayatti et al -30%,t. minwuye et al-19.7%,p. gaikwad et al-26.6% and sowmya .k et al-32%. in this study occurrence of meconium stained liquor seen in 14.70% for that lscs done for better outcome of newborn, and this is compare to casey et al. 54%, mangal puri et al. 14%, p.kaur 50%, & vibha moses 12.5% . among patients of caesarean section most of patients indication was fetal distress .in our study 53.91% patients within case lscs done for fetal distress of that meconium stained liquor with fetal distress was 14.70%,similarily in control 21.56% patient undergone lscs out of which msl fd was 6.86%.in others studies lscs for fetal distress was casey et at 51%,sriya and singhai et al 43.05%,vibha moses et al 14%,maha al. bayatti et al 27%,t. minwuye,p. gaikwad et al 34.6% and sowmya .k et al-50% . the 5 min apgar score <7 is seen in 11.76% of oligohyd ramnios group and control group of 5.88 % which required nicu admission. 11.76% and 5.88% of newborns were x 31gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra variable casey et al 2000 (11) sriya & singhai 2001 (12) mangal p. et al 2017 (13) purvi .p et al 2014 (14) preshit chate et al 2012 (15) p.kaur et al 2015 (16) vibha moses 2016 (17) maya al .bayatti 2002 (18) tamiru minwuye et al 2017(19) nonreactive nst 41.35% 32% 65% 38% 38% vaginal delivery 24% 18.75% 36% 52% 58% 30% 19.7% lscs 76% 81.25% 64% 48% 42% 70% 80.3% fetal distress 51% 43.05% 14% 27% msl 54% 38.88% 14% 51.25% 46% 50% 12.5% 42% apgar<7 @5” 58.38% 28% 20% 16% 40% 16.3% 16% 1.7% nicu admission 7% 88.88% 16% 20% 42% 40% 35% 11.86% mortality 2% 8% 3.33% birth weigth <2.5kg 35% 58.38% 18% 62% further compounded in high risk pregnancies. however, the quantum of risk with reduced amniotic uid is less clear in low risk pregnancies. many studies shown conict between results. reduced afi in low risk pregnancies that is isolated reduction in amniotic uid in the presence of intact membranes and with no other risk factors is not a common nding parameter k. jagatia et al 2011(20) r. ghosh et al 2017(21) sowmya. k et al 2012(22) p.gaikwad et al 2016(23) present study 2019 non-reactive nst 32% 12% 42.8% 10.78% vaginal delivery 58% 50.9% 32% 26.6% 22.54% lscs 42% 49.1% 68% 73.4% 77.4% fetal distress 21% 50% 1% 53.91% msl 32% 14.70% apgar<7 @5” 15% 43.6% 14% 15% 11.76% nicu admission 22% 14% 22% 11.76% mortality 2% 3% 0 2% 0% birth weigth <2.5kg 70.9% 70.9% 18.63% admitted in the neonatal ward for various morbidities like birth asphyxia, meconium aspiration, etc. this is consistent with studies by mangal purvi et al 28%,purvik. patel et al 20% ,and casey et al 7%. a study by sriya and singhai et and p.kaur et al showed a higher incidence of 58.38% and 40%. we studied the perinatal outcome in the two groups and compared the nicu admissions in both the groups. in our study 11.76% of neonates had nicu admissions in oligohydramnios group compared to 5.88 % in afi >5 group and difference was not found to be statistically signicant in between the two groups. casey et at 7%, sriya and singhai et al 88.88%, purvi k. patel et al 20%, t. minwuye-11.86%, p. gaikwad et al 28.5%,mangal puri et al 16% and sowmya .k et al 14%. birth weight below 2.5 kg neonates in case is 18.63% and control group is 16.66% ,comparing to other studies this less. in casey et at, sriya and singhai et al ,mangal puri et al,p. chate et al ,t. minwuye,p. gaikwad et al and sowmya .k et al is 35%, 58.38% ,18% ,62% ,11.5% ,67.3% and 48% respectively in this study there is no mortality of neonates in both groups compare to other studies in which mortality was present like p.chate et al 2%,vibha moses et al 3.33% and p. kaur et al 8%. result 1) mean age of the women is 24.94± 4.275 years in case and 25.62± 4.45. most of the patients is between 21 to 25 years (57.84% and 47.05%) and the least number of patients is ≤20 years (3.92% and 6.86%) in case and control groups. 2) 62.74% and 52.94% of patient are primigravida in case and control groups. so primiparity is probably more associated with oligohydramnios, though statistically not signicant. 3) mode of induction in our institute was combined i.e misoprostol, foley's, arm, and oxytocin. for better fetal outcome lscs is done in study 4) most common indication for lscs in both groups is fetal distress i.e 53.91% (case)& 21.56% (control). 5) in case group maximum patient has lscs as mode of delivery, while in control group mode of delivery was vaginal delivery 6) occurrence of meconium (14.7%), failure of induction (0.98%), failure to progress (5.88%), cpd (2.94%) and variable fhs (12.74%) is minor indication in study. 7) variable fhs is more common in case group 12.74% than 2.94%control group. 8) nst and fhs by doppler or stethoscope are used for fetal record. non-reactive nst is 10.78% in case and 7.84% in control. 9) from above inferences we understand that probably oligohydramnios leads to increased intrapartum fetal compromise. 10) only % 11.76% and 5.88% neonates have apgar <7 at 5min and all of these neonates are admitted to nicu. but there was no neonatal death in this study. recommendation all of above studies recommend afi measurement at or after 37 weeks of gestation in low risk pregnancy is considered as one of the very sensitive method for fetal surveillance. references 1. taylor mf, fisk nm. hydramnios and oligohydramnios. in james dk, steer pj, weiner cp, gonik b, editors. high risk pregnancy, 3rd edition. philadelphia: wb saunder publications, 2006; 278-285. 2. phelan jp, ahn mo, smith cv. et al, "amniotic uid index measurements during pregnancy". j reprod med, 1987; 32: 601-604 3. manning fa, hill lm, platt ld. "qualitative amniotic uid volume determination by ultrasound in antepartum detection of intrauterine growth retardation". am j obst gynaecol 1981; 139: 254-258. 4. ever hf. comparalibity of amniotic uid index and single deepest pocket measurements in clinical practice. aus nj j obs and gynecol. 2003; 43:75-7 5. volent e, llimi g. alteration of amniotic uid and neonatal outcome. acta biomed. 2004; 75(1):71-5 6. nicolini u, fisk nm, rodeck cli. low amniotic pressure in oligohydramnios is this cause of pulmonary hypoplasia. am j obstet gynecol. 1989; 161(5):1098101] 7. ever hf. comparalibity of amniotic uid index and single deepest pocket measurements in clinical practice. aus nj j obs and gynecol. 2003; 43:75-7] 8. william m.g. amniotic uid disorders. in jennifer r.n, joe l.s, henry g, eric m.j, laura g, editors. obstetrics normal and problem pregnancies, 7th edition. elsevier publications 2016. 9. everett f, magan, dorota a, doherty, karan field et al. “biophysical prole with amniotic uid volume assessments.” journal of the american college of obstetricians and gynecologists, 2004;104:5-10 10. windrim r, bennett k, mundle w, young dc. “oral administration of misoprostol for labor induction : a randomized controlled trial” j obstetrics and gynecology ;1997, vol. 89, pp. 392-397. 11. casey bm, mcintire dd, bloom sl, lucas mj, santos r, twickler dm, remus rm. “ pregnancy outcomes after ante partum diagnosis of oligohydramnios at or beyond 34wks of gestation”. am j obstet gynecol 2000; 182: 909-920. 12. sriya r, singhai s. perinatal outcome in patients with amniotic uid index ≤5cm. j obstet gynecol india. 2001;51:98-100. 13. mangal puri, kanika sharma, ijmhr issn: 2454-9142 volume 3; issue 11; november 2017; page no. 129-134 “low amniotic uid index and intranatal and perinatal outcome in term pregnancy “ 14. patel pk, pitre ds, gupta h, “pregnancy outcome in isolated oligohydramnios at term”. ntl j of community med 2015; 6(2):84-88. 15. preshit chate, meena khatri, c. hariharan “pregnancy outcome after diagnosis of oligohydramnios at term” international journal of reproduction, contraception, obstetrics and gynecology, obstet gynecol. 2013 mar;2(1):23-26 www.ijrcog.org 16. kaur p et al.” a study on the perinatal outcome in cases of oligohydramnios ” int j reprod contracept obstet gynecol. 2016 jan;5(1):98-109 www.ijrcog.org pissn 2320-1770 | eissn 2320-1789 doi: http://dx.doi.org/10.18203/23201770.ijrcog20151608 17. vibha moses, sarita thakre” a study of maternal and fetal outcome in third trimester diagnose case of oligohydramnios” moses v et al. int j reprod contracept obstet gynecol. 2016 sept;5(9):2944-2948 www.ijrcog.org doi: http://dx.doi.org/10.18203/2320-1770.ijrcog20162969 18. maha m. al-bayat” amniotic fluid index as a predictor of perinatal outcome in patients with prolonged pregnancy” iraqi j. comm. med. jul. 2008 vol. (3) p 216-219. 19. tamiru minwuye , zelalem mengistu1 and simegnaw handebo, “severe oligohydramnios at term pregnancy and associated factors among pregnant women “acta scientic women's health” volume 1 issue 2 july 2019 20. jagatia k, singh n, patel s. maternal and fetal outcome in oligohydramnios: a study of 100 cases. int j med sci public health 2013; 2:724-727. doi:10.5455/ijmsph.2013.070520132 21. ghosh r et al” maternal and fetal outcome in oligohydramnios: study from a tertiary care hospital”. int j reprod contracept obstet gynecol. 2018 mar;7(3):907-910 www.ijrcog.org pissn 2320-1770 | eissn 2320-1789 doi: http://dx.doi.org/10.18203/2320-1770.ijrcog20180864 22. sowmya k “effect of isolated oligohydramnios in otherwise normal term pregnancy” international journal of biomedical research issn: journal doi:10.7439/ijbr coden:ijbrfa ijbr (2014) 05 (02) www.ssjournals.com 23. gaikwad pr et al. perinatal outcome in oligohydramnios and borderline amniotic uid index: a comparative study “int j reprod contracept obstet gynecol. 2016 jun;5(6):1964-1968 www.ijrcog.org pissn 2320-1770 | eissn 2320-1789 doi: http://dx.doi.org/10.18203/2320-1770.ijrcog2016169 24. chandra p, kaur sp, hans dk, kapila ak. the impact of amniotic uid volume assessed intrapartum on perinatal outcome. obstet gynaecol today 2000;5:478-81 volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 32 x gjra global journal for research analysis introduction: hermaphroditism is the condition of having both male and female reproductive organs. conditions that involve discrepancies between external genitalia and internal reproductive organs are described by the term intersex. intersex conditions are sometimes also referred to as disorders of sexual development. in true hermaphroditism, an individual has both ovarian and testicular tissue. the ovarian and testicular tissue may be separate, or the two may be combined in what is called an ovotestis. affected individuals possesses both the male xy and female xx chromosome pairs. in 46, xx intersex (female pseudo hermaphroditism), individuals have male external genitalia but the chromosomal constitution and reproductive organs of a female. in 46,xy (male pseudo hermaphroditism), individuals have ambiguous or female external genitalia but the chromosomal constitution and reproductive organs of a male. intersex surgery was performed to remove the gonads of the opposite sex. the remaining genitalia were then reconstructed to resemble those of the chosen sex. in older individuals the accepted gender may be reinforced by the appropriate surgical procedures and by hormonal therapy. case report: a 30-year-old male presented to our general surgery opd with small penis and hypospadiasis since childhood and enlargement of bilateral breasts for 16 years. associated with mild pain which was recent in onset for 16 years. he had no history of altered bladder habits, voice change, any comorbidities or any previous surgical history. his secondary sexual features were normal. upon local examination, he had bilateral gynecomastia, small size penis with single perineal urethral opening on the dorsal surface, bilateral small testis with right side rmer than the left. routine investigations were under normal limits. usg abdomen showed hypoechoic lesion in left iliac fossa probably left ovary. scrotal doppler revealed well dened hypo echoic lesions in the right testis with no internal vascularity probably ovary. fluorescence in situ hybridization revealed presence of 2x chromosomes in all the analyzed cells and he was positive for sry gene. urologist opinion was sought for hypospadiasis correction, which was planned at a later date. patient was taken up for bilateral webster procedure followed by right orchidectomy and laparoscopic left oophorectomy, as dysgenetic testis has high chances of turning malignancy. g 1: separating the ovo-testis from the peritoneum covering fig 2: ligating the pedicle fused to the ovo-testis. fig 3 & 4: ovo testis has been cut and removed. late presentation of a true hermaphrodite original research paper dr. pradhyumna koushik t.p. junior resident, associate professor, head of the department, associate professor, assistant professor department of general surgery general surgery one of the rarest variety of disorders of sexual differentiation (dsd) is true hermaphrodite and it represents only 5% of all cases. these cases usually present in early childhood or late adolescence with ambiguous genitalia. we are here reporting a rare case of a true hermaphrodite at 30 years of age with two cellular lines (46xx/46xy), small testis, hypospadias and breast pain. histology of the gonads revealed right ovotestes. abstract keywords : true hermaphrodite, ovo-testes, sexual differentiation disorders volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra prof. dr. mohanapriya t.* junior resident, associate professor, head of the department, associate professor, assistant professor department of general surgery *corresponding author dr. manuneethi maran junior resident, associate professor, head of the department, associate professor, assistant professor department of general surgery prof. dr. k. balaji singh junior resident, associate professor, head of the department, associate professor, assistant professor department of general surgery dr. nitesh junior resident, associate professor, head of the department, associate professor, assistant professor department of general surgery 58 x gjra global journal for research analysis post-operative period was uneventful. hpe revealed benign breast tissue and ovo-testicular tissue and benign serous cyst of ovary. patient was planned for testosterone replacement after surgery for continuing as male. discussion: the diagnosis of a true hermaphrodite depends on the histologic conrmation of testicular and ovarian tissue in the same individual. 90% of cases present at birth with ambiguous genitalia including micro phallus, hypospadias, urogenital s inus, fusion of penoscrotal labia, or cryptorchidism. individuals which present with even the slightest of ambiguity in the external genitalia and unilateral or bilateral undescended testicles should be investigated. 70% of cases of true hermaphrodites have 46 xx karyotypes. only 10% of cases are 46 xy karyotype, while the rest represent complex karyotypes of which the most common is 46 xx / 46 xy. true hermaphrodites can be classied according to the position and the histology of the gonads. i. lateral: testis and a contralateral ovary (30% of cases). ii. bilateral: both testicular and ovarian tissue, usually represented by an ovotestis that is identied on both sides (50% of cases). iii. unilateral: ovotestis on one side and a testis or ovary on the other side (20% of cases). imaging modalities that may aid in the diagnosis of true hermaphrodites include ul trasonogram, mri and genography. testis and ovaries have textural differences on ultrasound. management involves medical treatment, correction of the ambiguous genitalia and removal of dysgenic gonads by surgery if patient presents in their childhood or adolescent age. a soft testicular portion and a rm ovarian portion on palpation should arise a suspicion of ovo testis for diagnosis of a true hermaphroditism references 1. ouhilal s., turco j., nangia a., stotland m., manganiello p. d. true hermaphroditism presenting as bilateral gynecomastia in an adolescent phenotypic male. 2. barseghyan h., vilain e. the genetics of ovotesticular dsorders of sex development. genetic steroid disorders. 2014:261–263. doi: 10.1016/b978-012-416006-4.00020-x. 3. kropp b. p., keating m. a., moshang t., duckett j. w. true hermaphroditism and n o r m a l m a l e g e n i t a l i a : a n u n u s u a l p r e s e n t a t i o n . u r o l o g y. 1995;46(5):736–739. doi: 10.1016/s0090-4295(99)80314-8. 4. iqbal m. z., jam m. r., saleem m., ahmed m. true hermaphrodite: a case report. apsp journal of case reports. 2011;2, article 16 5. creighton s. surgery for intersex. journal of the royal society of medicine. 2001;94(5):218–220. 6. ceci, m., calleja, e., said, e., & gatt, n. (2015). a case of true hermaphroditism presenting as a testicular tumour. case reports in urology, 2015, 598138. doi:10.1155/2015/598138 volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 59gjra global journal for research analysis introduction surgical infection continues to affect the practice of every surgeon. at the minimum they lead to inconvenience to the patients and the surgeon. infection can cause an increase in patient's hospital stay, creat e discomfort, cause disgurement and lead to failure of operation. ÿ surgical wound infection continues to consume considerable portion of health care nances. the nancial drain that these infections place on the resource constrained hospitals in the form of prolonged hospitalization along with increased duration and dosage of medications that need to be administered to the patient. ÿ infection control is a major concern in health care in general, but it is particularly important issue in the sterile environment of the operating room, where patients undergo surgical procedures and are at signicant risk for peri operative nosocomial infection. even the best operative room design will not compensate for improper surgical technique or failure to pay attention to infection prevention. disinfection of surfaces, proper sterilization of surgical instruments with effective methods , maintenance of positive pressure in operating room, temperature and humidity regulation are some of the important factors to prevent infection. ÿ it is in the context that the preventive measures need to be constantly evaluated and updated and hence we have to study and analyse the causes of postoperative wound sepsis. aims and objectives ÿ the aims and objectives of this study were to evaluate the various factors in operating room affecting the post operative wound sepsis in obstetrical and gynecological wards of civil hospital ahmedabad during the period of october 2018 to september 2019. the data so obtained were studied to: ÿ to obtain an accurate infection rate as a guide to the efcient functioning of operating rooms, surgeons and staff. ÿ to determine the factors in operating room that inuences our infection rate. ÿ to decrease infection rate and improve bed utilization by practicing various methods of antisepsis. materials and methods ÿ this study was conducted prospectively in the obstetrical and gynecological wards of department of obstetrics and gynecology in this hospital during the period of october 2018 to september 2019( 12 months). it included all clean and clean contaminated surgical procedures conducted in planned or emergency surgeries. ÿ the case records were maintained for each patient from the time of admission to the time of discharge and updated on a daily basis. inclusion criteria: ÿ all general surgical clean(class 1) and clean contaminated (class 2) wounds those were managed on scheduled basis were included in the study. exclusion criteria: criteria for exclusion of patients were: ÿ contaminated (class 3) and dirty (class 4) wounds. observations and discussion ÿ the data for present study were obtained from the obstetrical and gynecological wards of department of obstetrics and gynecology in our hospital. the study was conducted over a period of 12 months from october 2018 to september 2019, covered a total of 3122 patients undergone scheduled (elective and emergency) operations for their disease processes and satisfying the inclusion and exclusion criteria. of these 3122 patients ,wound sepsis was detected in 255 patients which were then analysed on the basis of different factors affecting the infection rate. distribution of patients by the type of surgery the highest number of operated cases were those of cesarean sec t ion (88 .7 ) , f o l lowed by those o f abdomina l hysterectomy(8%). the least number of cases were those of laparotomy surgery(3.2%). the highest rate of wound sepsis was found in laparotomy cases in view of increased duration of a study of wound infections in post-operative patients in a tertiary care centre original research paper dr. lalit d. kapadia professor and hou, department of obgy, civil hospital, ahmedabad x 51gjra global journal for research analysis obstetrics and gynaecology background: infection occurs at the incision site within 30 days of surgery and may involve supercial or deep tissues with purulent discharge from the wound, culture conrms pathogenic organism and presence of pain, tenderness, swelling, erythma and increased local temperature. methods: to study association and contributing factors leading to post operative surgical site infections, a prospective study of 255 cases of wound infections in post operative patients was carried out in obstetric and gynecology department of civil hospital over a period of 12 months. results: highest number of operated cases were those of caeserean section(88.7%) with highest rate of wound sepsis in laparotomy(11%). rate of wound sepsis was higher in emergency cases(10.26%), longer duration of surgery(24.55%) and in patients with 2 or more comorbid conditions(44.2%)…. abstract keywords : dr. surabhi arya* 3rd year resident, department of obgy, civil hospital, ahmedabad *corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra type of surgery number of cases number of infected cases percentage caesarean section 2772(88.7%) 231 8.2% abdominal hysterectomy 250(8%) 15 6% laprotomy 100(3.2%) 11 11% 52 x gjra global journal for research analysis surgery, contaminated surgery, more amount of blood loss etc. overall wound sepsis rate postoperative follow up of the patients in this study showed that 8.1% developed postoperative surgical site infection.it is also high as compared to the study reported by varsha, jan 2017 in pune(6%). the difference is statistically highly signicant(p<0.001) and can be partially explained on the following reasons: ÿ poor nutritional status of the patients included in this study ÿ compared to western studies. ÿ lack of facilities in the resource strapped government hospitals . ÿ poor socio-economic status and lack of health care facilities for the masses. ÿ also, ours being the largest tertiary care centre in the state has the largest referral rate with maximum number of high risk and neglected cases being referred to our hospital, increases the rate of postoperative wound sepsis. ÿ the other factor which can affect the increased rate is the technique of autoclaving. there is mass autoclaving in the hospital and at times it can be defective. ÿ the improper scrubbing technique and the failure to maintain proper asepsis by different personnel of the hospital can also lead to increased rate of postoperative wound sepsis. wound sepsis according to category of surgery ÿ in the present study, elective surgeries including elective lscs and abdominal hysterectomies, constituted 36.8% of the total surgeries and emergency surgeries including emergency lscs and laparotomies were about 63.16%. the rate of wound sepsis was more in emergency surgeries (10.26%) as compared to elective surgeries (4.5%). this could be attributed to slightly more number of high risk factors in patients operated on an emergency basis. also the patients operated on an emergency basis are usually referred as complicated or neglected cases and thus carry higher rate of wound sepsis. moreover in elective surgeries factors such as operating conditions , scrub duration and techniques, proper administration of pre operative antibiotics, associated comorbid conditions are better taken care of as compared to emergency surgeries. wound sepsis as a function of number of comorbidities ÿ the wound sepsis rate was approximately 8.79% when the operative procedure ended in less than 1 hour . the rate increased to almost three times(24.55%) when the operative procedure lasted for more than two hours. reasons being; ÿ dosage of bacterial contamination increases with time of tissue exposure. ÿ wound cells are damaged by drying and by exposure to air and retractors. ÿ increased amounts of suture and electroco a gulation may reduce the local resistance of the wound. ÿ association with more blood loss and shock reduces the general resistance of the patient. wound sepsis according to preoperative antibiotics preoperative antibiotics are known to decrease the incidence of ssi.. patients who are operated on an emergency basis may or may not receive preoperative antibiotics. this leads to increased risk of post operative wound sepsis. relation ship between prolonged duration of labour and post operative wound infection the data showed that patients with prolonged duration of labour (includes patients with prolonged prom, obstructed labour, non progression of labour and induction failure ) were at increased risk of post operative surgical site infections. this could be attributed to as duration of labour increases, the number of vaginal examinations also increase and repeated p/v examinations increase chances of iatrogenic contamination during examination. also after premature and prolonged rupture of membranes, amniotic uid is no longer sterile and this may act as a transport medium by which bacteria may come into contact with uterine and skin incision there by leadind to risk of developing surgical site infections. wound sepsis according to culture sensitivity report volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra number of cases percentage infected 255 8.1% non infected 2867 91.9% total no of surgeries 3122 category of surgery number of infected cases total number of cases (percentage%) percentage elective( elective lscs+ abdominal hysterectomies) 52 1150(36.8) {900+250} 4.5% emergency ( emergency lscs+ laparotomies) 203 1972(63.16) {1872+100} 10.26% duration of surgery number of infected cases total no of cases percentage (%) <1 hour 54 632 8.79 1-2 hour 189 1890 10.04 >2 hour 177 600 24.55 preoperative antibiotics no of infected cases total no of cases percentage administered 100 2000(64.06%) 5% not administered 155 1122(35.94%) 13.8% duration of labour no of infected cases total no of cases percentage (%) prolonged (>24 hrs) 71 667 10.64% < 24 hrs 160 2105 7.6% conclusion the development of post operative surgical site infection is an important event that can be prevented by taking various measures: ÿ there should be proper autoclaving and set guidelines should be strict followed. ÿ the preparation of the patient in the form of preoperative antibiotics, shaving etc should be standardized and followed. ÿ in those associated with comorbid conditions, proper care like blood transfusion in cases with anaemia, higher antibiotics in cases of sepsis and timely management of related comorbid conditions can reduce surgical site infection rate.as per the condition of the patient, she should be operated by a skilled personnel to reduce postoperative complications. ÿ there should be proper fumigation periodically of all operation theaters. ÿ the scrubbing technique protocols should be strictly followed. ÿ there should be judicious use of antibiotics in the post operative period. in event of early ÿ signs of sepsis , antibiotics to be administered properly as per culture sensitivity report ÿ as far as the preparation of patient is considered, proper scrubbing, antibiotic coverage and surgical techniques all should be nearly same in emergency surgeries as in elective surgeries. references 1. alexander jw,aerni s, plettner jp. development of a safe and effective one minute skin preparation. arch surg 1995;120:1357 2. altemeier wa, burke jf,pruitt ba jr.,et al. manual on control of infection in surgical patients. 3. martin ja, hamilton be, menackerf, sutton pd , methews t j preliminary births for 2004: infants and maternal health..released n0v15, 2005. 4. owen j, andrews ww. wound complication after caeserean section clin.obstetgynecol 1994;37:842-55 5. te linde’s operative gynecology 11th edition 6. robbins pathologic basis of disease, 7th edition,edited by r cotran,vinay kumar,wb saunders…… x 53gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 1.introduction in recent years, low-cost, high-throughput, digital rna-seq technology has gradually replaced traditional gene chip technology, and its widespread application has played an important role in genomics and gene expression [1]. the rnaseq technique is mainly used for sequencing the cdna fragments which are reversely transcribed by the mrna, and a large number of reading segment data is obtained for researching the expression degree of the gene. with the development of sequencing technology, how to analyze these gene expression values and process rna-seq data is the content of this paper. in biocomputing, genes will have different levels of gene expression in different situations [2]. the common regulation of genes will affect the traits of organisms, so cluster analysis can cluster genes into different classes according to different expression patterns. by clustering genes with similar functions into the same class, the unknown biological functions of the genes can be obtained. in this paper, the application of some clustering algorithms in rna-seq is introduced. first, we need to understand the application of rna-seq technology. rna-seq, also known as full transcription shotgun sequencing, is the next generation sequencing technology to sequence the transcriptome of biological samples [3]. this technology extracts all the transcriptional rna from the samples, and then through reverse transcription to cdna for sequencing, so as to estimate the expression form and level of rna, and understand and analyze the gene expression. the resulting data is getting larger and more diverse, so on this basis, the processing of data through data mining technology also came into being. clustering [4] is to divide the data set in the sample into different classes according to the internal connection, and make the same class have great similarity. there are four types of clustering algorithm: distributed, structured, density and graph structured. distributed clustering [5] is a kind of clustering that can be generated at one time, and the representative algorithm is k-means clustering. structural clustering uses aggregators that have been successfully classied, which can be calculated from top to bottom or from bottom to top, which represents hierarchical clustering. the density clustering algorithm is used for categories of arbitrary shape features, and these categories are considered as areas in the data set that are larger than a certain threshold. the graph structured clustering algorithm only returns one solution, which can reduce the running cost, and the representative algorithm is louvain algorithm. 2. algorithm research method 2.1 k-mean algorithm k-mean algorithm is a relatively simple algorithm in clustering, which can be applied to many elds. clustering cells with the k-mean algorithm is also a successful method. given a set of data (x , x ,… x ), divide the n data into k sets so 1 2 n that the variance within each class is minimized. the k initial points are randomly selected from the training data as the initial points of the class, the euclidean distance from each point to the center point is calculated, and the mean value of the data points in each class is calculated as the new center point. if there is no change relative to the original center point or the change value is less than the threshold, then the algorithm ends, otherwise the algorithm is repeated. the key of k-mean algorithm is the choice of k value and initial point. the value range of k value is [-1, 1]. the larger the value of k, the better the result. 2.2 hierarchical clustering algorithm method hierarchical clustering algorithm is a kind of structured clustering method, which constructs hierarchical clustering tree by calculating the similarity between different categories of data points. the creation of hierarchical clustering tree is divided into two ways: top-down splitting and bottom-up merging. hierarchical clustering can be divided into two types: splitting and cohesion [6]. splitting is a top-down idea. at the beginning, all data are regarded as a class until there is only one sample in the class. cohesion is a bottom-up idea [7]. at the beginning, each sample is regarded as a different class, and the latest pair of classes are combined repeatedly until all the data belong to the same class. there are three methods for determining the distance by the agglomeration hierarchical clustering algorithm: single linkage, complete linkage, average linkage. the distance determined by the rst method is the distance when the sample points in the two classes are closest. the distance determined by the second method is the distance when the sample points in the two classes are farthest, which may make the two similar classes unable to be combined because the extreme values are too far. the last method is to calculate the mean value of all distances between samples. although this method has a large amount of calculation, the results are reasonable. 2.3 graph structure clustering algorithm lougain [8] algorithm is a heuristic clustering algorithm based on optimization. the implementation of this algorithm mainly consists of two steps. firstly, the nodes in the network are traversed continuously, and all the neighbors are traversed for each node. the income generated by adding neighbors to the node is calculated, and the neighbor who gets the maximum income is selected to join the group. if there is no income or the income is negative, the node remains in the group. repeat the process until all the nodes no longer change. secondly, the group formed in the rst stage is folded, each combination is combined and the super node is taken as a super node to reconstruct the network, and the weight value among the new nodes is calculated. the two steps are iterated analysis of differential gene expression levels based on rna-seq original research paper wenyan jiang tiangong university, no. 399 binshui road, xiqing district. engineering in the research of life science, bioinformatics has become the main direction of current research, mainly in the aspects of gene expression analysis, genomics and so on. with the development of the rna-seq technique, we have made a breakthrough in the biotechnology, and on the basis of the expression level of the rna-seq data, the data is getting bigger and more and more and more, and the accuracy of the gene expression level is improved by the method of clustering. in this paper, four clustering algorithms are introduced, and the clustering algorithm with relatively good performance is compared. abstract keywords : rna-seq, clustering, k-mean, louvain volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 82 x gjra global journal for research analysis until the algorithm ends. compared with other algorithms, this algorithm is relatively easy to implement, and the results are unsupervised. this algorithm is very fast and the complexity of typical sparse data is linear. after several iterations, the data will become less sharply, so the time of this algorithm is mainly consumed in the rst iteration. 3.conclusions these traditional clustering methods are based on heuristic algorithm, which is difcult to compare the advantages and disadvantages of various algorithms. these algorithms can get better clustering results when applied to rna-seq data. these methods basically use poisson distribution to model rna-seq data, but there are some differences between these data and poisson model [9][10], and there is no specic principle to determine the optimal number of classes, so it is also a problem to be solved in the future to propose a better algorithm for clustering. references: [1] wang z, gerstein m, snyder m. rna-seq: a revolutionary tool for transcriptomics[j]. nature reviews genetics, 2009, 10(1): 57. [2] pachter l. models for transcript quantication from rna-seq[j]. arxiv preprint arxiv:1104.3889, 2011. [3] marioni j c, mason c e, mane s m, et al. rna-seq: an assessment of technical reproducibility and comparison with gene expression arrays[j]. genome research, 2008, 18(9): 1509-1517. [4] tyagi a, sharma s. implementation of rock clustering algorithm for the optimization of query searching time[j]. international journal on computer science and engineering, 2012, 4(5): 809. [5] zhang t, ramakrishnan r, livny m. birch: an efcient data clustering method for very large databases[c]//acm sigmod record. acm, 1996, 25(2): 103-114. [6] tamayo p, slonim d, mesirov j, et al. interpreting patterns of gene expression with self-organizing maps: methods and application to hematopoietic differentiation[j]. proceedings of the national academy of sciences, 1999, 96(6): 2907-2912. [7] guha s, rastogi r, shim k. rock: a robust clustering algorithm for categorical attributes[j]. information systems, 2000, 25(5): 345-366. [8] blondel v d, guillaume j l, lambiotte r, et al. fast unfolding of communities in large networks[j]. journal of statistical mechanics: theory and experiment, 2008, 2008(10): p10008. [9] witten d m. cla ssification and clust ering of sequencing data using a poisson model[j]. annals of applied statistics, 2011, 5(4): 2493 -2518. [10] wang n, wang y, han h, et a l. a b i-poisson model for c lustering gene expression proles by rna-seq[j]. brie ngs in bio informatics, 2013, 15(4): 534-541. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 83gjra global journal for research analysis introduction: otitis media is the inammation of the middle ear cleft and the tympanum with otorrhoea lasting from 2 weeks to more than 3 months, with permanent perforation mainly caused by 1,2bacteria . ear infection may be acute or chronic purulent 3type . about 65–330 million people suffer from ear infection 4worldwide and 60 % of them had signicant hearing loss . even though ear infection is primarily a disease of infants and 5young children, it can also affect adults . the disease may begin in childhood or as a complication of untreated or inadequately treated acute suppurative otitis media or may 6be chronic from onset . the microorganisms may gain entry to the middle ear through a chronic perforation. children tend to have higher predisposition to ear infection than adults because anatomy of the eustachian tube in children permits easier access of organism through the nasopharynx. 5,7moreover, the incidence is higher in males than females . aom is the most frequent reason of medical consultation and 8,9the main indication of antibiotic therapy in childhood . it usually occurs between the age of 3 months and 3 years, with a peak of incidence from 6 to 11 months. by the age of 3 years, up 10,11to 80% of all children have suffered at least once from aom . about 40% have had six or more aoms by their seventh year of 12life . the global incidence has doubled from 1970 to 1990 and was recently calculated to be 10.85% or 709 million per year, varying from 3.64% in central europe to 43.37% in central 8,12africa . csom usually develops in the rst years of life but can persist during adulthood. the disease affects 65–330 million people worldwide, mainly in developing countries. it has been estimated that there are 31 million new cases of csom per 12year, with 22.6�% in children less than 5 years old . a crosssectional study of bacterial microbiota in middle ear, adenoid and tonsil specimens from a paediatric patient with chronic serous om utilizing 16s rrna gene-based pyrosequencing analysis revealed pseudomonas spp. as the most common pathogen present in the middle ear, whereas streptococcus spp. dominated the tonsil microbiota at relative abundance 13rates of 82.7 and 69.2� %, respectively . bacteroides spp., clostridium spp., peptococcus spp., peptostreptococcus spp., prevetolla melaninogenica and fusobacterium spp. are 14,15anaerobic pathogens that can cause csom . materials and method: patients with ear problems coming to regional hospital bilaspur from surrounding rural areas of bilaspur, solan, hamirpur and mandi districts, constituted the study subjects. a total of 40 subjects with otitis media infection were included in the study. according to the age, the patients were grouped into 1–17 years and 19–30 years. the specimens collected from patients with ear exudates by using sterile cotton swabs under strict aseptic precautions and assist of aural speculum then processed immediately in the lab. of microbiology. age and sex proles and results of bacterial isolates and drug susceptibility of patients who had ear infection were retrieved. ear discharge samples were inoculated on macconkey agar, blood agar, mannitol salt agar and chocolate agar. all of the inoculated media were incubated at 37 °c for 18–24 h. bacterial species were identied by standard microbiological methods manually. susceptibility testing was done on mueller–hinton agar using 16disk diffusion technique according to kirby–bauer method . the antimicrobial agents tested were: benzyl penicillin, ampicillin, tetracyclin, erythro, gentamicin, clindamycin, tmp/smx, amoxyclav, ciproox, levoox, pip/taz, cefuroxime, ceftriaxone, cefoperazone/sulb, amikacin, ertapenem, imipenem, l inezolid and cefepime. the antibiotic susceptibility proles were interpreted based on clinical and laboratory standards institute (clsi 2014) guidelines. results: a total of 40 patients from clinically suspected patients of otitis media were tested and analyzed. of them, 18 were children with age group 1-17 yrs and 22 were adult with 19-30 yrs of age. out of 18 children 9(50%) were male and 9 (50%) were female. out of 22 adult patients 8(36.4%) male and 14(63.6%). out of 18 children 17 (94.4%) had microbial growth (no growth was present in 1 male patient), and all 22 (100%) adult patients had microbial growth (table 1). in children (figure-1), the most frequent bacterial isolates were staphylococcus aureus 10 (55.5%), followed by escherichia coli in 2(11%), pseudomonas aeruginosa 1(5%) and proteus mirabilis 1(5%). in adults (figure-2), the most frequent bacterial isolates were staphylococcus aureus in 6(27.2%), followed by pseudomonas aeruginosa in 5(22.7%), klebsiella pneumonia in 3(13.6%), staphylococcus epidermidis in 3(13.6%), and staphylococcus saprophyticus in 1(4.5%). in children out of 10 s. aureus isolates, 9 (90%) were resistant to benzyl penicillin, 8 (80%) each for erythromycin, infective profile of ear infections in pediatric vs adults original research paper dr ankur dharmani md pediatrics regional hospital, bilaspur, himachal pradesh, india medicine introduction: even though ear infection is primarily a disease of infants and young children, it can also affect adults. materials and method: a total of 40 subjects with otitis media infection were included in the study. patients were grouped into 1–17 years and 19–30 years. bacterial species were identied by standard microbiological methods manually. results: the most frequent bacterial isolates were staphylococcus aureus in children 10 (55.5%) and adults 6(27.2%). conclusion: predominant bacterial isolate was s. aureus in both adults and children, however there were more s. aureus in children than adults. abstract keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr sonia kashyap md internal medicine ddu hospital, shimla, himachal pradesh, india dr manjeet singh* ms ent regional hospital bilaspur himachal pradesh, india *corresponding author 44 x gjra global journal for research analysis clindamycin, ciproox, and levoox, 4(40%) for tmp/ smx, and 1(10%) for teracyclin. out of 2 escherichia coli isolates, 1(50%) each was resistant to ampicillin, ciproox, levoox, cefuroxime, and cefuroxime. out of 2 isolates of staphylococcus epidermidis 2(100%) were resistant to benzyl penicillin, erythromycin, and ciproox. 1(50%) were resistant to teracyclin, clindamycin, tmp/ smx and levoox. there were no resistant in pseudomonas aeruginosa isolates. 1 isolate of proteus mirabilis were showing resistant in ampicillin, pip/taz, cefuroxime, ceftriaxone, imipenem, and cefepime (table-3). in adult patients, out of 6 s. aureus isolates, 6(100%) each were resistant for ciproox and levoox, 5(83.3%) for erythromycin, 4(66.6%) for clindamycin and benzyl penicillin, 3 (50%) for tmp/cmx, 2(33.3%) each for ampicillin and amoxyclav, and 1(16.6%) for cefuroxime. out of 5 pseudomonas aeruginosa isolates 1(20%) each were resistant for benzyl penicillin, erythromycin, clindamycin, ciproox, levoox. out of 3 klebsiella pneumonia isolates 3(100%) each were resistant for ampicillin, and cefuroxime. 1(33.3%) each of tmp/ cmx and ceftriaxone. out of 3 staphylococcus epidermidis isolates 2(66.6%) each were resistant to benzyl penicillin, erythromycin and tmp/ cmx. 1 isolate of staphylococcus saprophyticus were 1(100%) resistant to benzyl penicillin and tmp/cmx (table-4). discussion: a total of 40 patients from clinically suspected patients of otitis media were included in our study with 18 were children with age group 1-17 yrs and 22 adult patients with 19-30 yrs of age. out of 18 children 9(50%) were male and 9 (50%) were female. out of 22 adult patients 8(36.4%) male and 14(63.6%) (table171). in the study by derese hailu et al ., in 2016, 368 patients were included in the study with age range from 1-72 years. of them, 205 (55.7 %) were males and 163 (44.3 %) female 3patients. araya gebereyesus wasihun et al ., in 2015, total 162 patients were included in the study with age range 3 months to 69 years, 105 (64.8 %) of them were males and 57 19(35.2 %) females. in the chandima p. karunanayake, et al ., in 2016, there were 2082 caucasian children who participated in the study, with age range 6–17 years, 1025 (49.2%) male and 1057 (50.8%) female. in the study by kasahun gorems et 20al ., in 2018, among 173 otitis media patients participated in the study; majority, 102(63%) were pediatrics out of 18 children 17 (94.4%) had microbial growth (no growth was present in 1 male patient), and all 22 (100%) adult patients had microbial growth. according to the study by derese hailu 17et al ., in 2016 overall, 296 (80.4 %) of otitis media had microbial isolates. in the study by araya gebereyesus 3wasihun et al ., in 2015, pathogens were isolated from 157 20(98.2 %), kasahun gorems et al ., in 2018, pathogens were isolated from 160 (92.5%) of the patients. according to our study in children (figure-1), the most frequent bacterial isolates were staphylococcus aureus 10 (55.5%), followed by escherichia coli in 2(11%), pseudomonas aeruginosa 1(5%) and proteus mirabilis 1(5%). in adults (figure-2), the most frequent bacterial isolates were staphylococcus aureus in 6(27.2%), followed by pseudomonas aeruginosa in 5(22.7%), klebsiella pneumonia in 3(13.6%), staphylococcus epidermidis in 3(13.6%), and staphylococcus saprophyticus in 1(4.5%). in the study by kasahun gorems et 20al ., in 2018 (figure-3), the predominant isolate was staphylococcus aureus (30.72%) followed by proteus spp. 17(17.89%). according to the study by derese hailu et al ., in 2016 (figure-4) the most frequent bacterial isolates were p. aeruginosa 88 (30.4 %) followed by s. aureus 78 (26.9 %) and proteus spp. 65 (22.3 %). in our study in children out of 10 (45.5%) s. aureus isolates, 9 (90%) were resistant to benzyl penicillin, 8 (80%) each for erythromycin, clindamycin, ciproox, and levoox, 4(40%) for tmp/ smx, and 1(10%) for teracyclin. out of 2 escherichia coli isolates, 1(50%) each was resistant to ampicillin, ciproox, levoox, cefuroxime, and cefuroxime. out of 2 isolates of staphylococcus epidermidis 2(100%) were resistant to benzyl penicillin, erythromycin, and ciproox. 1(50%) were resistant to teracyclin, clindamycin, tmp/ smx and levoox. there were no resistant in pseudomonas aeruginosa isolates. 1 isolate of proteus mirabilis were showing resistant in ampicillin, pip/taz, cefuroxime, ceftriaxone, imipenem, and cefepime. as per our study in adult patients, out of 6 s. aureus isolates, 6(100%) each were resistant for ciproox and levoox, 5(83.3%) for erythromycin, 4(66.6%) for clindamycin and benzyl penicillin, 3 (50%) for tmp/cmx, 2(33.3%) each for ampicillin and amoxyclav, and 1(16.6%) for cefuroxime. out of 5 pseudomonas aeruginosa isolates 1(20%) each were resistant for benzyl penicillin, erythromycin, clindamycin, ciproox, levoox. out of 3 klebsiella pneumonia isolates 3(100%) each were resistant for ampicillin, and cefuroxime. 1(33.3%) each of tmp/ cmx and ceftriaxone. out of 3 staphylococcus epidermidis isolates 2(66.6%) each were resistant to benzyl penicillin, erythromycin and tmp/ cmx. 1 isolate of staphylococcus saprophyticus were 1(100%) resistant to benzyl penicillin and tmp/cmx. 3according to araya gebereyesus wasihun et al ., in 2015, the highest number of bacteria 98 (45.3 %) were isolated in the age group of 0–5 years (p = 0.02). s. aureus, p. mirabilis, p. aeruginosa, s. pyogenes, s. pneumoniae and h. inuenzae were the dominant bacterial isolates in this age group. of 46 s. aureus isolates, 100 % were resistant to ampicillin, tetracycline and penicillin (100 % each), (67.4 %) to ceftriaxone and (63 %) to doxycycline. less resistance was observed to ciprooxacin, gentamicin, erythromycin and noroxacin. p. aeruginosa was resistant to tetracycline, ampicillin, nitrofurantonin (100 % each), 96.3 % to penicillin and amoxicillin clavulanic acid (88.9 %). similarly, e. coli showed 50 % resistance to doxycycline, and ampicillin and nitrofurantonin (83.3 % each). in our study there are more s. aureus isolates specially in children, findlay and janz showed that, among children aged 0 to 3 years, 46% of first nations children living off reserve had an ear infection compared to 40% of all canadian children 20within the same age range . these results are similar to ndings from other studies reporting that most children will 21,22have had an ear infection by their third birthday . conclusion: in conclusion, bacterial ear infection is a major health problem in the study area. predominant bacterial isolate was s. aureus in both adults and children, however there were more s. aureus in children than adults. the bacteria which have been isolated from otitis media have shown high level of antibiotics resistance in the study area. majority of the bacterial isolates had multiple antibiotic resistant patterns. hence antibiotics susceptibility test is mandatory before prescribing any antibiotics. akhnowledgement: first authors: dr ankur dharmani, dr sonia kashyap table 1: socio-demographic characteristics and clinical manifestations of patients volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra children (n=18) adult (n=22) sex (male) 9(50%) 8(36.4%) age 1-17 yrs 19-30 yrs asom 11 (61%) 8(36.4%) csom 6(33.3%) 14(63.6%) eac furunculosis 1 0 x 45gjra global journal for research analysis fig 1 bacterial isolates in children figure:2 bacterial isolates in adult figure:3 predominant bacterial isolates in the study by kasahun gorems et al., in 2018 figure:4 predominant bacterial isolates in the study by derese hailu et al., in 2016 volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 2 resistance pattern of antimicrobial agents (%) in children bp amp tc ery cm tmp/ smx cf lf pip/taz cfu cfx cfp/ sulb imi cfp pseudomonas aeruginosa (n=1) 0 0 0 0 0 0 escherichia coli (n=2) 1(50%) 0 1(50%) 1(50%) 0 1(50%) 1(50%) 0 0 0 staphylococc us aureus (n=10) 9 (90%) 1(10%) 8 (80%) 8(80%) 4(40%) 8(80%) 8(80%) proteus mirabilis (n=1) 1(100%) 0 0 1(100%) 1(100%) 1(100%) 1(100%) 1(100%) 1(100%) staphylococc us epidermidis (n=2) 2(100%) 1(50%) 2(100%) 1(50%) 1(50%) 2(100%) 1(50%) bp: benzyl penicillin, amp: ampicillin, tc: teracyclin, ery: erythromycin, cm: clindamycin, cf : ciproox, lf: levoox, cfu : cefuroxime, cfx : ceftriaxone, imi : imipenem, cfp: cefepime table 3 : resistance pattern of antimicrobial agents (%) in adults bp amp ery cm tmp/ cmx amxc cf lf cfu cfx pseudomonas aeruginosa (n=5) 1(20%) 1(20%) 1(20%) 0 1(20%) 1(20%) staphylococcus aureus (n=6) 4(66.6%) 2(33.3%) 5(83.3%) 4(66.6%) 3 (50%) 2(33.3%) 6(100%) 6(100%) 1(16.6%) 0 staphylococcus saprophyticus (n=1) 1(100%) 0 0 1(100%) 0 0 klebsiella pneumonia (n=3) 3(100%) 1(33.3%) 0 0 3(100%) 1(33.3%) staphylococcus epidermidis(n=3) 2(66.6%) 2(66.6%) 3(100%) 2(66.6%) 1(33.3%) 1(33.3%) bp: benzyl penicillin, amp: ampicillin, tc: teracyclin, ery: erythromycin, cm: clindamycin, amxc: amoxyclav, cf : ciproox, lf: levoox, cfu : cefuroxime, cfx : ceftriaxone references: 1. adoga as, ma’an en, malu d, badung bp, obiesie iv, nwaorgu og. swab and aspiration specimen collection methods and antibiogram in chronic suppurative otitis media at jos university teaching hospital: which is superior? ann afr med. 2010;9(4):230–234. 2. mesn w, muluken b. bacterial isolate and antibacterial resistance pattern of ear infection among patients attending at hawassa university referral hospital, hawassa, ethiopia. ind j otol. 2014;20(4):155–158. 3. wasihun ag, zemene y. bacterial prole and antimicrobial 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koneczny n, schmidt-troschke s, berger t, isfort j, floer b, vollmar hc, butzlaff m. akute otitis media (aom) bei kindern (icd: h66.0): eine evidenzbasierte leitlinie -neue perspektiven für kinderärzte in deutschland. 46 x gjra global journal for research analysis [acute otitis media in children: an evidence-based practice guideline]. klin padiatr. 2004 jul-aug;216(4):215–224. 9. wald er. acute otitis media and acute bacterial sinusitis. clin infect dis. 2011 may;52 suppl 4:s277–s283. 10. teele dw, klein jo, rosner b. epidemiology of otitis media during the rst seven years of life in children in greater boston: a prospective, cohort study. j infect dis. 1989 jul;160(1):83–94. 11. vergison a, dagan r, arguedas a, bonhoeffer j, cohen r, dhooge i, et al. otitis media and its consequences: beyond the earache. lancet infect dis. 2010;10:195–203. 12. monasta l, ronfani l, marchetti f, montico m, vecchi brumatti l, bavcar a, grasso d, barbiero c, tamburlini g. burden of disease caused by otitis media: systematic review and global estimates. plos one. 2012;7(4):e36226. 13. liu cm, cosetti mk, aziz m, buchhagen jl, contente-cuomo tl, price lb, keim ps, lalwani ak. the otologic microbiome: a study of the bacterial microbiota in a pediatric patient with chronic serous otitis media using 16srrna gene-based pyrosequencing. arch otolaryngol head neck surg. 2011 jul;137(7):664-8. 14. verhoeff m, van der veen el, rovers mm, sanders ea, schilder ag. chronic suppurative otitis media: a review. int j pediatr otorhinolaryngol. 2006 jan;70(1):1–12. 15. prakash r, juyal d, negi v, pal s, adekhandi s, sharma m, sharma n. microbiology of chronic suppurative otitis media in a tertiary care setup of uttarakhand state, india. north am j med sci 2013;5:282-7. 16. bauer aw, kirby wmm, sherris jc, turck m. antibiotic susceptibility testing by standard single disc method. j clin pathol. 1966;45:493–496. 17. hailu d, mekonnen d, derbie a, mulu w, abera b. pathogenic bacteria prole and antimicrobial susceptibility patterns of ear infection at bahir dar regional health research laboratory center, ethiopia. springerplus. 2016;5:466. 18. karunanayake cp, albritton w, rennie dc, et al. ear infection and its associated risk factors in first nations and rural school-aged canadian children. int j pediatr. 2016;2016:1523897. 19. gorems k, beyene g, berhane m, mekonnen z. antimicrobial susceptibility patterns of bacteria isolated from patients with ear discharge in jimma town, southwest, ethiopia. bmc ear nose throat disord. 2018;18:17. 20. findlay l., janz t. health of rst nations children living off reserve and métis children younger than age 6. health reports. 2012;23(1):31–39. 21. kong k., coates h. l. c. natural history, denitions, risk factors and burden of otitis media. medical journal of australia. 2009;191(9):s39–s43. 22. qureishi a., lee y., beleld k., birchall j. p., daniel m. update on otitis media prevention and treatment. infection and drug resistance. 2014;7:15–24. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 47gjra global journal for research analysis introduction to maintain the health of healthy person by preventing him from illness is the main goal of swasthavritta stin 21 century there is a dramatic change in the life style, habits and environment of the mankind. in ancient days man led a happy and healthy life, but as the life style and environment changed, man started facing all types of diseases which made him w eak and unable to carry out his routine life style. it reduces the immunity and makes them prone to many diseases. for prevention of disease and to maintain the health, there are some principles which are given in old classical texts 'dincharya upakram'. dantadhavan, nasya, and anjan are some of the upakramas described in dincharya for cleanliness of sensory organs. nasya means medication into nostrils to eliminate morbid doshas of the urdhavajatrugata region. all the ancient acharyas have given tremendous importance to nasyakarma in the treatment of various nasagata and shirorogas diseases. this nasyakarma is not only used for the purication but also for the curative purpose. according to ayurveda 'nasa' is the gate way of 'shira'. it has been observed that patients suffering from allergic rhinitis have a symptomatic relief, but face repeated episodes not getting a total relief. nasyakarma is one of the important procedures of panchkarma (shodhana and shaman) and it is very useful in the management of urdhavajatrugata rogas pratimarsha nasya is used for daily regime for maintain nasa swasthya. allergic rhinitisallergic rhinitis ,whether seasonal or perennial is characterized by sneezing, rhinorrheoa, obstruction of nasal passages, conjuctival and pharyngeal itching and lacrimation. allergic rhinitis is caused by deposition of allergens (often pollen) aetiology (1) age: usually it affects young adults from the age of 15 years onwards, and tends to recede after the age of 40 to 50 years. it may affect young children also. (2) sex: both sexes are affected. (3) predisposing factors (i) heredity: it may run in families. if both parents are allergic, there is a high incidence of the disease occurring in children. (ii) climate: change in humidity, and atmospheric pollution may make the nose more susceptible to allergy. (iv) emotional: psychological factors, may affect the nose. this factor is more likely in cases of vasomotor rhinitis. (4) precipitating factors (allergens) the allergens are exogenous or endogenous: (a) exogenous (external agents) (i) inhalants (the commonest allergens:) dust, pollens, animal odour, feathers, moulds, house dust and mites. (ii) ingestants: foods like eggs, sh, milk, citrus fruits and cocoa. (iii) contactants like cosmetics and powders. (iv) irritants like fumes and smoke. (v) drugs: aspirin, hypotensive drugs, iodides. (vi) infection: bacteria and products of inammation may cause allergy, or they may be secondary invaders. (b) endogenous (within the body) intestinal helminthes, tissue proteins in transudates and exudates. mechanism (1) reaginic antibodies are formed in the body due to the sensitization caused by the allergens. (2) allergens and the antibodies react in the body. (3) histamine or histamine – like substances are released. (4) allergic reaction develops. pathology (1) inltration with eosinophils and plasma cells occurs. (2) edema develops due to transudation of tissue uids as the capillary endothelium is damaged, and the intercellular cement loosens. (3) rhinorrhoea: there is increase in mucosal secretions which may contain eosinophils. (4) congestion due to the dilatation of blood vessels occurs with venous stasis and purplish discoloration. (5) infection may be superadded, and may result in purulent discharge. (6) polyps may form. (7) paranasal sinuses may also be involved in a similar manner. pseudo-cysts may due to distension of intracellular spaces in the submucosa. they may ll up the entire sinus (cystic polypus) clincal types the allergy can be of 2 types: (1) seasonal: hay fever due to pollen grains occurs at the time of pollination. (2) perennial: affects the patient throughout the year. pratimarsha nasya as preveventive measure in allergic rhinitis original research paper dr. shweta r. nakil md swasthavrittha, associate professor, dept of swasthavruttha, lrp ayurvedic medical college, islampur, sangli. x 103gjra global journal for research analysis ayurveda now a day's pollutant air is the big problem. and disease like allergic rhinitis, acute rhinitis, allergic asthmas, is seen very often. peoples 30 to 40%are having diseases are related with allergens. so for that prevention is also needed. ayurved told panchkarma therapy for maintenance of health. as above problem concern with nasa swasthya one should undergo nasya .but for better result one should adopt pratimarshya nasya as upakrama in our daily schedule. pratimarshya nasya plays important role in allergic condition like allergic rhinitis, so it helps to maintain nasa swasthya by preventing allergic disorders. abstract keywords : pratimarsha nasya, allergic rhinitis, nasa. dr. rahul b. nakil* md swasthavrittha, associate professor, dept of swasthavruttha, lrp ayurvedic medical college, islampur, sangli. *corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 104 x gjra global journal for research analysis symptoms (1) irritation in the nose is the initial symptom. (2) paroxysmal sneezing of recurrent type is usually present, which exhausts the patient. in chronic cases, sneezing may be less. (3) rhinorrhoea is watery and copious. (4) nasal obstruction due to venous stasis is often present. (5) anosmia may be present intermittently or continuously. (6) headache can be present. according to ayurved, samprapti of allergic rhinitis is as below (sneezing, rhinorrhoea,,pharyngeal ithing, obstruction of nasal passage) pratimarshya nasya medicated oil putting in nostril it is used for shodhana and snehana. it is harmless hence called nirdosh. dose of pratimarsha nasya – dose of pratimarsha nasya is 2 drops in each nostril. role of pratimarsha nasya in allergic rhinitis aacharya sushrut describes fourteen pratimarshya nasya sevan kal. (time of administration of drug) according to that pratimarsha nasya gives protection action against pollutants like dust, smoke pollen grains etc. so it can be benecial to nasal hygiene of that individual who continuously travels in highly polluted area and having symptoms like sneezing, rhinorrhoea, block nose and etc. so sevan kaal play an important role for action of pratimarsha nasya. by creating protective sheath over mucosal membrane of nose(su. chi.40/52) vayu prakop is main step in samprapti of nasagat rogas. hence vata dosha shaman is main role in samprapti bhang . tail having property like ushna virya and snigdha guna which may helped in reducing sneezing. it acts like lubricant in passage of nasal route hence reduces chances of irritation hence forth the sneezing. tail having property katu tikta rasa and ushna virya due to that helps in pacifying kapha dosha and therefore rhinitis symptom reduced .thus congestion is reduced. hence odema also decreased. tail having property of snigdha gun which might be helped in reducing itching in nasal passage. sense of smelling is role of vatvah dhamanya at shrungatak marma due to snigdha guna and ushna virya shaman of vata dosha is done hence sense of smelling is improved. conclusion ÿ pratimarsha nasya is very effective in treatment of allergic rhiniis. ÿ it reduces sneezing , rhinorrhoea itching, nasal obstruction and odema in nasal passage. ÿ pratimarshya nasya could be effective management in air pollution related nasal problem. ÿ pratimarshya nasya is one of the procedure coming under dinacharya. every person should follow nasya as dinacharya upakram to maintain their nasa swasthya (nasal health) and it also helps in preventing urdhvajatrugat rogas. references: 1) a s t a n g a h r i d a y a m b y d r. l a l c h a n d r a va i d y a . p u b l i s h e r – motilalbanarashidas publication, delhi.2nd edition, 1990. 2) charaka samhita (puravardha) by dr.brahmanand tripathi. publisher – chaukhambha surbharati prakashan, varansai.-reprinted edition 2004 3) sharangdhar samhita dr.brahmanand tripathi chaukhamma surbharati prakashan,varanasireprinted edition 2001 4) sushruta samhita (english translation) by priyavrat sharma, publisher – chaukhambha visvabharati, varanasi istedition –1999. 5) swasthavritta vigyana – dr.ramharsha sinha, chaukhamba sanskrit sansthan,varanasi-2004 6) textbook of e n t diseasedr.s.k.bhargav,dr.t.m.shah, usha publication 7thedition2005 7) human anatomy vol.-3dr.b.d.chaurasia-s.k.jain publication,delhi-3rd edition 8) nimi tantradr.ramanath dwivedichaukhamma sanskrit series ofce,varanasi, 12th edition 1997 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction the nitration reaction of the aromatic compounds occurs in the liquid phase, generally in the form of benzene compounds and their derivatives, naphthalene compounds, and their derivatives. one of these aromatic compounds is toluene or called methylbenzene or phenylmethane, the compound is insoluble in water and colorless. with respect to nitration of glycerol and rate of reaction [7], [11] introduced a nitration balance system in glycerolaqueous. [6] whereas proposed several examples of glycerin synthesis of glycerin. [5] then to produce of glycidyl nitrate from glycerol with 1.3 dinitroglycerin as the intermediate product. [8] found nitroglycerin kinetics parameters in the continues stirred tank reactor process. the effect of temperature on glycerol nitration was studied [1]. reaction order is required to set the rate equation of the reaction. the several compounds of nitration have been successfully modeled as the rst order of each reactant. [2] performed the nitration of benzene and several other reactive compounds used sulfuric acid, while [9] performed the nitration of benzene, chlorobenzene, toluene, and trimethyl benzene used triuoroacetic acid. [10] performed the same nitration reactants used perchloric acid as the rstorder reaction of each other [9]. the states that the rate of trinitroglycerin formation reaction of glycerol and nitric acid in the continues stirred tank reactor process of biazzi is as follows: where the values of n and m are 0.9350 and 1.117. [4] conducted a study on toluene nitration using microreactor and batch reactor, the study was conducted using nitric acid as a nitrating agent at constant reactor temperature. while the variables measured include reaction time, reaction temperature and acid concentration. it is used to know the performance of microreactor. the results of this study concluded that the use of microreactor to produce more reaction products than using reactor batch system. [12] conducted research and mathematical modeling of the nitration process of benzene compounds. the results of his research indicate that the reaction of nitration of aromatic compounds is inuenced by reactant composition, reaction rate, reactant diffusivity, mass transfer coefcient, acidity level, contact surface tension of the reactant and uid properties change during nitration reaction. [3] conducted a study on toluene nitration using reactor batches. the results concluded that transition reactions occur at high concentrations from low to high speed, an increase in product per unit of acid volume, and the total mass transfer coefcient increases slowly at a xed temperature. methods the study is used to know the effect of reactant velocity on the rate of glycerol nitration reaction in the microchannel. the microchannel geometry as in fig. 1, while the specication of reactants seen in table 1. table -1 reactan specifications fig. 1: scheme two-dimensional of microchannel where, material = acrylic d1,d2,d3,d4 = 300 μm, w = 200 μm l1, l2, l3 = 2000 μm l4 = 4000 μm. t1, t2 = 5 mm. fig. 2 shows a scheme of research equipment, consisting of four parts: lighting, optics, camera, and control. lighting using fluorescent bulb type lamp, daylight ma305-05, serves to clarify the color of the image. optics using bh2 bh-p olympus type bh2 microscope. this microscope is equipped the study on velocity to glycerol nitration reaction rate using microchannel hydrodynamics focused original research paper purwoko thmechanical department state polyteknic of malang, soekarno-hatta 9 street of malang engineering the article discusses the level of glycerol nitrate reaction based on ow rate. the purpose of this study was to determine the effect of ow velocity on the glycerol nitrate reaction rate with the correct experimental method. the focal channels ratio on microchannel uses a 1: 2 ratio (d sheath = 300 µm). the ow rate variations used range from 50 μm/s, 100 µm/s, and 150 µm/s.the results of this study indicate that the rate of glycerol nitrate reaction is inuenced by the ow rate of the reactants. the faster the ow rate of the reactants in the inlet the greater the rate of glycerol nitration reaction, because with the greater ow rate will increase the number of collisions between reactant molecules. the greater the number of collisions, the greater the molecular energy of the reactants to move, thus increasing the reaction rate. the 0.65142 1.32858results showed that the ow rate of 50 μm/s resulted in nitration reaction rate r = 0.00388 [c3h5(oh)3] [hno3] . while 0.6998 1.3501the ow rate is 100 μm/s, the reaction rate is r = 0.00388 [c3h5(oh)3] [hno3] . and for a ow rate of 150 μm/s, the reaction 0.668276 1.391724rate of glycerol nitrate is r = 0.00388 [c3h5(oh)3] [hno3] . abstract keywords : velocity, glycerol, nitrate acid, reaction rate sugeng hadi susilo* thmechanical department state polyteknic of malang, soekarno-hatta 9 street of malang *corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra no. reactan molar mass (gr/mol) density (gr/cm3) reactan volume (ml) 1 glycerol 92,09 1,26 73 2 nitric acid 63,01 1,51 186 130 x gjra global journal for research analysis with a 2 mm linear 2-way motion control. this microscope is integrated with am7023b dino-capture camera. this serves to record reactant reactions in the output channel. the image data is stored as a jpg le on the computer. as for drain reactant using pump-type ts-1b / w0109-1b sprynge. this type consists of four channels. the four drive units can operate independently. this study used variations of a ow velocity of 50 μm/s, 100 μm/s, 150μm/s at a focal ratio of 1:2. focus ratio is the discharge ratio focused on focusing discharge. the result is color data of reactants and reaction products. then calculate the reaction rate by determining the empirical equation of the reaction rate n order. fig. 2: set up research glycerol nitration reaction the nitration process of glycerol uses glycerol and nitric acid as reactants with sulfuric acid as a catalyst. the equation of the glycerol nitration reaction process is as follows: reaction rate in order for a collision, it must have enough energy to overcome the energy barrier of activation and the molecule must have the right geometry to form the bond back. the speed of the reaction is called the reaction rate. the more collisions, the faster the reaction rate. the reaction rate is measured by a number of reactants that become the product over time. the reaction rate is a change in the concentration of the reactant or product over time. the study of reaction rates is called reaction kinetics. reaction rate = δ [a] / δt 3) the chemical reaction with the stoichiometric equation is as follows: the unit of r is the concentration/time. how to determine empirical equations rate of reaction n order. if the reaction mechanism is not known, the n-order rate equation adjusts the data with the form of the equation: result and discussion fig. 3: the relationship of concentration change (mole) of nitric acid to time (s) at variation ow 50 �m/s, 100 �m/s and 150 μm/s. based on fig. 3 can be calculated reaction rate using guessing method to determining the order n. the data changes the concentration of reactants in the input into the equation 5. the results of nitrate acid reactant calculation at a velocity of 50 μm/s, 100 μm/s, 150 μm/s obtained data such as table 2, 3 and 4. table 4. the change of nitrate acid concentration to time using the n-th order guessing method at velocity 50 μm/s. table 4. the change of nitrate acid concentration to time using the n-th order guessing method at velocity 100 μm/s volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra v =50 um/s n=1,98 t ca ca^(1-n)-ca0^(1-n) a/(n-1) b/t = k 0 3,0 0 0 0 10 2,12 0,1387 0,1321 0,01321 20 1,48 0,3470 0,3305 0,01652 30 1,13 0,5640 0,5371 0,01790 40 0,98 0,7059 0,6723 0,01680 50 0,82 0,9161 0,8725 0,01745 60 0,74 1,0563 1,0060 0,01676 70 0,67 1,2072 1,1497 0,01642 80 0,58 1,4562 1,3868 0,01733 variance 1,8e-06 v =100 um/s n=2,02 t ca ca^(1-n)-ca0^(1-n) a/(n-1) b/t = k 0 3 0 0 0 x 131gjra global journal for research analysis table 4. the change of nitrate acid concentration to time using the n-th order guessing method at velocity 150 μm/s. where, t = reaction time, ca0 = initial concentration of reactants nitric acid (mol), ca = concentration of reactants nitric acid after t (mol), n = order, and k = rate of reaction constant. from the calculation results can be made graph of concentration (ca^((1-n))-ca0^((1-n)))/((n-1))) to time as in fig. 4, 5 and 6. fig. 4: the concentration relationship (ca ^ ((1-n)) ca0 ^ ((1-n))) / ((n-1))) over time at velocity of 50 μm/s. fig. 5: the concentration relationship (ca ^ ((1-n)) ca0 ^ ((1-n))) / ((n-1))) over time at velocity 100 μm/s. fig. 6: the concentration relationship (ca ^ ((1-n)) ca0 ^ ((1-n))) / ((n-1))) over time at velocity 150 μm/s. at fig. 4, 5 and 6 obtained by value of the order, then calculate order value a and b. this is done by entering the value of the equation y at the value of k tting. then enter the value of mole coefcient of glycerol at α and coefcient of mole amount of nitric acid at β. after that do the trial and error method on the value of b that get the difference k = 0. table 3 shows the results of the ordering of n, a and b. table 5. the results of ordering n, a and b at 50 um/s table 6. the results of ordering n, a and b at 100 um/s table 7. the results of ordering n, a and b at 150 um/s in table 5, 6 and 7 obtained, for ow rate 150 um/s the calculation results obtained data a order =0.668276 while b order = 1.391724 with the value k = 0.00388. because the calculation of the rate of this reaction is based on the concentration of the reactant, and with increasing time there is a reduction of concentration so that the value of the constant is negative (-). so the equation of the reaction rate for glycerol nitration can be written as follows: r = 0.00388 0.668276 1.391724[c h (oh) ] [hno ] . for ow rate 100 um/s, the results 3 5 3 3 a order = 0,65929, b order = 1,36071 and value k = 0.00388. so 0,65929 the equation of the reaction rate: r = 0.00388 [c h (oh) ]3 5 3 1,36071[hno ] . while ow rate 50 um/s, the results a order = 3 0,65142, b order = 1,32858 with the value k = 0.00388. so the equation of the reaction rate for glycerol nitration can be 0,65142 1,32858written as follows: r = 0.00388 [c h (oh) ] [hno ] . it's 3 5 3 3 because of the faster the ow rate of reactants, the greater the chance of collisions between molecules, the greater the reaction occurs with the collision between reactant molecules. faster streams will provide a ow force that enlarges the activation of energy and the molecules easily form bonds again in the form of reaction products, thus increasing the reaction rate. conclusions the results of the study concluded that the equation of the reaction rate for glycerol nitration was inuenced by the ow rate of the reactants. the greater the ow rate will enlarge the reactant collision so as to enlarge the reaction order. it's seen that at a ow rate of 150 μm/s, the reaction rate is formulated r 0.668276 1.391724= 0.00388 [c h (oh) ] [hno ] , and respectively the 3 5 3 3 reaction rate formed at a speed of 100 μm/s and 50 μm/s can 0.6998 1.3501be written as follows: r = 0.00388 [c h (oh) ] [ hno ] 3 5 3 3 0.65142 1.32858and r = 0.00388 [c h (oh) ] [hno ] .3 5 3 3 acknowledgement the authors would like to thank to state polytechnic of malang who have supported this research project. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 10 2,2 0,1213 0,1178 0,0117 20 1,6 0,2937 0,2851 0,0142 30 1,18 0,5207 0,5055 0,0168 40 1,02 0,6572 0,6381 0,0159 50 0,88 0,8182 0,7943 0,0158 60 0,74 1,0410 1,0107 0,0168 70 0,64 1,2610 1,2243 0,0174 80 0,56 1,4945 1,4509 0,0181 variance 3,6e-06 v =150 um/s n=2,02 t ca ca^(1-n)-ca0^(1-n) a/(n-1) b/t = k 0 3 0 0 0 10 2,3 0,1013 0,1034 0,0103 20 1,56 0,3060 0,3122 0,0156 30 1,2 0,4956 0,5057 0,0168 40 1,02 0,6400 0,6531 0,0163 50 0,88 0,7927 0,8089 0,0161 60 0,75 0,9849 1,0050 0,0167 70 0,67 1,1398 1,1631 0,0166 80 0,59 1,3363 1,3636 0,0170 variance 4,3e-06 v = 50 um/s n 1,98 ḱ tting 0,0167 α 1 ḱ calculate 0,0167 β 3 ḱ difference -7,3e-13 b 1,32858 a 0,65142 k 0,00388 v = 100 um/s 2,02 ḱ tting 0,0171 1 ḱ calculate 0,0171 3 ḱ difference 9,82e-12 1,36071 0,65929 0,00388 v = 150 um/s n 2,02 ḱ tting 0,0179 α 1 ḱ calculate 0,0179 β 3 ḱ difference -9,1e-12 b 1,391724 a 0,668276 k 0,00388 132 x gjra global journal for research analysis references [1] astuti erna, supranto, rochmadi, prasetya agus, ström krister & andersson bengt, 2014. kinetic modeling of nitration glycerol, modern applied science, vol. 8, no. 2; issn 1913-1844 e-issn 1913-1852, published by canadian center for science and education. [2] coombes, r. g., moodie, r. b., & schoeld, k., 1968. electrophilic aromatic substitution. part i. the nitration of some reactive aromatic compounds in concentrated sulphuric and perchloric acids. j. chem. sot. b, 800-804. [3] cox p.r., strachan a.n. 1972, two-phase nitration of toluene-i, chemical engineering science, volume 27, issue 3, 457-463. [4] halder r., lawal a., and damavarapu, 2007. nitration of toluene in a microreactor, catalysis today 125 (74-80) new jersey center for microchemical systems, department of chemical, biomedical and material engineering, united states. [5] highsmith, t. k., & johnston, h. e., 2005. continuous process and system for production of glycidyl nitrate from glycerin, nitric acid and caustic and conversion of glycidyl nitrate to poly (glycidyl nitrate). us patent no. 6, 870061. [6] highsmith, t. k., sanderson, a. j., cannizzo, l. f., & hajik, r. m., 2002. polymerization of poly(glycidyl nitrate) from high purity glycidyl nitrate synthesized from glycerol. us patent no. 6, 362, 311. [7] kazakov, a. i., kirpichev, e. p., lagodzinskaya, g. v., andrienku, l. p., yunda, n. g., korolev, a. m., rubtsov, y. i., eremenko, l. t.,1990. study of nitration equilibrium in the glycerin—aqueous nitric acid system. 2. change in �h and δs in the nitration reactions. russian chemical bulletin, 39(8), 15651570. [8] lu k. t., luo, k. m., yeh, t. f., & lin, p. c., 2008. the kinetic parameters and safe operating conditions of nitroglycerine manufacture in the cstr of biazzi process. process saf. environ. prot., 86(1), 37-47. [9] moodie r. b., schoeld, k., & tobin, g. d., 1977. electrophilic aromatic substitution. part 17. products, kinetics, and mechanism of nitration in triuoroacetic acid. j. chem. soc. perkin trans., 2, 1688-1693. [10] moodie r. b., schoeld, k., & tobin, g. d.,1978. electrophilic aromatic substitution. part 19. the nitration of some aromatic compounds in perchloric acid. j. chem. soc. perkin trans., 2, 318-323. [11] yunda, n. g., lagodzinskaya, g. v., kazakov, a. i., korolev, a. m., rubtsov, y., anelis, g. b., & eremenko, l.t.,1991. nitration equilibrium in the glycerolaqueous-nitric-acid system 3. pmr parameters, conformational structure, and main properties of glycerol and its nitrates. russian chemical bulletin, 40(2), 325-332. [12] zaldivar j. m., molga e., alos m.a., 1995. aromatic nitrations by mixed acid. slow liquid-liquid reaction regime, chem. eng. & proc. v. 34.– p. 543 – 559. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 133gjra global journal for research analysis india has achieved tremendous success in halting the steep rise in mortality rates of mothers, mmr has declined from 212 in 2007-2009 to 167 in 2011-2013. (1) though the decline is obvious and healthy, yet we need more decline in terms of mmr for us to near our sustainable development goals (sdgs) (2). india has wide variations of mmr across the country with 300 in assam while 61 in kerala. uttar pradesh is placed at the top in northern part of the country with mmr of 285 maternal deaths per 100,000 live births. (1) of the reported cause of deaths 38% were from hemorrhage, 11% due to sepsis and 5% was from obstructed labor (1), majority of these can be prevented if timely intervention in the form of quality anc can be done for all pregnant women registered for anc in tertiary care institutions, deliver according to norms and appropriate post-natal care. anc visits during antenatal period provide an opportunity which is not only important but also detrimental to the pregnancy and its outcome including maternal health post partum, immediate context and long term context as it provides ample time and space for counselling to prepare for birth, making the timely decision, reaching the right place for delivery and managing the health of both baby and mother after delivery. it is well known and widely accepted that use of maternal health services reduces maternal morbidity and mortality (3, 4, 5, and 6). nfhs -4 data paints a grim picture regarding anc care as only 31.1% pf pregnant females accessed full antenatal care which includes not only timely visits but also the quality of services being given on those visits like , immunization , counselling , lab screening , testing etc. utilization of maternal health services is inuenced by multiple factors and this required focused attention. (7) studies done across country have demonstrated in india that health system including the environment in which services are being delivered along with socio economic factors of the beneciaries are responsible for a quality anc, as demonstrated in other studies seeking the percentage of institutional delivery in the basis of socio economic status where it was shown that only 13% of females going for institutional delivery were from low ses [6, 8]. it has also been shown that anc is the gateway for other healthy behaviors adopted during and after pregnancy, like institutional delivery, providing newborn care, exclusive breastfeeding, complimentary feeding and many more .utilization of antenatal care can be affected by large number of factors including socio-demographic factors and economic factors such as age of the woman, education, work status, parity, income, accessibility and availability of maternal and child health services etc. (9,10,11) studies done in uttar pradesh exploring the epidemiology and other sociodemographic factors for quality anc according to the goi norms are non-existent in context of community health care settings. with an aim to understand the various determinants and associated existing indigenous picture in community health care setting a study was done to 1) establish the ses conditions of the females seeking anc in chc muradnagar. 2) establish the extent of anc being delivered under the norms of government of india (goi) 3 ) establish the reasons behind the gaps if any found between health care service delivery and its utilization if any . methodology this study was conceptualized in department of community medicine, santosh medical college and hospital. after an iec clearance from the irb of the university, the study progressed. this study was a cross sectional observational study done in hospital setting. study was started in october 2017 and data collection was done till april 2018. data of all females coming for anc in chc muradnagar's immunization clinic was reviewed from the anc register available. an age limit of 18-45 years was decided to include the pregnant females. we included all females who gave their consent for participating in the study while those who were not willing to participate in the study and were having any severe complications . a questionnaire was designed in the department of psm which incorporated questions from ses , education level , being approached by sahiya etc. ,all components of a quality anc according to goi norms like number of anc , check up by doctors during anc , screening of diseases like hepatitis b , hiv , stis , thyroid , anemia etc. , lab testing for other ailments , routine ultrasound etc. were checked for . the questionnaire was pretested in the hospital before proceeding for data collection in chc muradnagar. data collection was done using hard copy questionnaire which was later entered in an msofce excel sheet. data thus collected was analyzed using spss version 21.0. an epidemiological investigation of anc seeking pattern for pregnant women coming in immunization clinic of chc muradnagar in ghaziabad original research paper dr narendra singh professor, department of community medicine , esic, faridabad , haryana preventive and social medicine background: anc visits during antenatal period provide an opportunity which is not only important but also detrimental to the pregnancy and its outcome including maternal health post -partum, immediate context and long term context this study was done to 1) establish the ses conditions of the females seeking anc in chc muradnagar. 2) establish the extent of anc being delivered under the norms of government of india (goi) 3 ) establish the reasons behind the gaps if any found between health care service delivery and its utilization if any . methodology: a hospital based cross sectional observational study was done in chc muradnagar on patients coming to the immunization clinic . study was done from october 2017-april 2018 . results: a total of 209 females participated in this study out of which majority were housewives (94.4%) . we saw during anc majority (95% ) being given ifa tablets (180 tabs ) and tt rst dose being administered . the hemoglobin levels were checked for also for all females while majority (46%) had their 2 anc done . abstract keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr susmita thakur* tutor, department of psm , pmch , dhanbad, jharkhand, 826005 *corresponding author 6 x gjra global journal for research analysis standard measures of central tendency was used to evaluate the results while p value of less than .05 was considered to be statistically signicant. results we in our study saw 209 females coming for participating in the study , with age of 1634 , mean of 23.53±3.45 , while family income reported were in the range of inr 300014000 per month , mean of inr 5770 per month ±2913.75 . we had more than 70% as hindu clients while 28% were muslims and 1% were christians while rest were sikhs. we had more housewives coming to us while rest were either working as farmers, laborers. some (48, 22% ) participated but were willing to share some personal details only . they however were not reluctant in giving their medical history. only 49 (22%) were mobilized by some asha for coming in this center to get their anc check ups while others 160 were here on their own . females from different socioeconomic prole came for their anc check ups , majority of them being illiterate or educated up to primary level ( up to class 5 ) ( table 1) we were looking for the quality of anc check up being done according to the goi norms ( table 2) . majority of females were given tt shots which came down when we counted the dosing of tt into first tt , second tt and booster tt ( table 2 ) . majority of the females came for anc were having more than 2 ancs while almost all got 180 ifa tablets . ( table 2 ) while other components were not seen in such majority like calcium tablets , hepatitis screening , routine usg checks, thyroid abnormality screened etc (table 2) . a chi square test also gave us the relationship between number of anc check ups and other factors like anemia status , age and parity status . out of these we saw a p value less than .05 in anemia status and parity status with anc check ups . (table 3) table-1: socio demographic and maternal child health characteristics of women tending antenatal care *some participating females were not comfortable sharing their personal data but were willing to tell about medical details and willing to participate in the study too. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra age in years 115 71.4 <30 years >30 years 46 28.6 women occupation 9 5.5 employed housewives 152 94.4 women education 70 43.5 illiterate primary 76 47.2 secondary 15 9.3 total monthly income of household (rs) 137 85 1,000–10,000 >10,00 24 15 parity 40 24.8 primi gravida multigravida 121 75.2 abortions 52 32.3 yes no 109 67.7 still births 157 97.5 no yes 4 2.5 child deaths 7 4.3 yes no 154 95.7 family planning practice 37 23 yes no 124 77 variables frequency (n=161)* % table 2. checking the quality of anc indicators total n =209 percentage 1. total number of pregnant women registered for anc, all were checked by doctors 209 100% 2. out of the total anc registered, number registered within 1st trimester (within 12 weeks) 96 45.93 3. number of pw given tt1 200 95.69 4. number of pw given tt2 186 89.00 5. number of pw given tt booster 1 0.48 6. number of pw given 180 iron folic acid (ifa) tablets 200 95.69 7. number of pw given 360 calcium tablets 98 46.89 8. number of pw given one albendazole tablet after 1st trimester 3 1.44 9. number of pw received 2 or more anc check ups 97 46% 10. number of pw given anc corticosteroids in pre term labour 0 0.00 11. new cases of pw with hypertension detected 2 0.96 12. out of the new cases of pw with hypertension detected, cases managed at institution 2 0.96 13. number of eclampsia cases managed during delivery 0 0.00 14. number of pw tested for haemoglobin (hb ) 200 95.69 15. number of pw having hb level<11 (tested cases)(7.1 to 10.9) 150 71.77 16. number of pw having hb level<7 (tested cases) 40 19.14 17. number of pw having severe anemia (hb<7) treated 28 13.40 18. number of pw tested for blood sugar using ogtt (oral glucose tolerance test) 6 2.87 19. number of pw tested positive for gdm 0 0.00 20. number of pw given insulin out of total tested positive for gdm 0 0.00 21. number of pw tested using poc test for syphilis 0 0.00 22. out of above, number of pw found seropositive for syphilis 0 0.00 23. number of pregnant women tested for syphilis 0 0.00 24. number of pregnant women tested found seropositive for syphilis 0 0.00 25. number of syphilis positive pregnant women treated for syphilis 0 0.00 26. number of babies diagnosed with congenital syphilis 0 0.00 27. number of babies treated for congenital syphilis 0 0.00 28. number of females screened with usg 30 14.35% 29. number of females screened for thyroid abnormality 10 4.78% 30. number of females screened for hepatitis 40 19.13% x 7gjra global journal for research analysis discussion as we peered into the quality of anc check ups being done in chc we saw the anc check ups need more time , effort and patience . major tests were being missed like hypertension screening , usg etc . the heartening thing was that females are slowly but surely aware that these services are being offered in chc and they are coming to attend them . they are themselves conscious of the fact that anc check ups are important for a safe mother hood . others tudies done in rural india set ups either in community or hospital set upos have shown similar results where more focus is on number of anc check ups rather than evaluating the various components of the anc ( 12,13,14 ) . they too found that most females taking anc check ups are coming from a rural background while their employment status mostly are house wives . they too found that females are now aware that anc is important but they don't know every it of it . conclusions chcs are vital cog in uniform health care service delivery in rural hinter land of the country . anc check up and mch care forms the bulk of their work in most of the country , current scenario for achieving sdg targets need more focus on improving the quality of the anc being done for every female client in the chc . we saw in chc some basic tests still not being done on a routine basis whereas they were given tt shots ( first shot) in a routine manner . the intent to treat and care is there perhaps the capacity building part needs more emphasis on prioritizing the various components to get it right . references 1. sample registration system. maternal mortality ratio bulletin, 2011-13. available from: http://www.censusindia.gov.in/ vital_ statistics/ mmr_ bulletin_201113.pdf. accessed on 28 dec 2019. 2. sustainable development goals. target and indicators. goal 3.available from: https://sustainabledevelopment.un.org/sdg3 . assessed on 28 dec 2019. 3. pallikadavath s, foss m sr. antenatal care in rural madhya pradesh: provision and inequality. in: chaurasia ar sr (southampton: u of s, editor. obstetric care in central india. 2004. p. 73–88. google scholar 4. kesterton aj, cleland j, sloggett a, ronsmans c. institutional delivery in rural india: the relative importance of accessibility and economic status. bmc pregnancy childbirth. 2010;10(1):30. cross ref google scholar 5. stephenson r, tsui ao. contextual inuences on reproductive health service use in uttar pradesh, india. stud fam plan. 2002;33(4):309–20.cross ref google scholar 6. vora ks, mavalankar dv, ramani kv, upadhyaya m, sharma b, iyengar s, et al. maternal health situation in india: a case study. j health popul nutr. 2009;27(2):184–201. cross ref google scholar 7. national family health survey 4, (2015 16). ministry of health and family welfare, government of india, international institute for population sciences. available at: http://rchiips.org/nfhs/pdf/nfhs4/india.pdf. accessed on 28 december 2019. 8. khan me, hazra a, bhatnagar i. impact of janani suraksha yojana on selected family health behaviors in rural uttar pradesh. j fam welf. 2010; 56:22. google scholar 9. shah r, belanger d. socioeconomic correlates of utilization of maternal health services by tribal women in india. canad stud in popul. 2011; 38:8393. 10. simkhada b, teijlingen er, porter m, simkhada p. factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. j adv nurs. 2008; 61:244-60. 11. chandhiok n, dhillon sb, kambo i, saxena nc. determinants of antenatal care utilisation in rural areas of india: a crosssection study from 28 districts (an icmr task force study). j obstet gynaecol india. 2006; 56:47-52. 12. devasenapathy, niveditha et al. “association of antenatal care and place of delivery with newborn care practices: evidence from a cross-sectional survey in rural uttar pradesh, india.” journal of health, population, and nutrition vol. 36,1 30. 21 jun. 2017, doi:10.1186/s41043-017-0107-z 13. roy, manas p et al. “determinants of utilization of antenatal care services in rural lucknow, india.” journal of family medicine and primary care vol. 2,1 (2013): 55-9. doi:10.4103/2249-4863.109946 14. saseendran pallikadavath , mary fossr , william stones . antenatal care: provision and inequality in rural north india. data social science & medicine (1982), issn: 0277-9536, vol: 59, issue: 6, page: 1147-58 volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 3 relationship between anc checks and other quantitative factors anc_number n=209 total % 100% p value 1.00 24% 2.00 46% 3.00 27% 4.00 3% age wise category less than 20 5 % 6 % 3 % 1 % 15 % 0.05 21-24 16 % 25 % 16 % 2 % 59 % 24-30 3 % 14 % 5 % 0 % 22 % higher than 30 0 % 1 % 3 % 0 % 4 % parity status 0-1 2 % 14 % 8 % 0 % 24 % 0.041 2-3 11 % 18 % 12 % 1 % 42 % >3 11 % 14 % 7 % 2 % 34 % anemia severity very severe anemia 0 % 1 % 0 % 0 % 1 % 0.04 severe anemia hb <4.1-7.0 2 % 7 % 3 % 1 % 13 % mild severe anemia hb >7.1-<11.00 18 % 34 % 22 % 2 % 76 % normal hb>11.00 4 % 4 % 2 % 0 % 10 % total 24 % 46 % 27 % 3 % 100 % 8 x gjra global journal for research analysis introduction severe head injuries are associated with signicant nancial and health burden on society. these cases are having lots of complications in terms of mortality and morbidities, in spite of best intensive care and dedicated medical team. about 10 % of severe head injuries cases have refractory intracranial pressure(1), who does not respond to medical treatments like osmotic diuretics, hyperventilation and sedation. such patients need decompressive craniotomy to reduce intracranial pressure. in decompressive craniotomy, a part of calvarium is removed with or with duraplasty, so that edematous brain get herniated through craniotomy defect and intracranial pressure is reduced. this helps in optimizing brain circulation better and preventing brain from secondary type of injuries(2-4). several studies showed that in spite of decompressive craniotomy, functional outcome in severe head injury is not so good. though, there is paucity of such data, in developing world(5). the objective of this study is, to know outcome of decompressive craniotomy in severe head injury cases. methodologythis is a retrospective study , in which all patients of severe head injury, who underwent decompressive craniotomy were included between january 2015 to december 2018. exclusion criteria were age below 18 years and above 60 years and if patients have other systemic trauma. all pateints were operated in emergercy department vs trauma centre level 2, of maharani laxmi bai medical college jhansi. all patients were managed in dedicated emergency intensive care unit. data was collected from bed head tickets and follow up discharge cards and phone calls. procedurea standard decompressive craniotomy were done in all these cases and international standards were followed(3). in aseptic conditions, all decompressive craniotomies were done under general anesthesia. a large question mark incision was given covering, frontal, temporal and parietal lobe. scalp ap was raised laterally. after meticulous dissection of temporal muscle, burr hole were made one on key point and other on temporal region and bone ap was raised with the help of manman drill.duramater was opened based anteriorly and decompression was done of extradural ,subdural hematoma or hemorrhagic contusions and lax duraplasty was done with the help of facsia lata or perisoteum or articial duramater. in intensive care unit, all patients were electivel ventilated for atleast 24 hours and further according to need. temperature was maintained around 20 to 22 degree centigrade. none of the patients were hyperventilated . patients, who could not extubated after 05 days of surgery, elective tracheostomy were done. in all patients, parenteral nutrition was started after 24 hours of surgery and gradually feed were increased. all patients , who were operated(6-8), ncct head was done after 12 hours and repeat ncct head if any deterioration of gcs score , seizures, or before discharge of patients. outcome of all patients were recorded as per glasgow outcome score, at the time of discharge, after one month and after 03 months of follow up. all data were interpreted by spss version. factors like, age of patients, mode of injury, gcs at the time of admission, time interval before reaching to hospital, pupillary reaction to light were analysed in outcome of patient( gos). chi square test and binary logistic regression ere used(8-11). resultstotal 100 patients were operated in emergency department of mlb medical college jhansi during this duration, out of which 12 patients were excluded of this study. rest 88 patients were included in this study. this study showed mean age of 30.6. males 79.56%were affected more than female20.44%. mean gcs at the admission was 7 . the mean duration of stay was20_+ 5.road trafc injury was the most common mode of injury followed by fall from height. most of patients developed anisocorea before surgery. and 50% patients required tracheosomy. tracheostomy was negatively associated with functional outcome. the glasgow outcome scale was mortality in 18 ,severely disabled in 18,moderately disabled and good recovery in 45. patients. they were followed in one month ,and 2 patients were improved from severely disabled to moderately disabled. discussion in our study we evaluated 88 patients who underwent decompressive craniotomy for traumatic brain injury. though decompressive craniotomy is associated with decrease in intracranial pressure and also associated with decrease in morbidities and mortalities. we do not have facilities to monitor intracranial pressure in pre or post-operative period. in a study by jagannathan et al , which was a retrospective review of prospectively acquired data for decompressive craniotomy in children . all patients who underwent decompressive craniotomy , mortality rate were high but they reported that functional outcome were much better than outcome reported by several other control cohorts in literature. in our study,we observed good functional outcome in younger age group. gcs of patients befor surgery is also a good does decompressive craniotomy has better outcomean experience of level 2 trauma center original research paper dr dinesh kumar rajput assistant professor ,department of surgery ,m.l.b medical college ,jhansi neurosurgery severe head injuries are managed with conservative treatment but in refractory cases, decompressive craniotomies are indicated t as a last resort to reduce raised intracranial pressure. in present study, we tried to know functional outcome of decompressive craniotomies(1), severe head injury patients. abstract keywords : decompressive craniotomy, craniotomy, traumatic brain injury, severe head injury. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr neeraj singh rajput* senior resident ,department of surgery ,m.l.b medical college ,jhansi *corresponding author dr sucheta rajput assistant professor, department of obstetric and gynecology, m.l.b medical college ,jhansi 110 x gjra global journal for research analysis determinant in outcome after decompressive craniotomy. functional outcome is better in gcs > 8 and poor in lower gcs at time of surgery. other factors, who negatively affect the outcome are, polytrauma, pupillary abnormalities(12-13). but gcs is only factor which has statistically signicant association. our results are comparable with results of other studies in developed world. which means that clinical monitoring in dedicated intensive care unit also comparable results, even without icp monitoring? other noninvasive methods for monitoring intracranial pressure in traumatic head injury patients are rotterdam score and optic nerve sheath diameter. these are associated predictors of functional outcome and mortality. after decompressive craniotomy, optic nerve sheath diameter is no relationship with outcome. however rotterdam score for head injury had strong association with outcome after decompressive craniotomy. limitation of our study is , this retrospective study and so we could not able make comparison group. secondly sample size is also relatively small so results can not generalized. decompressive craniotomy patients are associated with increased riskof having second injury(14-15). these patients need cranioplasties after 3-6 months, which are also have some complications. which should be considered and discussed with family at the time of decompressive craniotomy. furher large prospective, multicentric randomized control trails must be planned to conclude further. comparison of gcos at different periods of follow up at discharge dead 18 vegetative state 7 severely disabled 18 moderately disabled 19 good recovery 26 total 88 at 1month dead 18 vegetative state 7 severely disabled 17 moderately disabled 20 good recovery 26 total 88 fig-1 at 2month dead 18 vegetative state 7 severely disabled 17 moderately disabled 19 good recovery 27 total 88 fig-2 at 3month dead 18 vegetative state 7 severely disabled 16 moderately disabled 18 good recovery 29 total 88 fig-3 references 1. marshall lf. head injury: recent past, present, and future. neurosurgery. 2000;47:546–61. [pubmed: 10981741] 2. brown da, wijdicks ef. decompressive craniectomy in acute brain injury. handb clin neurol. 2017;140:299–318. [pubmed: 28187804] 3. adams h, kolias ag, hutchinson pj. the role of surgical intervention in traumatic brain injury. neurosurg clin n am. 2016;27:519–28. [pubmed: 27637401] 4. kamal alam b, bukhari as, assad s, muhammad siddique p, ghazanfar h, niaz mj, et al. functional outcome after decompressive craniectomy in patients with dominant or non-dominant malignant middle cerebral infarcts. cureus. 2017;9:e997. [pmcid: pmc5338989] [pubmed: 28286721] 5. coplin wm, cullen nk, policherla pn, vinas fc, wilseck jm, zafonte rd, et al. safety and feasibility of craniectomy with duraplasty as the initial surgical intervention for severe traumatic brain injury. j trauma. 2001;50:1050–9. [pubmed: 11426120] 6. jaeger m, soehle m, meixensberger j. effects of decompressive craniectomy on brain tissue oxygen in patients with intracranial hypertension. j neurol neurosurg psychiatry. 2003;74:513–5. [pmcid: pmc1738358] [pubmed: 12640077] 7. cooper dj, rosenfeld jv, murray l, arabi ym, davies ar, d’urso p, et al. decompressive craniectomy in diffuse traumatic brain injury. n engl j med. 2011;364:1493–502. [pubmed: 21434843] 8. syed ab, ahmad ih, hussain m, al-bya f, solaiman a. outcome following decompressive craniectomy in severe head injury: rashid hospital experience. pan arab j neurosurg. 2009;1:29–35. 9. gupta r, connolly es, mayer s, elkind ms. hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review. stroke. 2004;35:539–43. [pubmed: 14707232] 10. khalili h, derakhshan n, niakan a, ghaffarpasand f, salehi m, eshraghian h, et al. effects of oral glibenclamide on brain contusion volume and functional outcome of patients with moderate and severe traumatic brain injuries: a randomized double-blind placebo-controlled clinical trial. world neurosurg. 2017;101:130–6. [pubmed] [google scholar] 11. cooper dj, rosenfeld jv, murray l, arabi ym, davies ar, d'urso p, et al. decompressive craniectomy in diffuse traumatic brain injury. n engl j med. 2011;364(16):1493–502. [pubmed] [google scholar] 12. wang r, li m, gao ww, guo y, chen j, tian hl. outcomes of early decompressive craniectomy versus conventional medical management after severe traumatic brain injury: a systematic review and meta-analysis. medicine (baltimore) 2015;94(43):e1733. [pmc free article] [pubmed] [google scholar] 13. hutchinson pj, kolias ag, timofeev is, corteen ea, czosnyka m, timothy j, et al. trial of decompressive craniectomy for traumatic intracranial hypertension. n engl j med. 2016;375(12):1119–30. [pubmed] [google scholar] 14. aarabi b, hesdorffer dc, ahn es, aresco c, scalea tm, eisenberg hm. outcome following decompressive craniectomy for malignant swelling due to severe head injury. j neurosurg. 2006;104(4):469–79. [pubmed] [google scholar] 15. limpastan k, norasetthada t, watcharasaksilp w, vaniyapong t. factors inuencing the outcome of decompressive craniectomy used in the treatment of severe traumatic brain injury. j med assoc thai. 2013;96(6):678–82. [pubmed] [google scholar] volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 111gjra global journal for research analysis 1.introduction the word 'adolescence' is derived from the latin word 'adolescere' which means to grow up (lerner et al 1993). it is a period of psychosocial development between puberty and adulthood (erikson 1959). adolescence begins with the onset of physiologically normal puberty and ends when an adult identity and behaviour are accepted. this period of development corresponds roughly to the period between the ages of 10 and 19 years (who 1986). according to stang and story (2005), the age range is usually divided into three stages; early adolescence as stage i between 10 and 14years, middle adolescence as stage ii between 15-17years and late adolescence as stage iii between 18-21 years of age. a lack of awareness of the distinctiveness of adolescence has led the society to generally identify these stages with late childhood or early adulthood. increasing awareness of the potential and necessity for working with young people and an increased recognition globally on investing in adolescents, and that the failure to do so runs the risk of undermining the progress made in the rst decade of life has paved the way to work towards enhancing the need to have more meaningful interventions. schooling without learning is not just a wasted development opportunity, but also a great injustice to children and youth. the convention on the rights of the child (crc) denes a child as “every human being below the age of 18 years”. consequently, adolescents upto 18 years are holders of all the rights enshrined in the convention; they are entitled to special protection measures and according to their evolving capacities, they can progressively excercise their rights. 2. an overview of the indian situation in the recent past india has seen some positive movement in the enrolment and participation in school education. through the inception of the national policy on education in 1986, india aimed to achieve complete enrolment through making free and compulsory education mandatory at school levels. the constitution of india in its directive principles of state policy (article 45), directs the state to provide free and compulsory education for all children up to fourteen years of age. after more than seventy years of independence india continues to struggle with issues pertaining to school dropouts, child labour, child trafcking and even issues of child marriage. a historic milestone was achieved in the year 2010 when article 21a, and the right of children to free and compulsory education act, 2009 became a reality. it anchored the values of equality, social justice and democracy that can be achieved only through education. the adoption of the 'right of children to free and compulsory education' has created a momentum to further the efforts of ensuring quality education for all. the national youth policy 2003 includes 13-35-year olds as youth but recognizes adolescents aged 13-19 as a special group. the launch of sarva shiksha abhiyan – education for all 2011 was a major leap forward in providing education for all. india is a signatory to several international commitments towards human progress. one such signicant document is the 'dakar framework for action', which aims at 'quality education' for all by the year 2015, emphasising the literacy goal, gender equality and other quality parameters. the nation also has to its credit several well intentioned interventions that are planned and executed by the ministry of human resource development (department of school education and literacy), ministry of labour, ministry of youth, ministry of tribal affairs, ministry of women and child development and the ministry of health and family welfare. the new education policy in 2016 and the draft policy of 2019 highlights inclusive education, learning outcomes, strengthening vocational education, reforming school systems, accelerating rural literacy, new teaching pedagogies, comprehensive education with ethics, physical education and arts and crafts. the adoption of the crc general convention on the rights of children during adolescence in 2016 testies to the increased recognition during the adolescent period. the world bank has warned of a learning crisis in global education particularly in low and middle-income countries like india. the unicef strategic plan 2018-2021 highlights 'adolescent empowerment' as a key strategy for major change. 'national skills development adolescents and right to development a case study for skills development original research paper dr. sandra joseph associate professor department of social work stella maris college (autonomous) chennai, india x 137gjra global journal for research analysis social science a challenging action-research study titled, 'continuing education for disadvantaged adolescents in chennai city', a community intervention project for adolescents residing in an urban shing community was carried out between 2016-2018. identifying needs of disadvantaged adolescents is a complex interplay of socio-politico and cultural institutions and structures in a given location. challenges confronting adolescents are hidden behind other urban social evil and have not been duly recognized as pertinent to their development. it is important to understand that the adolescent stage of life is crucial and that adolescents too have an equal right to live in dignity and in a proactive environment. the study explores social meanings and contexts of disadvantaged adolescents and their environments. it analyses the dilemmas of adolescents residing in an urban developing area along the shoreline of the marina beach, chennai. it depicts everyday experiences of out-of-school adolescents and its impact on their aspirations for a better life. using qualitative research methods, the study uses life trajectories to collect data. the study nds that most of their lived experiences act as impediments to their personal growth and development. the study offers a model that enables the adolescents express their needs and identies that alternative skills training is a possible answer to their current needs. it covers a gamut of needs, the main focus however being on education; training and capacity building that leads to holistic development. the research is intervention-based and hopes to serve as a guide of informed strategies and as a model for working towards creating meaningful 'space' for continuing education for adolescents. abstract keywords : out-of-school adolescents, equitable access, disadvantaged adolescents, skills, livelihood skills, multi-stakeholder partnerships, continuing education volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 138 x gjra global journal for research analysis initiative' in 2009 that provides adolescents, women and school dropouts with opportunities to acquire vocational skills. the government of india further launched through the ministry of labour and employment in 2009, a scheme that provides adolescents, women and school dropouts with opportunities to acquire vocational skills titled the 'saakshar bharat scheme' (ministry of human resource development 2009). however, in spite of these advances the space for adolescent engagement is much less ourishing than for youth, with adolescents falling somewhere in the middle, sometimes considered as children (technically they are while under 18 years) and sometimes considered as youth (15-19 year olds). the distinct issues affecting adolescents has tended therefore to receive less attention, as can be seen in the minimal number of adolescent-specic policies or forums. india's youth policy of 2014 reiterates the need for 'adolescent friendly clinics' to provide counselling and treatment. as early as in the year 2002, the national education policy reected a sense of urgency to work towards achieving international goals such as early childhood care and education, ensuring children in difcult circumstances and those belonging to ethnic minority groups gain access to free and compulsory education, equitable access, improving adult literacy, eliminating gender discrimination and improving the quality ensuring literacy, numeracy and life skills. the recent past, further saw the launch of the draft of the new education policy in 2016 and very recently in 2019, that speaks about enabling inclusive education, ensuring learning outcomes in elementary education, strengthening vocational education, reforming school systems, accelerating rural literacy, implementing new teaching pedagogies in science and maths, and evolving a comprehensive education with ethics, physical education, arts and crafts. a critique of the draft policy highlights that by and large this policy has not given priority to the actual needs of those who represent the marginalised sections of the society. despite these massive responses, parameters such as equity, inclusion and justice still evade the nation's progress, particularly for the disadvantaged sections. the country has not made signicant accomplishments particularly in the primary, elementary and high school education levels. social stratication of the indian society reects marked inequalities in the educational and employment scenario of the disadvantaged sections. predominantly, caste, class, religion, ethnic boundaries and gender have persistently been the impeding factors for low levels of education among the disadvantaged sections in the nation. attempts to address these inequalities have been poorly implemented and have not sufciently reduced disparities and unequal access, resulting in large numbers of disadvantaged adolescents. after more than seventy years of independence india continues to battle with issues pertaining school dropouts, child labour, child trafcking and even with issues of child marriage. despite india's constitutional guarantee for providing free and compulsory education for all children up to the age of fourteen years, the country still grapples with issues of inadequate access and poor quality of education. sustained efforts committed partnerships and well-coordinated processes by concerned bodies, (local/ government bodies, ingos and ngos) is an imperative for concerted action. not only has india the onerous task of providing quality education, but also the responsibility of equitable and accessible education. investing in adolescents' education and empowerment needs to be identied as a separate development agenda. the adolescent stage of human life is sandwiched between the child and the adult stage and invariably does not nd its independent position. there is a growing need to focus on adolescent' transition from childhood to adulthood. informal learning opportunities, both in and out of school can build competencies and skills for gaining access to the world of employment. providing opportunities to participate in processes and decision-making for the self and family can build their abilities to communicate, participate in civic activities and provide for invaluable contributions to development of family, community and the wider society. when it comes to the girl child, globally they still lag behind boys in secondary school participation. girls' disadvantage is highest in least developed countries, particularly in subsaharan africa and south asia. girls' secondary education is critical to their development and can help postpone early marriage and pregnancy that can have adverse effects on girls' health, well-being and economic prospects. providing opportunities for adolescent girls and boys to participate in processes and decisions that affect them is one of the most effective ways to build their skills and condence, and to improve their ability to communicate with others. participation in social, economic, political and cultural debates not only contributes to civic engagement, it also improves adolescents' ability to hold governments and other duty bearers to account. adolescents can provide unique and invaluable contributions to their families, communities and wider society and must be supported in doing so. evidence shows that when adolescent girls and boys are supported and encouraged by caring adults, along with policies and services attentive to their needs and capabilities, they have the potential to break long-standing cycles of poverty, discrimination and violence. 3.existing initiatives in india it is wellknown that the ministry of human resource development, government of india, has set in place a number of programmes and policies aimed at increasing enrolment and retention in school and providing technical and vocational education training. however, there is a growing need to focus on adolescents' transition from primary to secondary school, which is often difcult in developing countries. innovative non-formal learning opportunities, both in and out of schools, can help provide 21st century competencies and skills for gaining adequate employment. adolescents are one of the most voiceless groups in our society. they are either treated like children or pushed into adulthood. adolescents aged 10–19 years constitute about one-fourth of india's population with an enormous potential to contribute to india's economic growth and development. in order to contribute, adolescents must be healthy, educated and equipped with information skills and condence that would enable them to contribute to the growth of their communities and the country as a whole. a key challenge in addressing these issues is the lack of a universal denition for adolescents. investing in the education of adolescents needs to be given due priority and identied as a separate development agenda in the planning process. the adolescent stage of human life is sandwiched between the child and the adult stage and invariably does not nd its independent position. there is a growing need to focus on the adolescent's transition from childhood to adulthood. informal learning opportunities, both in and out of school can build competencies and skills for gaining access to the world of employment. providing opportunities to participate in processes and decision-making for the self and family can build abilities to communicate, participate in civic activities and provide for invaluable volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra contributions to development of family, community and the wider society. the scarcity of quality schools is one of the major reasons for high rates of dropout from schools before completing ve years of primary education. girls are more likely to dropout even earlier. at the global level, who and unicef dene adolescents as those aged 10–19 years (who 2012; unicef 2005). while the ministry of health and family welfare, government of india (goi) has adopted the who denition, various agencies of the government continue to use different denitions and age groups. one of the major actors in the eld of child development in india is the unicef. a disturbing fact reported in unicef's state of the world's children 2016, states 'that unless the world tackles inequality today in 2030, sixty million of primary school age children will be out of school'. the report further states that 'they will become part of a vicious, intergenerational cycle that curtails children's opportunities, deepens inequality and threatens societies everywhere'. they will become part of a vicious, intergenerational cycle that curtails children's opportunities, deepens inequality and threatens societies everywhere. unicef supports the national programme of sarva shiksha abhiyan in ensuring that all children complete ve years of education. the strategy is built around three inter-linked themes: access, quality and equity. it also supports the provision of equal opportunities for disadvantaged children, especially girls, urban poor, scheduled castes and scheduled tribes, and working children. it also works closely with the government of india to support the education of the girl child at the elementary school level. it further supports alternative learning strategies, such as bridging courses and residential camps for adolescent girls who are out of school. this is to ensure that these girls emerge motivated and continue education. educational advancement has seen vast changes and new concepts in the recent past. the rights-based approach to elementary education, student entitlement, shift in emphasis from literacy and basic education to secondary, higher, technical and professional education, the endeavour to extend universalization to secondary education and to reshape higher education has been the centre of paradigm shifts in the country. even more recent developments include a new impetus to skills development through vocational education in the context of the emergent technologies and multi-disciplinary learning methodologies. these efforts over the last few years have improved levels of accessibility, infrastructure and literacy but to a large extent still lack in equity and quality education. 4. rationale and expected outcome of the study it is imperative to pay attention to the adolescent period as india as a nation will soon experience this high proportion of adolescent population in the next two decades (central statistics ofce, ministry of statistics and programme implementation 2017). efforts of the government of tamil nadu to include the disadvantaged adolescents into the mainstream of development in the state is said to be signicant in relation to other states in the county. however, much of the interventions are criticised for being welfare oriented rather than developmental/participatory in nature, which ideally leads to higher achievements in holistic development. despite such emphasis, challenges confronting adolescents has not been duly recognized as important and therefore not in the forefront of urban social planning. other priorities such as poverty mitigation, health care and primary education have taken precedence and rightly so. identifying specic needs of adolescents and negotiating their legitimate space, given their unique characteristics and challenges, needs visibility and has to be brought to the forefront of development practice. the study, therefore, seeks to explore social meanings and contexts of adolescents from disadvantaged coastal communities and their environments in the specied geographical location. it additionally aims to depicts everyday experiences of out-of-school adolescents and its impact on their aspirations for a better life. 5. statement of the problem challenges confronting adolescents have not been duly recognized as imperative and therefore have been prevalent with little intervention. there has been much research on children and youth, but adolescents are usually made to t within these two categories and are not recognised as an independent category according to their age specic needs. the research seeks to sufciently answer questions on the causes of children dropping out of school and suggests possible ways to rectify this urban challenge. the study envisages launching a strong initiative for the 'empowerment of disadvantaged adolescents'. using the 'systems approach' in the intervention plan, the study presents the complex interplay of social institutions and structures and furthermore highlights the importance of 'family' and 'community' for appropriate and meaningful change. being an action-research study, it suggests creating new spaces in terms of their age-specic needs. it negotiates and strategizes a proposal with multi stakeholders to carry forward the creation of 'adolescents space'. through its interventions it seeks to further empower poor and disadvantaged individuals, families and communities towards fostering an inclusive and just education for adolescents. one of the major intervention outcomes envisaged is to provide educational and training support through multi stakeholder partnerships for adolescents through life /soft skills and livelihood skills training. one of the major intervention outcomes envisaged is to provide educational and training support space through a multi stakeholder partnership for adolescents with the aim of developing their core competencies, life /soft skills and livelihood opportunities. it suggests and intervention model to be implemented in order to establish a visible space for developing skills specically for the disadvantaged adolescents. in view of enabling the adolescent population to realise their fullest potential, it is important that they must have access to recent opportunities for training and to face the world of work. 6. methodological outline the article stems from an action research study funded by the international federation of catholic universities, paris, titled 'continuing education for disadvantaged adolescents' executed in a coastal shing community named nochikuppam, in chennai, india. the design was qualitative in nature that involved observing and describing social, economic and political issues that out-of-school children face and the reasons for which they drop out of school. as it was not possible to identify adolescents who were out-of-school, using purposive sampling technique under the non-probability sampling design was appropriate. the sampling comprised of drawing up life trajectories of twenty respondents (school going and out of school) between the age group of 11 to 17 years. using case narratives to collect data, the study nds that most of their lived experiences act as impediments to their personal growth and development. eliciting from respondents, the study suggests negotiation of 'adolescent space' and recognition of this is a major requirement to full their aspirations. it covers a gamut of needs, the main focus however being on skills training and capacity building of the x 139gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra adolescents. based on eld observations and participatory techniques such as transect walks, focus group discussions (fgds) and in-depth interviews that enabled to gain deeper insights into the day-to-day lived experiences of adolescents under study. besides secondary data were collected to corroborate facts elicited from the study. required consent from the concerned respondents was obtained. informed consent, condentiality, safety and health of researchers were important considerations. the study offers sufciently clear research results, so that practitioners may decrypt tangible situations and make decisions on social work interventions that are both curative and preventative, adapting it to their own context and requirements. 7. theoretical directions and conceptual understanding the 'systems approach' has grown with a wide acceptance in social work theory since the 1970s. the term 'systems theory' to social work was rst introduced in 1930 (hollis & taylor 1951). even before the term 'systems theory' was proposed, social workers adopted a 'person-in-environment' perspective (whittaker & tracy 1997). systems theories provide an intellectual foundation for reintegrating the psychological and sociological discourses by recognising that a range of socio-economic and cultural systems impact on people in myriad ways. the initial proponents of the systems theory highlighted its potential to provide scientic credibility to the profession and to develop an integrated theoretical foundation that would capture the central elements of social work practice in all its varied forms. in the decades of the seventies and eighties, the systems approach in social work practice gained wide recognition and acceptance. the shift focused on a unifying perspective, one that was not bound by methods but rather was shaped by situational or environmental parameters. (goldstein 1973, pincus & minahan 1973, middleman & goldberg 1974, siporin 1975, bronfenbrenner 1979). to prepare social workers for practice, the social work curriculum needs to emphasise on teaching practice perspectives that view the whole of social problems in a more broad-based understanding. an integrated practice framework for social work assumes that the root of problems originates in the larger environmental context and be resolved by collective action. criticisms about the application of the systems theory to social work portray it as being weak in what should be its concern about oppressive forces, does not consider the incomp atibilities of capitalism and class and its hindrances to social integration. a major criticism has been in its limitations to dene boundaries of systems and sub-systems in the realm of societal structures. despite these ideological criticisms, systems thinking does enable a methodological and organizational rigor in practice (milner & o' byrne 1998; milner, myers & o' byrne 2015). the model is well suited to work in communities as it aids the practitioner in assessing the broader territory of intervention and to work in collaboration with other agencies. this experiment is an attempt to map the systems theory through a eld work project that provides a perspective to locate the practitioner and enhances an understanding of the complexities of social work practice. in social work, the term 'system' means a set of dynamic general relationships that together process 'stimuli' (inputs) through a subsystem of closer relationships, thereby producing 'responses' (outputs). the process is one of changing inputs into outputs. in each case, the process takes place within boundaries. to place the eco-systems model in the context of a theoretical framework, an elucidation of several key concepts in the model, its goals, and skills of practice is briey discussed. the model is based on the ecosystems theory and opens-up a variety of opportunities for intervention and change. it subscribes to the philosophy of social work and to people's participation in development. the focus of social work practice is on the interactions between people and systems in their social environment. people are dependent on social systems for help in obtaining the materials, emotional or spiritual resources and the services and opportunities they would need to realize their aspirations that help to cope with their life tasks. the eco-systems theory views an individual as existing in a web of relationships (evans and kearney, 1996). there are six steps involved in the change process identied as the action system: engagement, assessment, planning, intervention, evaluation, and termination. engagement is when practitioners orient themselves to the problem and begin to establish communication and a relationship with the client system and others addressing the problem. assessment is the investigation and determination of situations affecting an identied problem or issue as viewed from a micro, mezzo or macro perspective. it is gathering information about a problem so that decisions can be made about solutions. planning species as to what should be done by whom and when. intervention or implementation is the process whereby the client and the practitioner follow the plans to achieve the goals. once goals are met and change takes place it is imperative to terminate the relationship. evaluation is a process of determining whether a given change effort was worthwhile (pincus and minahan, 1973). subsequently, followup is carried out to examine if the intervention is successful and moving in the right direction as envisaged in the planning stage. the study focussed on the systems theory applicable to social work practice (pincus and minahan 1973). the theory states that behaviour is inuenced by a variety of factors that work together as a system. a person's parents, friends, school, economic class, home environment and other factors all inuence how a person thinks and acts. seeking to help correct missing or ineffective parts of that system can have a positive impact on behaviour. in systems theory, one must observe and analyse all of the systems that contribute to an individual's behaviour and welfare, and work to strengthen those systems. this may take the form of providing positive role models, therapy or other services to help create a more supportive system for the individual. 8. aim and objectives of the study the aim of the study is to explore social meanings and social contexts of adolescents and their environments. since focussed attention is on disadvantaged adolescents, the present study envisages launching a strong initiative for empowerment of adolescents. adolescents also have an equal right to live in safety and dignity in a proactive environment. this study aims to cover a gamut of needs for adolescents in the community ranging from basic needs to health and education, empowerment and protection from abuse. this will lead to a holistic development initiative for disadvantaged adolescents in the community. since the study was an action research study based on a qualitative approach the objectives of the study were to: 1. study the reasons for dropping out of school 2. understand the challenges faced by adolescents that hinder education 3. explore the programmes provided by government and non-government organisations for adolescents 4. develop a link with government, non-governmental bodies and corporate initiatives working for adolescents 5. enhance opportunities for adolescents that will build selfesteem and overall development applying the process for social work intervention as suggested by pincus and minahan (1973) the following presentation gives an overview of the research ndings and volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 140 x gjra global journal for research analysis intervention of the action research study. i phase – exploration, assessment and planning, ii phase– implementation and goal attainment, iii phase – evaluation and termination. 9. implementation i phase – exploration, assessment and planning prole of the community the study was carried out in nochikuppam, primarily a shing community located in an urban developing area along the shoreline of the marina beach, chennai. it is one of the oldest settlements in the city with a population of over 2670 families and the second largest shing community in tamil nadu. the area is populated by migrants from the neighbouring rural districts and consist primarily of the mbc (most backward community), a caste group strongly associated with the shing occupation. caste discrimination is widely observed between the dominant shing community and the non-shing communities such as the sc (scheduled caste community). the primary occupation being shing, several of them are daily wage earners. there is a high incidence of child labour, illiteracy and high school dropouts, domestic violence and alcohol and substance use. infrastructure and basic amenities are minimal. poor housing facilities and lack of basic amenities, a lack of access to water, sanitation and garbage disposal systems. lack of health care and medical facilities, an unstable political system and a high debt status of the community marks the distinctiveness of the community. there are a number of government and private schools surrounding the community but not located within the community. schools are well maintained in terms of structure and buildings, some schools being better than others. government schools are free of cost while private schools require fees. the children go to both government and private schools. early childhood education does not seem to be a challenge. it is during middle school, that children between the age group of 12-17 dropout of school due to various reasons. the problem does not lie with the unavailability of schools as there are many schools around the area that provide education and have sufcient amenities. some of the problems with regard to education are: low academic performance and fear of public examination children complain that the teachers in their schools question them on the subject that they are teaching and beat and embarrass them if they are not able to answer. the double periods of classes for each subject make classes very boring and children avoid going to school on those days. the children are more often associated with poor academic performance because unlike other children in the city they cannot afford high tuition fees for extra classes. the fear of class x and xii board exams has terried these children, they either attempt the exam, fail and dropout or they dropout before they write these exams leaving them with no educational certicates further leading to no proper employment opportunities. there are a large number of single parents in the slum whose husbands have either passed away due to alcoholism or certain illnesses like tuberculosis and communicable diseases. a good number of either parent abandons the family. these single parents have great difculty in taking care of their children with no support of any kind. being uneducated worsens the problem as they have no choice but to do menial jobs and earn money to take care of their children. the children on the other hand might be stopped by the parent from going to school and forced to go to work or the child himself/herself feels guilty for the struggle of the parent and willingly drops out of school to support the basic needs of the family. another reason why children drop out of school is due to ill health. they cannot afford to go to the hospital and be treated as the private hospitals require fees and the government hospitals are too far away and require travel and thus they stay at home for many days and once they recover they have already missed too many days of school and they are forced to dropout as they are not readmitted or they don't feel like going to school because of the number of missed classes that they fear they will not be able to catch up. schools do not readmit children who have been absent for a number of days without a medical certicate. many of the school going children are found to be taking many days of leave in the name of sickness and eventually dropout of school due to frequent absenteeism. girls in the area are married by the age of 18 or younger either by their own wishes or the wishes of their parents. the children have constant pressure from their peers and start bad habits such as alcoholism, smoking and drugs at a very small age. they join together and bunk school, roaming the streets and come back home in the evening without the knowledge of their parents. they also get into relationships and run away from home to get married and then come back home being pregnant. some teachers give the children a severe beating and collect nes for any misbehaviour of the child like playing in the classroom or coming late to school. prole of the respondents age of respondents ranged between 11-17 years, 10 of the respondents were school going and 10 were out of school and an equal number of boys and girls in each. there was a mixture of adolescents from both private and government schools, all belonging to nochi kuppam. some belonged to the most backward community-mbc, and others belonging to the scheduled caste – sc community. the family occupation was primarily shing and the sc community, although residing in the same area, were not allowed to practice shing as an occupation but other menial jobs such as net picking, cleaning and segregating the sh, etc. they were also involved in occupations outside the community such as painting, driving, housekeeping, etc. among the out of school adolescents, two were married and living with their husbands. the families were rather small, detrimental to the common belief that families of the lower socio-economic groups tend to be large. the income of the family was around rs. 500-600/per day or between rs.2500 – 10,000/per month. the out of school children who went to work were paid between rs.7000-8000/ per day and for smaller odd jobs such as a mechanic assistant or water delivery, they earned rs.200-300/per day. although the background information of the respondents was similar, there were hardly any differences between school going and out of school children with regard to support they received from outside, their family education, income and school experiences. parents and the family environment inuence the behaviour and decisions taken by adolescents. adolescents are moving towards becoming independent physically, emotionally and cognitively, and yet growing. they require reassurance, support and unconditional love in tough times. parents of the school going and out of school adolescents had little or no education. none of them reached class twelve. although among the out of school adolescents, sibling's education seemed to have an effect on the other siblings. in volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 141gjra global journal for research analysis families were the older siblings dropped out, the younger sibling was more likely to dropout and in fact much earlier that the older sibling. parents worked in low paying jobs which was not sufcient to take care of the family's needs. they often got into debts and found it difcult to pay it back. among the school going children, few received support for their education from relatives and institutions which helped them to stay in school, they reported that they were never without food and always got help from outside if they needed it. out of school respondents stated that they were many days without food and their parents were in debts. gender inequality, alcohol dependency and domestic violence was common in the households of both school going and out of school adolescents. fathers under the inuence of alcohol created havoc which affected the lives of the adolescents in different ways. gender inequality is seen in the maternal home and in the home after marriage. mothers are given the responsibility to take care of the children. death in the family usually resulted in many life changes as the family member might have been a source of entire or partial provision to the family. this traumatic event left families in poverty and struggling to continue their education. discrimination in school and community much data pointed out to discrimination experiences in school and community. respondents had grave experiences to share which point to the poor quality of teaching and a lack of sensitivity to the adolescent stage of life. these life experiences have made life more difcult for them and as a result created a disinterest in continuing their education. ii phase– implementation and goal attainment having collected data on the respondents' background, a deeper understanding of the community and the adolescent environment was built. the social workers/researchers focussed on establishing a good and meaningful relationship with the community and the adolescents. this phase of the action research was to identify and create meaningful spaces for the adolescent expressions and for their current needs in terms of psychosocial and spiritual development. it was important to identify the physical, emotional, intellectual, and social needs. space can represent all of these ideals and more. schools can create spaces for young adolescents. the most important spaces we might create is the space to express one's worth, one's deepest desires, one's aspirations, especially those from the marginalised sections. everyone rightfully need space, but the question is: have the right types of spaces been created for them. several direct and indirect data were collected in keeping with the plan of action. networking with the local corporation/ private schools and health centres to identify key questions of the research was a major task of the project. it aimed to research and analyse complexity, sensitive areas in need of exploration such as the involvement and contribution of the parents, teachers and the community as a whole. ÿ as part of the intervention phase of the project, leadership skills training is being given to students of classes vii, viii and ix in nearby schools in partnership with idf (indian development foundation) an ngo working towards health, education and empowerment. ÿ a summer camp was conducted for the children of the area in which life skills were taught over three days. ÿ a rally was conducted for girl child education with the students of st. raphael's school ÿ a life skill training centre was initiated in partnership with multiple stakeholders furthermore, the following are the envisaged intervention plans as a follow up of the research. assessment of physical and mental health status ÿ training programme for trainers ÿ situational assessment of the girl child ÿ coping skills for adolescent related issues ÿ sexual and gender-based violence ÿ personal security of adolescents ÿ provision of basic social services, including education ÿ enrolment of dropouts in mainstream education. ÿ awareness on reproductive and sexual health, hiv and aids ÿ participation of girls/young women in empowerment programmes ÿ participation in environmental protectio ÿ awareness on civic rights and social responsibility ÿ cultural exhibition of talents and honing of abilities ÿ networking with parents, family members and service providers like teachers, etc iii phase – evaluation and termination adolescents have an equal right to express their aspirations, live in safety and dignity in a proactive environment despite the hindering forces. young people from disadvantaged coastal communities denitely face shame, dishonour, discrimination and isolation which has indelible scars on their psychological health and their learning capacities. though several efforts to cater to this group is evident, the interventions are still uneven which leaves a large number of young people out of the development agenda. even though enrolment in school in almost complete, the completion of schooling has a long way to go. the mean years of schooling thfor india is 5.12 (planning commission, 12 five year plan, govt. of india) is lower than the average for developing countries which in 7.09 years. strategically planned and designed programmes for adolescent will result in high social returns and an improved human capital. the research suggests the following to stakeholders concerned with adolescent development. to the government – scrap rote learning, encourage research based learning from a young age, enhance the quality of teacher's training institutes, reduce heavy load of syllabus and include activity-based, student-centered teaching methods, skill based training for adolescents who have already dropped out of school, availability of a counsellor in every school. to schools – regular assessments to measure progress in learning, only recruit trained teachers even at the primary level. teacher evaluation on a regular basis to teachers – make the classroom learning fun and activitybased, identify students who are more likely to drop out, take efforts to go beyond classroom learning, establish working relationships with family and community, understand that education is not merely passing in examinations. to parents – send children to school despite difculties, awareness on importance of educatin and on the need for girl child education, involvement in the child's wellbeing, meeting with the teachers regularly. 10. conclusion in conclusion, there are many reasons why adolescent dropouts of school. incapable government, poverty, unemployed parents, teacher factor, peer pressure, child labour, illness, lack of interest, etc. it is essential that the government, schools, teachers, community and parents work volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 142 x gjra global journal for research analysis together holistically to bring about a positive environment for adolescents to grow in. the convention on the rights of the child (crc) clearly outlines their rights and heralds them as the innate benet of both boys and girls. unicef is guided by the crc along with cedaw and therefore is mandated to invest in adolescencts, espicially girls as right bearers and a marginalized population. neglecting the growth of adolescents will deeply cause harm to a successful future and will only lead to continue the cycle of poverty. one drawback is that adolescence is not a signicant demograpic in the component of youth population. a good education is the key to ending poverty among adolescents. skill training is essential in times of early school dropout, so that they are equipped to nd employment. implementation of effective and early prevention is essential in areas where high dropout rate is evident. references 1. bronfenbrenner, u. (1979). the ecology of human development experiments by nature and design. harvard university press. massachusetts. 2. d'souza, barnabe (2004). understanding adolescents at risk. mumbai: multitech publishing co. 3. erikson, eric (1959). identity and life cycle. new york. international university press. 4. hollis, e.v., and taylor., a. l. (1951). ‘social work education in the united states'. new york, columbia university press. 5. evans, d. and kearney, j. (1996). working in social care a systemic approach. aldershot, areana. 6. goldstein, h., (1973). social work practice: a unitary approach; columbia; sc. university of south carolina press. usa. lerner, richard m. (2002) concepts and theories of human development. 3rd ed. mahwah, nj: erlbaum. 7. middleman, r., & goldberg, g., (1974). social service delivery: a structural approach to social work practice; new york; columbia university press. 8. milner, j., myers, s. o'byrne p. (2015). assessment in social work. palgrave, london, n1 9xw. 9. milner, j., o'byrne p. (1998). assessment in social work. macmillan, london 10. pincus, a. and minahan, a. (1973). ‘social work practice: model and method', peacock, itasca, il 11. siporin, m., (1980). ecological system theory in social work; journal of sociology and social welfare; volume 7. 12. whittaker s., j., and e. tracy. (1997). ‘person-in-environment practice'. the social ecology of interpersonal helping'. new york: aldine de gruyter. web resources 13. stang, j., story, m. in guidelines for adolescent nutrition services. available at: http://www.epi.umn.edu/let/pubs/img/adol_preface_materials.pdf. retrieved on 12 jan 2017 14. unesco. principal regional ofce for asia and the pacic. appeal training materials for continuing education personnel (atlp-ce) vol. i continuing education: new policies and directions. bangkok, 1993. 108 p. (asia-pacic programme of education for all) 15. https://www.unicef.org/ghana/really_simple_stats_-_issue_4(1).pdf retrieved on 12 jan 2017 16. “adolescents in india: a desk review of existing evidence and behaviours, programmes and policies." 2013. new delhi: population council & unicef. 17. https://www.unicef.org/about/annualreport/les/india_coar_2013.pdf retrieved on 12 jan 2017 18. “school dropout: patterns, causes, changes and policies.” ricardo sabates, kwame akyeampong, jo westbrook and frances hunt 2010. “paper commissioned for the efa global monitoring report 2011, the hidden crisis: armed conict and education” http://unesdoc.unesco.org/images/ 0019/001907/190771e.pdf retrieved on 15 may 2017 19. “poor quality education holding back south asia, world bank says.” 2014. washington: the world bank. http://www.worldbank.org/en/news/pressrelease/2014/06/30/poor-quality-education-holding-back-south-asia etrieved on 23 june 2017 20. national policy on education 2016. report of the committee for evolution of the new education policy. ministry of human resource development http://nuepa.org/new/download/nep2016/reportnep.pdf retrieved on 16 april 2017 21. the new education policy critique 22. https://www.nationalheraldindia.com/india/new-education-policy-draftmisses-out-on-critical-thinking-deeper-understanding retrieved on 20 aug, 2019 23. indian education system, an overview 2014, the british council, india. 24. https://www.brit ishcouncil . in/sites/default/les/ indian_school_ education_system_an_overview_1.pdf retrieved on 15 june 2017 25. history of education in india 26. http://www.academia.edu/1747225/history_of_education_in_india retrieved on 15 aug 2017 27. ‘a study on adolescent drug abuse in india’ 2016. american international journal of research in humanities, arts and social sciences. 28. http://iasir.net/aijrhasspapers/aijrhass16-244.pdf retrieved on dec 8 2017 29. causes of student absenteeism and school dropouts 30. https://www.researchgate.net/prole/seyma_sahin4/ publication/ 291362982_causes_of_student_absenteeism_and_school_dropouts/links/5 a59dea3aca2727d6082a3eb/causes-of-student-absenteeism-and-schooldropouts.pdf?origin=publication_detail retrieved on aug 9 2019 31. national youth policy, ministry of youth affairs and sports retrieved on 7 july 2019 32. http://www.rgniyd.gov.in/sites/default/les/pdfs/scheme/nyp_2014.pdf 33. planning commission of india 34. http://planningcommission.nic.in/plans/planrel/veyr/welcome.html retrieved on 17 july 2018 35. world health organization young people’s health – a challenge for society report of a study group on young people and health for all by the year 2000, technical report series, no 731. geneva: world health organization; 1986. 36. http://whqlibdoc.who.int/trs/who_trs_731.pdf retrieved on aug 2017 37. https://www.unicef-irc.org/portfolios/general_comments/gc4_en.doc.html retrived on sept 2019 38. https://springer.com/chapter/10.1007/978-3-319-40743-2_23 retrieved on sept 2019 39. https://www.unicef.org/adolescence/index_rights.html retrieved on sept 2019 volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 143gjra global journal for research analysis introduction the successful economy is that economy which is functioning under the legitimate rules and regulations setup by the government. but in the present era no business is working under the eye of law. when a government attempts to maintain the mandatory pricing policy but nds the demand and supply imbalance, there are the chances of emergence of black marketing. the 'black market' is the market where the goods and services are sold and bought in such a way that is illegal or punishable. the parties engaged in all these unofcial or prohibited activities are punishable by law. the black market isn't a market in physical structure it can be through digital media also where collective transactions take place between buyers and sellers. it works in secrecy. it involves all the illegal transactions on which income and other taxes are not paid. it can also be termed as 'under the table' or 'underground market'. there are obviously some goods and services that ow through black market likeillegal purchase of guns, narcotic drugs, arsenic or nuclear material, illegal currency transactions, etc. the trading of all these items is illegal and strictly prohibited. the economy suffers a lot because of these transactions. nowadays, black marketing is seen in almost every sector, whether it is government or private, national or international. the common motives for black markets are to trade contraband, avoid taxes and regulations, or skirts price controls or rationing. the black market is distinct from the grey market, in which commodities are distributed through channels which, while legal, are unofcial, unauthorized or unintended by the ofcial manufacturer. the black markets have online counterparts consisting of dark net market websites such as the silk road, individual websites, forums and chat rooms. black market especially targets places with high organized crimes and poverty and places with low resources and high tax rates. here all the prohibited items are traded. weapons, narcotic drugs, tobacco, etc are one of the biggest things sold in the black market. people want these things so they try their best to sell them as long as the demand is high. most people, when they think of the black market, think of things like drug deals or fencing stolen items. but technically, bartering goods or services with your neighbor or anyone is a black market activity, because the transaction occurs without regulation or taxes. review of literature various studies have been reviewed to study the effects of black marketing. michaely (1954), in his classical analysis of black market behavior, also recognized the role of legal activity in hiding illegal activity. he commented that 'increase in production for black market will often be accompanied by some increase in the amount offered legally, since it is difcult to hide the additional product completely from the authorities , some of it must be offered legally' . mohsen bahmani-oskooce and gour g.goswami in southern economic journal 2005, 71(3), 483-493 investigates that in many developing nations , because of government restrictions on capital and trade ow , there exists a black market for foreign exchange . items sold on black markets different types of underground activities are omnipresent that are willingly excluded from the institutional system of rules and regulations. major items that are being traded under black market economy are: 1. smuggling of drugs. 2. illegal currency transfer 3. human parts and organs 4. weapons and bombs 5. computer software 6. crude oil 7. animals skin, ivory, etc. 8. child laborers 9. diamonds and gold item 10. fake clothing and cosmetics emergence of black marketing the presence of black markets all over the world is evidence that the laws of supply and demand are virtually defy .the primary reason for black market growth is weak economic system .black markets develop when the government places certain limitations on the production or provision of goods and services. during such situations, black markets take advantage and buy and sell these prohibited commodities illegally. the transactions are done under hush-hush conditions, necessarily in the dark, hence the name black market. the people handling these transactions are very clever and will do anything to save their faces if caught in a scam. the main reasons behind the emergence of black marketing are given below: 1. heavy tax ratesevery person tries to escape himself from heavy taxes. in order to ignore it, people engage in various activities like hoarding, theft, evasion, etc. the stricter the government regulations in a country, the great the chances of black economy. 2. high regulations on trade and commercethe numerous restrictions that government puts on various activities indulges people to evade them. black markets will continue to exist as long as we have regulations and taxes. laws that prevent people from buying and selling the goods and services they desire and taxes that prevent people from keeping what they feel is their fair share of income will always cause people to hide their activities from law enforcement agencies, tax authorities and other regulators. 3. high demand goods that are short for supplyblack markets can provide legal necessities that are short in supply. the perpetual shortages tend to increase the market value of the commodity and thereby encourage the manufacturer and trader to trade the product from the ofcial to the unofcial channels and thereby make a fast buck. 4. inationthe genesis of black money can also be found in black markets original research paper rachna chanyal x 99gjra global journal for research analysis commerce the paper investigates conceptually the effects and emergence of black market activities that might be controlled for the growth of the economy. the paper analyses the reasons behind the overspreading of these activities and the actions that have to be taken to make the economy white. the practice of black marketing is at the alarming stage that thrives unregulated and untraceable, provides prots and growth in the short run but if not controlled will give a better sense of threat that will not only severely affect the business but also the economy of the country. abstract keywords : black marketers, smuggling, government restrictions, taxes, ination. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 100 x gjra global journal for research analysis the persistent ination in the country, which has enhanced incentives and opportunities to earn such incomes. ination inevitably leads to growth of parallel markets and strengthens evaders to hide incomes and to evade taxes. since ination causes capital erosion, there is always a temptation to maintain dual accounts for tax evasion by diverting portion of inventories and output from white channels to black channels of deployment. as the matter of fact, ination is both the cause as well as consequence of the growth of black money in the indian economy. 5. political funding political funding in india also causes a signicant amount of black income. our election laws and behavior of political parties are primarily responsible for this. today contesting of elections has become a very costly affair. the candidate has to spend much in excess of the ofcially sanctioned amount. this has to be arranged somehow in black money. the politicians largely resort to industrialists and trading community for the help — the funds are raised in terms of black money. 6. goods at high costusually the buyers have two motives for their purchases. first, they want to obtain a legal good or service at a lower price. for examplethe cost of stolen or smuggled goods is lower than the cost of manufacturing the goods. there are no taxes involved. often they are sold on the street corner. second, some want to obtain a legal good or service in short supply. in these cases, the good or service will cost more in the black market, but it is readily available. 7. high unemploymenthigh unemployment can give rise to black markets. when workers cannot nd jobs in the above-ground economy, they may turn to jobs in the underground economy, which obviously will lead to generation of black marketing. remedial measures for black marketing the black economy has become so powerful that even an incorruptible ofcial of government is often helpless to control it. it has been argued that if the black savings accumulated overtime, it could be channelized into white economy then at least it could contribute to the development of the economy. the various measures are undertaken to overcome the problem of black marketing. these are 1. easing legal restrictionswith the increase in government restrictions, black market prices for relevant products rise, as restrictions represent a decrease in supply and increase risk in the supply of these products. black markets can be reduced or eliminated by removing legal restrictions, thus increasing supply and quality. 2. increase availability of goods -the other reason for the existence of black markets is the shortage of production and distribution of legal goods and services. to avoid this loophole, the goods that are excessive in demand should be produced or make available in the legal market. 3. strict actionsstrict actions against hoarding and black marketing under essential commodities act, imposition of stock holding limits, buffer stock of articles are the steps taken by government to curb black marketing. conclusion black marketing is not only the reason for ination in the country but other factors like demandsupply mismatch, price trend in global market are also responsible. it also has active operations in the eld of real estate, gold, government transactions, snuggling, illegal transportation, etc. the adoption of this practice creates serious damage in all our economic policies, thus results in adverse effect to the scal and monetary management of the economy. the diversion of the commodity into black market channels results in the government and local bodies losing all the revenue in the form of excise, sales tax, etc. the growing illegal service includes stolen personal and nancial information. it is used to gain access into black accounts and credit cards or to establish new lines of credit. the buyers and sellers could be exposing themselves to violent consequences. they cannot appeal to government for any protection. both buyers and sellers risk punishment, including nes and jail time for engaging in illegal activities. if the good or service itself isn't illegal, then the evasion or theft is. in june 2014, the then finance minister arun jaitley on behalf of the indian government requested the swiss government to handover all the bank details and names of indians having unaccounted money in swiss banks. the elimination of black markets cannot be achieved by government action alone, but rather involves an agreement on the part of the people and government as to which goods or services may be traded by ethical and legal aspects of trade. it is a matter of shame that some industrialists are hoarding their products to be sold at a much higher price than their actual cost. we also see black marketers selling fuel in bottles by the road side without hindrance and, thereby, making a huge prot. here we should not only blame the black marketers for what is happening. people who buy such items are also encouraging these illegal practices, though they are doing so under a kind of compulsion. in the meantime, the country's economy is taking a severe beating while the general people are in a pitiable plight. essentials like fuel should be made available through rationing by ensuring that its distribution is fair. this means, except for some bodies providing essential services, fuel should be rationed and sold in a fair manner. black marketers should be discouraged and made to face stern punishment which is not the case now. the government is now facing a serious challenge to provide the essentials to the public by ensuring fair distribution. it is the duty of the government to bring these illegal activities to a halt. black marketers should be discouraged and made to face stern punishment. references: 1.www.economictimes.com 2.the hindu times business news google volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introductionsuicidal behavior is a leading cause of death and disability worldwide. fortunately, recent developments in suicide theory and research promise to meaningfully advance knowledge [1]and prevention. for the goal of improved detection and treatment of suicidal individuals to be achieved, we need to develop a detailed understanding of the origin, mechanisms [2]and outcomes of inammation in suicidal behaviour. c-reactive protein (crp) is an acute-phase inammatory protein synthesized by hepatic kupffer cells signalling other [3]body cells for destruction by the complement system. inammation has been linked with a potential vital role in suicidality, among which hs-crp play an important role. suicidal ideation and attempt in context of depression is very common. many studies have demonstrated an association between suicidal behaviour and inammatory markers 4-10primarily crp. however, the caveats of most studies was that they evaluated the crp in patients demonstrating suicidal behaviour but not in settings of depression, leading to a bias and variations due to controls having different pathophysiology making it difcult to differentiate the altered inammatory states that could be attributed to suicidality in depression or other causes. most of the studies have not differentiated between suicidal attempt and ideation since both can inuence crp levels acutely and chronically. our study is a pioneer research in comparing hscrp levels in depression patients with suicidal attempt and with suicidal ideation. in the present study, we explore a clinical inammatory marker (crp) in psychiatric patients hospitalized in an acute adult inpatient facility following suicidal attempt and ideation. we hypothesized that patients hospitalized in a “real world” adult inpatient population following a recent suicidal attempt will display higher crp values than those with suicidal ideation. methodologythe present study was conducted at department of psychiatry, m.g.m medical college, indore. this is a cross-sectional comparative study conducted between january 2018 to december 2018. after obtaining the institutional review board (scientic and ethical) approval, 50 consecutive subjects (25 each in depression with suicidal attempt and depression with suicidal ideation group) who attended in-patient treatment from the psychiatry department of a tertiary care medical college were taken. inclusion criteria patients aged 18–65 years, both genders, who satised the 11icd diagnostic criteria for research-10 (icd dcr-10) criteria for depression (f32) or rdd (f33), without psychotic symptoms were included. as per diagnostic and statistical manual of mental disorders (dsm-v) active suicidal attempt is a self-initiated sequence of behaviours by an individual who at the time of initiation, expected the set of actions would lead to his or her own death. the speciers include currentnot more than 12 months since last attempt and in early remission 12-24 months since last attempt. while the suicidal ideation group has never attempted suicide but have ideas of suicide. only those patients who were drug naïve or treatment free for more than 3 months before the onset of current episode and subjects/informants who gave written informed consent were taken. exclusion criteria any other psychiatric comorbidity (schizoaffective, bipolar affective disorder, organic mood disorder). current use of antipsychotics , anti-depressant, mood stabilizers, or drug free < 3 months. patients with history of mental retardation, seizure disorder, permanent neurological decits, cognitive impairment and affective illness secondary to general medical condition or psychoactive substance use (except tobacco) were excluded. we also excluded patients with poor physical health and those with informants who cannot provide adequate information. subjects were taken from dept of psychiatry, mgm medical collegemy hospital and mental hospital indore fullling the a comparative study of inflammatory marker highly sensitive c-reactive protein between depression patients with suicidal attempt and depression patients with suicidal ideation original research paper rastogi p dept. of psychiatry mgm mc indore m.p 452001 india x 105gjra global journal for research analysis psychiatry background: suicidal ideation and attempt in context of depression is very common. many studies have demonstrated an association between suicidal behaviour and inammatory markers primarily crp. we explore a clinical inammatory marker (crp) in psychiatric patients hospitalized in an acute adult inpatient facility following suicidal attempt and ideation aims: to compare hscrp levels between depression patients with suicidal attempt and suicidal ideation. methodology: comparison of 25 depression patients with suicidal attempt and 25 depression patients with suicidal ideation was done, diagnosis as per icd10. hamilton depression rating scale (hdrs-17), beck scale for suicidal ideation (bssi), suicide behaviour questionnairerevised (sbq-r), were applied for assessment of depression and suicidality. highly sensitive crp was measured using autoanalyzer. results: hscrp levels were signicantly high in depression patients with suicidal attempt (6.11 mg/dl) than depression with suicidal ideation (2.14 mg/dl). duration of illness, ham-d, bssi & sbq-r scores correlated positively with hscrp levels. conclusion: depression with suicidal attempt patients demonstrated a statistically higher hs-crp levels than depression with suicidal ideation. patients of depression with suicidal attempt have a strong positive correlation between hs-crp levels and ham-d, bssi & sbq-r scores. abstract keywords : suicide; depression; c-reactive protein; inammatory marker mudgal v* dept. of psychiatry mgm mc indore m.p 452001 india*corresponding author pal v. s dept. of psychiatry mgm mc indore m.p 452001 india lohokare r dept. of biochemistry mgm mc indore m.p 452001 india volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 106 x gjra global journal for research analysis inclusion criteria. after complete description of the study to the subjects, written informed consent was obtained from all participants. a detailed physical examination was done to rule out major medical or neurological illness. sociodemographic data was collected. after that clinical assessment of patient group was done using hamilton 12depression rating scale (ham-d), beck scale for suicidal 13 14ideation (bssi), suicide behaviour questionnaire (sbq-r). blood samples of all groups were drawn after explaining the procedure and were collected in a clot activator (red top) tube at my hospital indore dept. of biochemistry. post which serum was processed from the sample via centrifuge machine and the serum was analysed for hs-crp with automated analyser using immunoturbidimetry method. results were analysed using spss 23. resultstable 1sociodemographic variables of the patients in comparison to the depression with suicidal ideation the depression with suicidal attempt group had younger age of onset (28.64 years), more male (56%), unmarried (32%), hindu faith (80%), literates, low socioeconomic (76%), unemployed (66%), nuclear family (64%) subjects. about a quarter (24%) of patients had family history of suicidal attempt in the attempt group which is higher than ideation group (16%). table 2. description of duration of illness (months) in study participants in depression patients with suicidal attempt and depression with suicidal ideation depression patients attempting suicide had a mean duration of illness as 6.32 ± 2.32 months while depression with suicidal ideation group had a mean duration of 4.84 ± 2.51 months. the minimum duration for attempt group was 3 months while that for ideation group was 2 months, while maximum duration for attempt and ideation group was 12 and 11 months respectively, this duration is when the patient presented to the o.p.d and could have been more. table 3. description of age of onset of depression (years) in study participants in depression patients with suicidal attempt and depression with suicidal ideation suicidal attempt group had mean age of onset at 28.24 ± 9.33 years while ideation group had onset at 37.04 ± 12.733 years. the minimum age of onset for both the case and control group was 18 years while maximum for attempt group was 54 years while that of ideation group was 65 years. table 4. clinical characteristics of depression patients with suicidal attempt and depression with suicidal ideation (continuous variables) ham-d scores showed a higher mean 23.92 ± 6.35 in the suicidal attempt group while the ideation group mean was 16.80 ± 5.87, the t test demonstrated statistical signicance. beck's scale for suicidal ideation showed a higher mean of 22.92 ± 7.44 in the suicidal attempt group in comparison to 16.48 ± 4.08 as mean for ideation group, the t test demonstrated statistical signicance. the suicide behaviour questionnaire revealed mean scores of 12.20 ± 3.22 and 8.60 ± 2.21 for attempt and ideation group respectively with a statistical signicance of t test for higher mean sbq score for attempt group. table 5. comparison of hs-crp between depression pati ents with suicidal attempt and suicidal ideation volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra depression with suicidal attempt (n=25) depression without suicidal ideation (n=25) age(mean) in years 28.64 years 35.52 years males females 14 (56%) 11 (44%) 12 (48%) 13 (52%) marital status in %: married 56% 68% unmarried 32% 16% divorced 4% 4% widowed 4% 4% remarried 4% 8% religion in %: hindu 80% 62% muslim 20% 38% education in %: illiterate 16% 20% thprimary (5 ) 28% 36% thmiddle(8 ) 20% 20% high school 16% 8% inter 8% 8% diploma/graduate/post graduate professional 12% 8% socioeconomic low 76% 72% middle 22% 24% high 2% 4% occupation employed 34% 46% unemployed 66% 54% family type nuclear 64% 44% extended/ joint. 36% 56% locality urban 64% 68% rural 36% 32% family history positive 19 (76%) 21 (84%) negative 6 (24%) 4 (16%) n minimum maximum mean std. deviation suicidal attempt patients 25 3 12 6.32 2.322 suicidal ideation patients 25 2 11 4.84 2.511 n minimum maximum mean std. deviation suicidal attempt patients 25 18 54 28.24 9.333 suicidal ideation patients 25 18 65 37.04 12.733 variables suicidal attempt patients mean± sd n=25 suicidal ideation patients mean± sd n=25 t value p value ham-d scores 23.92 ± 6.35 16.80 ± 5.87 4.11 .001 beck's ssi scores 22.92 ± 7.44 16.48 ± 4.08 3.79 0.001 sbq-r scores 12.20 ± 3.22 8.60 ± 2.21 4.59 0.001 hs-crp (mg/l) suicidal attempt patients (n=25) suicidal ideation patients (n=25) mean 6.11 2.14 n 25 25 *statistically signicant table 5 shows comparison of hs-crp levels between depression patient with suicidal attempt and ideation. the attempt group had a mean hs-crp value of 6.11 ± 6.09 mg/l which is considered as high value as per our criteria for cut off (≥3mg/l), while ideation group had a mean of 2.14 ± 2.10 mg/l. suicidal attempt patient group has shown higher hscrp levels than ideation patient group of depression which was statistically signicant. table 6. severity of depression in depression patients with suicidal attempt and suicidal ideation table 6 displays depression severity as per icd-10 criteria. severe depression was 76% in suicidal attempt patients and 40% in suicidal ideation patients. about 24% patients were in the moderate depression category belonging to the attempt group while 40% ideation subjects had moderate depression. 20% patients had mild depression with suicidal ideation while there were no patients in the suicidal attempt group who had mild depression. table 7. comparison of hs-crp with severity of depression between depression patients with suicidal attempt and ideation table 7 show comparison of hs-crp within depression with suicidal behaviour group. the attempt group had the highest mean hs-crp value 7.04 ± 6.68 mg/l while ideation group had 3.53 ± 2.33 mg/l hs-crp in severe depression. in moderate depression, the attempt group had a greater mean in comparison to ideation group. t test revealed no statistical difference in means of hs-crp as per severity of depression in the intragroup comparison. table 8. chi square test for hs-crp samples (low & high) between depression with suicidal attempt and suicidal ideation pearson chi-square value = 8.11 , p= 0.004 table 8 describes the high and low hs-crp counts which is dened by a cut off of 3mg/l as per literature and methodology in depression patients with suicidal attempt and depression patients with suicidal ideation. the chi square test was statistically signicant implying that depression patients with suicidal attempt have more hs-crp samples in high group than depression patients with suicidal ideation. cramer's v = .403, moderate effect size table 9. correlation of hs-crp with ham-d scores in patients of depression with suicidal attempt and depre ssion with suicidal ideation **. correlation is signicant at the 0.01 level table 9 displays pearson correlation between hscrp and ham-d scores. there is a statistically signicant strong positive correlation between ham-d scores and hs-crp levels in suicidal attempt group, while the suicidal ideation group also had a strong positive correlation between ham-d scores and hs-crp. table 10. correlation of hs-crp with sbq-r scores in patients of depression with suicidal attempt and depression with suicidal ideation *. correlation is signicant at the 0.05 level table 10 displays pearson correlation between hscrp and sbq-r scores. there is a statistically signicant medium positive correlation between sbq-r scores and hs-crp levels in suicidal attempt group, while the suicidal ideation group also had a medium positive correlation between sbq-r scores and hs-crp. table 11. correlation of hs-crp with bssi scores in patients of depression with suicidal attempt and depression with suicidal ideation **. correlation is signicant at the 0.01 level *. correlation is signicant at the 0.05 level table 11 displays pearson correlation between hscrp and bssi scores. there is a statistically signicant strong positive correlation between bssi scores and hs-crp levels in suicidal attempt group, while the suicidal ideation group had a medium positive correlation between ham-d scores and hscrp. x 107gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra std. deviation 6.09 2.10 std. error of mean 1.21 0.43 minimum .27 .12 maximum 26.80 6.76 range 26.53 6.64 t value 3.07 p value 0.005* depression severity suicidal attempt n=25 suicidal ideation n=25 mild 0 (0%) 5 (20%) moderate 6 (24%) 10 (40%) severe 19 (76%) 10 (40%) hs-crp (mg/l)suicidal attempt patients (n=25) hs-crp (mg/l)suicidal ideation patients (n=25) t value p value mild depression .81 ± .66 moderate depression 3.16 ± 1.91 2.04 ± 2.01 0.94 0.37 severe depression 7.04 ± 6.68 3.53 ± 2.33 2.06 0.05 hs-crp result total hs-crp high (value >3mg/l) hs-crp low (value ≤ 3mg/l) suicidal attempt count 16 9 25 expected count 11.0 14.0 25.0 suicidal ideation count 6 19 25 expected count 11.0 14.0 25.0 total count 22 28 50 expected count 22.0 28.0 50.0 pearson chi-square 8.11 p value 0.004 cramer's v 0.403 ham-d suicidal attempt ham-d suicidal ideation hs-crp r p r p .519** .008 .735** .001 sbq-r suicidal attempt sbq-r suicidal ideation hs-crp r p r p .483* .015 .311 .130 bssi suicidal attempt bssi suicidal ideation hs-crp r p r p .512** .009 .456* .022 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra discussionthe sociodemographic parameters (table 1) revealed the mean age of depression with suicidal attempt was 33.08 ± 11.9 years while that of depression with suicidal ideation group was 34.20 ± 10.3 years, this implies that suicidality 15, 16appears earlier in presence of depression. the number of female patients were higher in the depression without suicidal behaviour. group (58%) than depression with suicidal behaviour group. our results suggest that males have higher suicidal behaviour than females. the married subjects were higher in depression with suicidal behaviour group (68%) than depression without suicidal behaviour (64%) groups. our results suggest that being married might have protective effect on suicidal behaviour due to better social and 17, 18interpersonal support. the depression with suicidal behaviour group had higher preponderance of (76%) hindu subjects which is in agreement of the local geographical 16distribution of the religion. most participants in both depression with suicidal behaviour (32%) and depression without suicidal behaviour (32%) group were literate till primary education, depression without suicidal behaviour group had more percentage of illiterates (22%), previous studies found that poorly educated subjects were more 19vulnerable to suicidal attempts. low socio-economic income groups were found to be the majority in both depression with suicidal behaviour (74%) and depression without suicidal behaviour groups (76%). in terms of sociodemographic variables studies have shown that depression is more 20, 21common in subjects from poor economic background. the distribution of depression with suicidal behaviour group (66%) and depression without suicidal behaviour (62%) sample were urban dwelling in majority, while about one third sample 22in both groups belonged to rural background. the depression with suicidal behaviour group had higher composition of nuclear family (66%) than depression without 22suicidal behaviour group (54%). patients attempting suicide had a mean duration of illness as 6.32 ± 2.32 months, suicidal ideation group had a mean duration of 4.84 ± 2.51 months (table 2). these ndings are 23similar to the mean duration of depression in most literature. therefore, we suggest the depression with suicidal behaviour patients presented to the health-care settings later as compared to depression without suicidal behaviour patients whereas the suicidal ideation subgroup presented earlier in comparison to the suicidal attempt subgroup. since majority of suicidal attempt patients were in the severe depression category the above nding can be attributed to severe psychomotor retardation in severe depression and poor interpersonal interaction in suicide attempters. all the samples of our study were identied with major depression as per inclusion criteria and the mean age of all 50 subjects was 32.6 ± 11.9 years, similar mean age have been 10, 22, 24found in multiple previous studies. the mean age of onset in the suicidal attempt subgroup was 28.24 ± 9.33 years while in the ideation subgroup was 37.04 ± 12.70 years (table 3), suggesting that suicidal attempt patients develop depression at an earlier age in comparison to suicidal ideation counterparts. hence, young impressionable age is another risk factor for suicidal attempt. our results are in concordance with previous the studies where in one 73% of the patients with 25suicidal behaviour were <30 years of age, and in another study age at <25 years was reported as being a signicant 19risk factor for suicidal attempt. the mean ham-d scores in suicidal attempt subgroup (table 4) were higher 23.92 ± 6.35 than the suicidal ideation subgroup was 16.80 ± 5.80, suggesting attempt can be an indicator for severe depression since suicidal attempt patients were in the very severe category of depression as per ham-d 12scale, and that suicidal ideation alone does not warrant the diagnosis of severe depression. as per literature severe depression was found to be associated with suicidal attempt one study found severe depression as one of the factors signicantly associated with suicide, (or=2.20, 95% 26ci=1.05–4.60). in another study it was seen that nding of severe depression was associated with a sensitivity of 87.3% 27, 28and specicity of 63% for suicide attempt. the suicidal attempt group had a mean beck's ssi score of 22.92 ± 7.44 in comparison to 16.48 ± 4.08 as mean for ideation group (table 4), the student's t-test demonstrated statistical signicance. as the beck's ssi relates positively with the suicidal behaviour the suicidal attempt group had a higher mean score. sbq-r scores more than 8 are suggestive 13of suicidal behaviour which is seen in our sample population. the sbq-r mean scores of 12.20 ± 3.22 and 8.60 ± 2.21 for attempt and ideation group (table 4) respectively with a statistical signicance of t test for higher mean sbq-r score in 14the attempt group. comparison of hs-crp levels between subgroups of depression patient with suicidal attempt and ideation (table 5) the attempt group had a higher mean hs-crp (6.11 ± 6.09 mg/l) value than ideation group (2.14 ± 2.10 mg/l). suicidal attempt patient group has shown statistically signicant high mean hs-crp than ideation patient group of depression. to the best of our knowledge no study had replicated the above results comparing suicidal attempt with suicidal ideation in context of hs-crp. however, in a previous study conducted in 2015 no signicant difference in crp levels between high vs 4low suicidal ideation was reported. comparison of depression patients with suicidal attempt and ideation revealed severe depression was 76% in suicidal attempt patients and 40% in suicidal ideation patients (table 6) which is in agreement with most guidelines which states suicidal attempt is an indicator of severe depression. however, moderate and severe depression made up for 80% of patients in having suicidal ideation. on evaluating hs-crp mean as per severity of depression (table 7) we found a statistically signicant difference in means of hs-crp cases amongst mild, moderate and severe depression. the depression with suicidal attempt group had the highest mean hs-crp value 7.04 ± 6.68 mg/l while ideation group had 3.53 ± 2.33 mg/l hs-crp in severe depression. in moderate depression, the attempt group had a greater mean in comparison to ideation group. t test revealed no statistical difference in means of hs-crp as per severity of depression in the intragroup comparison. chi square test was applied in the suicidal attempt and ideation patients (table 8) the high and low hs-crp counts which is dened by a cut off of 3mg/l as per literature and methodology in depression patients with suicidal attempt and depression patients with suicidal ideation. the chi square test was statistically signicant implying that depression patients with suicidal attempt have more hs-crp samples in high group than depression patients with suicidal ideation. the cramer's v score was .403 which is suggestive of a moderate effect size. there is a statistically signicant strong positive correlation ®= 0.51) between ham-d scores and hs-crp levels in suicidal attempt group, while the suicidal ideation group also had a strong positive correlation (r= 0.73) between ham-d scores and hs-crp (table 9). in previous literature it was found 29 that ham-d scores to be correlated positively with hs-crp. in another study it was found that individuals with higher 30depression scores have higher levels of hs-crp. 108 x gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra there is a statistically signicant medium positive correlation ®= 0.48) between sbq-r scores and hs-crp levels in suicidal attempt group, while the suicidal ideation group also had a medium positive correlation (r= 0.31) between sbq-r scores and hs-crp (table 10). there is a statistically signicant strong positive correlation ®= 0.51) between bssi scores and hs-crp levels in suicidal attempt group, while the suicidal ideation group had a medium positive correlation (r= 0.45) between ham-d scores and hs-crp (table 11). there are a few limitations to our study design like there is a lack of longitudinal follow-up which could be utilized to compare hs-crp scores before and after intervention. inammatory marker hs-crp could be confounded by other inammatory conditions despite strict inclusion criteria. sample size and study duration can attribute to factors limiting the study. conclusiondepression patients with suicidal attempt have more hs-crp high (≥3mg/l) samples than depression patients with suicidal ideation. there is a strong positive correlation between hamd scores and hs-crp levels in suicidal attempt group, while the suicidal ideation group also had a strong positive correlation. moderate positive correlation was found between sbq-r scores and hs-crp levels in suicidal attempt and ideation group. strong positive correlation exists between bssi scores and hs-crp levels in suicidal attempt group, while the suicidal ideation group have a moderate positive correlation between ham-d scores and hs-crp suicidal attempt contributed to the higher hs-crp levels in depression patients. thus hs-crp an inammatory marker can serve as a potential marker of suicidal behaviour in depression patients and such at risk patients may be identied prior to suicidal attempt by high hs-crp levels. references1. klonsky ed, may am, saffer by suicide, suicide attempts, and suicidal ideation, annu rev clin psychol. 2016;12:307-30. doi: 10.1146/annurevclinpsy-021815-093204. epub 2016 jan 11. 2. brundin l, erhardt s, bryleva ey, achtyes ed, postolache tt. the role of inammat ion in su ic ida l behav iour. ac ta psych ia t r scand. 2015;132(3):192–203. doi:10.1111/acps.12458 3. thompson, d., pepys, m.b., wood, s.p., 1999. the physiological structure of human c-reactive protein and its complex with phosphocholine. structure 7 (2), 169e177. 4. courtet p1, jaussent i2, genty c1, dupuy am3, guillaume s1, ducasse d4, olié e1 increased crp levels may be a trait marker of suicidal attempt.eur neuropsychopharmacol. 2015 oct;25(10):1824-31 5. suchankova, p., et al., 2013. the þ1444c>t polymorphism in the crp gene: a study on personality traits and suicidal behaviour. psychiatr. genet. 23 (2), 70e76. 6. o'donovan, a., et al., 2013. suicidal ideation is associated with elevated inammation in patients with major depressive disorder. depress. anxiety 30 (4), 307e314. 7. gibbs hm1, davis l2, han x2, clothier j2, eads la2, cáceda r2.association between c-reactive protein and suicidal behavior in an adult inpatient population. j psychiatr res. 2016 aug;79:28-33. 8. loas g1, dalleau e2, lecointe h2, yon v2.relationships between anhedonia, alexithymia, impulsivity, suicidal ideation, recent suicide attempt, c-reactive protein and serum lipid levels among 122 inpatients with mood or anxious disorders. psychiatry res. 2016 dec 30;246:296-302 9. e gambji, d. de berardis i -3, d. campanella\ a. carano\ g. sepedel , g. salini, a retrospective evaluation of the inammatory marker c-reactive protein (crp), cholesterol and high-density lipoproteins in patients with major depression: preliminary ndings, european journal of inammation vol. 3, no. 3,127-134 (2005) 10. ryoung jinpark, yang hyunkim association between high sensitivity crp and suicidal ideation in the korean general population 10.1016/j.euroneuro. 2017.06.010 11. world health organization. the icd-10 classication of mental and behavioural disorders: diagnostic criteria for research. geneva: world health organization; 1993. p. 89-103. 12. hamilton m. a rating scale for depression. j neurol neurosurg psychiatry 1960;23:56-62. 13. beck a, kovacs m, assessment of suicidal intention:the scale for suicide ideationjournal of consulting and clinical psychology 1979, vol. 47, no. 2, 343-352 14. osman, a; bagge, cl; gutierrez, pm; konick, lc; kopper, ba; barrios, fx (december 2001). "the suicidal behaviors questionnaire-revised (sbq-r): validation with clinical and nonclinical samples". assessment. 8 (4): 443–54. doi:10.1177/107319110100800409 15. islam, md.r. and adnan, r. (2017) socio-demographic factors and their correlation with the severity of major depressive disorder: a population based study. world journal of neuroscience , 7, 193-202. https://doi.org /10.4236/wjns.2017.72014 16. maqbool dar, mohammad & tarfarosh, shah faisal ahmad & manzoor kullah, shahid & mushtaq, raheel & manzoor, mushbiq & maqbool, sumaira. (2016). socio-demographic and clinical prole of patients suffering from severe depressive disorders in kashmir valley. international journal of contemporary medical research. 3. 3389-3392. 17. okeafor cu, chukwujekwu cd, olose eo (2017) socio demographic correlates of depressed patients attending a tertiary hospital in nigeria. j addict res ther 8:313. doi:10.4172/2155-6105.1000313 18. sanja musić milanović, katja erjavec, tamara poljičanin, božena vrabec & petrana brečić: prevalence of depression symptoms and associated sociodemographic factors in primary health care patients psychiatria danubina, 2015; vol. 27, no. 1, pp 31–37 19. kessler rc, borges g, walters ee. prevalence of and risk factors for lifetime suicide attempts in the national comorbidity survey. arch gen psychiatry 1999;56:617–26. 20. poongothai s, pradeepa r, ganesan a, mohan v (2009) prevalence of depression in a large urban south indian population — the chennai urban rural epidemiology study (cures – 70). plos one 4(9): e7185. https://doi.org/10.1371/journal.pone.0007185. 21. bagadia vn, shah lp, pradhan pv, gada mt. a double blind controlled study of amoxapine and imipramine in cases of depression. curr ther res. 1979;26:417–29. 22. srivastava a s, kumar r. suicidal ideation and attempts in patients with major depression: sociodemographic and clinical variables. indian j psychiatry 2005;47:225-8 23. solomon da, keller mb, leon ac, mueller ti, shea mt, warshaw m, maser jd, coryell w, endicott j arch gen psychiatry. 1997 nov; 54(11):1001-6 24. yang f, li y, xie d, shao c, ren j, wu w, et al. age at onset of major depressive disorder in han chinese women: relationship with clinical features and family history. j affect disord. 2011;135:89–94. 25. narang rl, mishra bp, mohan n. attempted suicide in ludhiana. indian j psychiatry 2000;42:83–7. 26. hawton k, comabella c, haw c, saunders k et al. risk factors for suicide in individuals with depression: a systematic review journal of affective disorders volume 147, issues 1–3, may 2013, pages 17-28 27. franklin jc, ribeiro jd, fox kr, et al. risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. psychol bull. 2017;143:187-232. 28. coentre r, faravelli c, figueira ml. assessment of depression and suicidal behaviour among medical students in portugal. int j med educ. 2016;7:354–363. published 2016 oct 29. doi:10.5116/ijme.57f8.c468 29. krogh, jesper & benros, michael & balslev jørgensen, martin & vesterager, lone & elfving, betina & nordentoft, merete. (2013). the association between depressive symptoms, cognitive function, and inammation in major depression. brain, behavior, and immunity. 35. 10.1016/j.bbi.2013.08.014. 30. ma y, chiriboga de, pagoto sl, rosal mc, li w, merriam pa, hebert jr, whited m, ockene is. (2011). association between depression and creactive protein. preventive and behavioral medicine publications. https://doi.org/10.4061/2011/286509 x 109gjra global journal for research analysis introduction: after independence, women in india have come a long way. from just being a skilled homemaker, women today have acquired skills and capabilities of not just being a homemaker but being at par with the male counterparts. this the new generation of women, wants to pursue their dream career. conicts arises with the working mother as one has to full the demand at work followed by demands of family including children, husband, in-laws, etc. in today's scenario the husband and wife both work for creating a balance with their work life as well as at home with their children. but it is difcult for women as she has to play multiple roles of a cook, a tutor, a nurse, a helper, as well as cater to the demands of ofce work. this can leave a working woman stressed and anxious, (1)especially if the family is not supportive. a housewife's main duties include managing the family, educating and taking care of her children, cooking food, buying goods, cleaning and maintaining the home, washing and sewing clothes for the family and so on, the list is endless. it is ironical that a woman employed within the home is referred to as a housewife, and outside the home, as a working woman. whereas, in both the situations, woman is working but how the woman is referred to, is based on the working place. the duty of the housewife is to take care of the day-to-day chores within the house. a woman who earns salary, wages, or other income through employment, outside the home, is (2)termed as a working woman. first of all, one should recognize the true sources of stress, which is the main problem. stress is quite common in todays life which may leads to many health problems as well, cognitive, emotional, physical and behavioural changes may occur. hence, this study was conducted to compare the level of stress experienced by housewives and working women. methodology: a cross-sectional study was conducted among housewives and working-women in the urban area of rohtak district, haryana. data was collected from 200 respondents, of which 100 respondents were housewives and 100 were working women, in a time span of 1month (1stoctober -1stnovember, 2018). general role stress scale (grss), which is a selfadministered questionnaire with a respondent rate of 12 items on a 5-point scale was used to assess the stress level among respondents. the data was collected and entered in the msexcel spread sheet, coded appropriately and cleansed for any possible typing error. results were expressed as mean (sd) and then the data were subjected to systematic analysis using statistical independent t-test by application of spss-20 software as per study objective. results: 200 females with mean age= 28.96 (sd=4.47) years took part in the study. an independent-sample t-test was conducted to compare the grss stress score among housewives and working-women. there was a signicant difference in the levels of stress in housewives (mean=29.08, sd=4.46) and working-women (mean=32.98, sd=5.44); t=12.084, p=0.001. out of all the study subjects only 15% were doing some efforts to decrease the levels of stress such as meditation, listeningmusic, exercising, keeping themselves busy in some or the other recreational activities (table-2). table1. distribution of the study subjects according to different variables a comparative study on stress levels among working women and housewives of district rohtak, haryana original research paper ginni agrawal junior resident, department of community medicine x 77gjra global journal for research analysis community medicine introduction: a woman employed within the home is a housewife, and outside the home is a working woman, but in both situations the woman is working. balancing work and family-life together is a major issue for women. family issues as well as work issues has resulted in women dealing with an increasing amount of stress. aim and objective: the objective of the study was to compare the level of stress experienced by housewives and working women in the district rohtak, haryana. methodology: a cross-sectional study was conducted among 100 housewives and 100 working women using general-rolestress-scale(grss), to assess the stress level among respondents. results: stress levels of working-women with mean 32.98(sd=5.44) and housewives with mean 29.08(sd=4.46) shows that working-women face more stress when compared to housewives, which was statistically signicant (p-value=0.001). conclusion: in order to avoid stress from negatively impacting lives, one needs to increase knowledge about stress management techniques. abstract keywords : stress housewives working-women rohtak piyush jain* junior resident, department of forensic medicine pt.b.d. sharma university health sciences, rohtak*corresponding author sarika yadav junior resident, department of community medicine tarun kumar junior resident, department of community medicine volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra age group housewives (n=100) working women (n=100) total (n=200) frequency (%) frequency (%) frequency (%) 1. 20-25 years 0 36 (36) 36 (18) 2. 26-30 years 72 (72) 31 (31) 103 (51.5) 3. 31-35 years 21 (21) 26 (26) 47 (23.5) 4. >36 years 7 (7) 7 (7) 14 (7) total 100 (100) 100 (100) 200 (100) education status 1. post-graduate 0 0 0 2. graduate /diploma 22 (22) 16 (16) 38 (19) 3. 12th pass 33 (33) 43 (43) 76 (38) 4. 10th pass 7 (7) 27 (27) 34 (17) 5. 8th pass 25 (25) 11 (11) 36 (18) 78 x gjra global journal for research analysis (figures in the parenthesis indicate percentage) table-2. distribution of the study subjects according to the sources of stress (figures in the parenthesis indicate percentage) discussion: in the current study it was exhibited that working-women feel more stressed-out as compared to the housewives. similar (1)results were found in the studies by tripathi et al , harilal et (2) (3) (4) (5)al , mamatha et al , shukla et al . in a study by kumar et al , concurrent conclusion was derived that working-women are suffering from moderate-to-high levels of stress. housewives are also suffering from the stress although less in comparison to the working-women. women should try to modify the stressful situation, and nd some time to move away for relaxation. stress being a part of human life; sometimes motivate us and helps us to become more productive. but too much stress is harmful which creates anxiety, tension, fatigue/burnout. complete healthy diet habits also help in keeping the stress levels controlled. activities such as walking, dancing, swimming, listening music, meditation, spending leisure time with family/ friends, painting, cooking or other recreational activities, etc may act as stress busters. changing the work environment also relives work stress at times. making the environment less competitive and creating positive vibes by reducing personal conicts also decrease some amounts of stress. conclusion: the study showed the stress levels among working women and housewives concluding that stress-levels are high for working-women when compared with housewives. in order to avoid negative effects of stress, one need to increase knowledge about stress and also use stress management techniques. references: 1. tripathi p, bhattacharjee s. a study on psychological stress of working women. international journal of multidisciplinary research [internet]. 2012[cited 2019 sep06];2(2):434-45. available from: https://www.researc hgate.net/publication/ 317558474_a_ study_on_psychological_ stress_of_working_women 2. harilal a, santosh va. a comparative study on stress levels among working women and housewives with reference to the state of kerala. nmims journal of economics and public health pol icy [ internet] . 2017[ci ted 2019sep06];2(1):29-35. available from: https://epp-journal.nmims.edu/wpcontent/uploads/2017/april/a-comparative-study-on-stress-levels-amongworking-women-and-housewives-with-reference-to-the-state-of-keralaharilal-a-santhosh-v-a.pdf 3. mamatha r. a study on stress among working women in india. international journal of multidisciplinary advanced research trends [internet]. 2017 [cited 2019 sep07];4(1):137-42. available from: https://ijmart.s3. amazonaws. com/2017janissues/volume4-issue1%282%29/21.pdf 4. shukla s, jaiswal m, agrahari k, shingh a. a study on stress level among working and nonworking women. international journal of home science [internet]. 2017 [cited 2019sep07];3(1):349-57. available from: http:// www.homesciencejournal.com/archives/2017/vol3issue1/parti/3-1-109.pdf 5. kumar v, purushothama m. a study on stress among working women in service sector with special reference to ramanagara district,bangalore. elk asia pacic journal of finance and risk management [internet]. 2018 [cited 2019sep07];9(3)2325-49. available from: https://www.elkjournals.com/ masteradmin/uploadfolder/a%20study%20on%20stress%20among %20working%20women%20in%20ser vice%20sector/a%20study %20on%20stress%20among%20working%20women%20in%20se rvice%20sector.pdf. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra s.no. respondents external/ outside/ workplace stress (%) internal/ within family stress (%) both (%) other sources (%) total 1. housewives 17 (17) 27 (27) 56 (56) 0 100 (100) 2. workingwomen 28 (28) 43 (43) 20 (20) 9 (9) 100 (100) total 45 (22.5) 70 (35) 76 (38) 9 (4.5) 200 (100) 6. 5th pass 13 (13) 3 (3) 16 (8) 7. illiterate 0 0 0 total 100 (100) 100 (100) 200 (100) employment status of husband 1. government 21 (21) 33 (33) 54 (27) 2. private 39 (39) 15 (15) 54 (27) 3. self-employed 36 (36) 52 (52) 88 (44) 4. unemployed 4 (4) 0 4 (2) total 100 (100) 100 (100) 200 (100) socio-economic class 1. upper class 0 20 (20) 20 (10) 2. upper middle 5 (5) 73 (73) 78 (39) 3. lower middle 68 (68) 7 (7) 75 (37.5) 4. upper lower 27 (27) 0 27 (13.5) 5. lower 0 0 0 total 100 (100) 100 (100) 200 (100) type of family 1. nuclear family 85 (85) 42 (42) 127 (63.5) 2. joint family 15 (15) 58 (58) 73 (36.5) total 100 (100) 100 (100) 200 (100) having children 1. yes 92 (92) 78 (78) 170 (85) 2. no 8 (8) 22 (22) 30 (15) total 100 (100) 100 (100) 200 (100) efforts done to prevent stress (%) 1. yes 5 (5) 95 (95) 100 (100) 2. no 24 (24) 76 (76) 100 (100) total 29 (14.5) 171 (85.5) 200 (100) introduction hypertension is dened as either a sustained systolic blood pressure of greater than 140 mm hg. or a sustained diastolic blood pressure of greater than 90 mm hg. according to joint national committee (jnc viii) guidelines on hypertension. it can lead to coronary artery disease cad, heart failure, stroke, 1renal failure and other health problems. among the recommended rst l ine agents for the management of hypertension, arbs are now widely used 2because of their favorable efcacy/tolerability proles. azilsartan discovered by japanese scientists by modifying the tetrazole ring present in candesartan. it blocks the binding of angiotensin-ii to its receptor (at-1r) and inhibit the 3-4vasoconstriction effects of angiotensin-ii. in an in-vitro study, azilsartan was shown to have a higher afnity and slower dissociation from at1 receptors than other arbs (as 5 olmesartan, telmisartan, valsartan and irbesartan). the present study was designed to compare the clinical effectiveness and tolerability of azilsartan 40 mg od with candesartan 12mg od in patients with grade 1-2 essential hypertension. materials and methods this was a prospective, randomized study carried out in department of pharmacology and department of medicine, n.m.c patna between january 2019 to march 2019. inclusion criteria: patients of either sex with age > 20 years with blood pressure of > 140/90 mmhg. were included in the study. exclusion criteria: severe hyper tens ion w i th b .p >180 /110 mmhg, hypersensitivity to arbs, secondary hypertension, presence of cardiovascular disease (cvd), cardiac arrhythmias signicant hepatic or renal disease, pregnant and lactating women. patients on antihypertensives, antianginal, antidepressant, nsaids, glucocorticoids, antiarrhythmic drugs. a total of 80 patients who fullled inclusion and exclusion criteria and provided informed consent were enrolled for participation in the trial. sitting b.p was measured 3 times at 1 or 2-min interval using mercury sphygmomanometer. then demographic data were recorded. blood sugar, urine analysis, renal function test, liver function test and ecg were assessed. after this patient were randomly divided into 2 groups. group i received azilsartan 40 mg and group ii received candesartan 12 mg and were instructed to take the tablet orally once a day in the morning. assessment of patients were done by measuring sitting b.p, pulse rate, physical examinations at 2-week, 4 week and 8 week prior to taking their daily dose of medication. primary end point for assessing efcacy was the change from baseline in mean systolic and diastolic b.p after 8 weeks of treatment. regarding adverse events, all patients were queried at every visit with non-leading questions. statistical analysisthe difference of the baseline characteristics and change in bp between groups were compared using an unpaired t test. the di f ference between values before and af ter antihypertensive medication within the same group were tested using a paired t-test. p value < 0.05 considered statistically signicant. result there were no remarkable differences between the treatment groups at baseline for any demographic characteristics (table no. 1 table no. 1: base line demographic characteristics of enrolled hypertensive patients comparative study of effectiveness and safety of azilsartan and candesartan cilexetil in patients with grade 1-2 essential hypertension in a tertiary care hospital original research paper indu priyadarshini junior resident, department of pharmacology, nmch, patnaprincipal investigator x 43gjra global journal for research analysis pharmacology introduction: hypertension is dened as either a sustained systolic blood pressure of greater than 140 mm hg or a sustained diastolic blood pressure of greater than 90 mm hg. . it can lead to coronary artery disease (cad), heart failure, stroke, renal failure and other health problems. the angiotensin receptor blockers are effective antihypertensive agent with excellent tolerability proles. the present study was designed to compare the clinical effectiveness and tolerability of azilsartan 40 mg od with candesartan 12mg od in patients with grade 1-2 essential hypertension. materials and methods: the present study was a randomized study in 80 eligible patients comparing the effectiveness and safety of azilsartan 40 mg with candesartan 12mg in patients with grade 1 or 2 essential hypertension. result signicantly greater reductions in the sitting dbp and sbp were recorded in the azilsartan group in comparison with the candesartan group at 2 weeks, 4 weeks and 8 weeks. (p value<0.001). the most common adverse effect occurring in the patients in azilsartan as well as in candesartan were nasopharyngitis, upper rti and pharyngitis. hypotension related adverse effects such as dizziness, syncope, vertigo was reported in both the drugs. conclusion: azilsartan is more effective and safe blood pressure lowering drug as comparable to that of candesartan. abstract keywords : blood pressure, azilsartan, candesartan volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra satish kumar associate professor, department of medicine, nmch, patna-co investigator nadia az zahra* junior resident department of pharmacology, nmch, patna * corresponding author azilsartan(40 mg) candesartan(12mg) no of patients 48 32 age 52 ± 8.4 51 ± 9.55 gender male 66.4 65.2 female 33.6 34.8 bmi 24 ± 2.4 23 ± 3 base line blood pressure dbp 92 ± 3.5 92 ± 3.3 sbp 146 ± 11.5 145 ± 12.8 44 x gjra global journal for research analysis table no 2: change in diastolic blood pressure (∆dbp) and systolic blood pressure (∆sbp) after 2,4 and 8 weeks the mean change from baseline in sitting dbp at week 2 (azilsartan -9.8mmhg, candesartan -8.8mmhg), both azilsartan and candesartan produced signicant decrease,the mean change from baseline in sitting sbp at week 2 (azilsartan-13.6mmhg, candesartan -10.0mmhg), both azilsartan and candesartan produced signicant decrease (p value<0.001).(table no. 2) the mean change in sitting dbp at week 4 was (azilsartan 11.6 mmhg, candesartan -9.8mmhg) resulting in a signicant decrease in the azilsartan group compared with the candesartan group (p value<0.001), the mean change from baseline in sitting sbp at week 4. (azilsartan -13.8mmhg, candesartan -10.8mmhg), both azilsartan and candesartan produced signicant decreases (p value<0.001.(table no.2) the mean change in sitting dbp at week 8 was (azilsartan 12.3 mmhg, candesartan -10.4mmhg) resulting in a signicant decrease in the azilsartan group compared with the candesartan group (p value<0.001) the mean change from baseline in sitting sbp at week 8. (azilsartan -14.8mmhg, candesartan -11.0mmhg), both azilsartan and candesartan produced signicant decreases (p value<0.001.(table no.2) fig. 1 shows, after 2, 4 and 8 weeks of treatment change in dbp and sbp with azilsartan 40 mg and candesartan 12 mg. signicantly greater reductions in the sitting dbp and sbp were recorded in the azilsartan group in comparison with the candesartan group at all measurement time points. the most common adverse effect occurring in both the drug group patients were nasopharyngitis, upper rti and pharyngitis. other adverse effects occurring in 3% of the patients in the azilsartan group were rashes, and in 3% were hypotension related events (dizziness, syncope, vertigo), whereas in candesartan group dizziness, postural syncope and vertigo were observed in nearly 8%. discussion present study was conducted for comparing the effectiveness and safety of azilsartan 40 mg with that of candesartan 12 mg in grade 1-2 hypertensive patients. azilsartan a newer angiotensin receptor blocker has shown cardiovascular benets of lowering blood pressure in preclinical as well as clinical trials. fig. 1change in dbp and sbp after 2,4 and 8 weeks of therapy these benets are due to its property of high afnity to and s low d issoc ia t ion f rom at1r. in c l in i ca l t r ia l s , antihypertensive therapy has been associated with reductions in stroke incidence, myocardial infarction (mi) and heart 6failure. in the present study, we have observed that both azilsartan (40mg once daily) and candesartan (12mg once daily) are effective agents in reducing both systolic and diastolic bp but azilsartan (40 mg od) provided a signicantly greater reduction of bp than candesartan 12 mg od) in patients of grade 1-2 essential hypertension at all time points from week 2 to 8 over the treatment period. most of the adverse effect were mild in severity, and the most commonly reported events wi th both drugs were nasopharyngitis, upper respiratory tract inammation and pharyngitis. there was a slightly higher incidence of hypotension related events (dizziness, syncope, vertigo), with candesartan (8%) than with azilsartan(3%).earlier clinical trials conducted compared azilsartan with other arbs, have reported similar ndings to our study. in a multicenter randomized, double blind study that compared azilsartan with olmesartan us patients with primary hypertension, azilsartan was signicantly effective in 7lowering mean 24 hr sbp than olmesartan. similarly, in a multicenter, randomized, double blind study in patients with grade i-ii hypertension conducted in latin american countries and the usa, treatment with azilsartan was signicantly more effective than valsartan and olmesartan in lowering mean 24 8hr sbp. in both trials, safety prole of azilsartan was like that of the arbs and the placebo with which it was compared. conclusion it may be concluded from the present study that azilsartan, a newer angiotensin receptor blocker is an effective and safe blood pressure lowering drug and is more effective than candesartan with additional benet of lesser side effects and hence can be safely used in all the patients. references 1. whalen karen, richard finkel, and thomas a. panavelil. lippincots illustrated reviews: pharmacology. sixth edition. philadelphia: wolters kluwer, 2015 pg.no:225. 2. smith dh. comparison of angiotensin ii type 1 receptor antagonists in the treatment of essential hypertension. drugs. 2008; 68:1207–1225. 3. takeda pharmaceuticals north america. edarbi prescribing information. 2011 4. elliott, wj, plauschinat, ca, skrepnek, gh, et al. persistence, adherence, and risk of discontinuation associated with commonly prescribed antihypertensive drug monotherapies. j am board fam med. 2007; 20(1): 72– 80. 5. ojima m, igata h, tanaka m, sakamoto h, kuroita t, kohara y, kubo k, fuse h, imura y, kusumoto k, nagaya h. in vitro antagonistic properties of a new angiotensin type 1 receptor blocker, azilsartan, in receptor binding and function studies. j pharmacol exp ther. 2011; 336:801–808. 6. neal b, macmahon s, chapman n. blood pressure lowering treatment trialists’ collaboration. effects of ace inhibitors, calcium antagonists, and other bloodpressure-lowering drugs: results of prospectively designed overviews of randomised trials. blood pressure lowering treatment trialists’ collaboration. lancet. 2000; 356:1955-64 7. bakris gl, sica d, weber m, white wb, roberts a, perez a, cao c, kupfer s. the comparative effects of azilsartan medoxomil and olmesartan on ambulatory and clinic blood pressure. j clin hypertens. 2011; 13:81–88. 8. white wb, weber ma, sica d, bakris gl, perez a, cao c, kupfer s. effects of the angiotensin receptor blocker azilsartan medoxomil versus olmesartan and valsartan on ambulatory and clinic blood pressure in patients with stages 1 and 2 hypertension. hypertension. 2011; 57:413–420. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra azilsartan (40mg) candesartan (12mg) 2 weeks dbp -9.8 -8.8 sbp -13.6 -10.0 4 weeks dbp -11.6 -9.8 sbp -13.8 -10.8 8 weeks dbp -12.3 -10.4 sbp -14.8 -11.0 introduction the present study is focussed on storage dependent changes in the viability of seeds of elsholtzia eriostachya which is a strong scented annual herb. this plant is present in pattan valley of lahaul and spiti is an aromatic erect mint like annual herb .the leaves are oblong to lanceolate in shape.the owers are tiny and yellow in colour. the seeds of e. eriostachya are ovoid, oblong and ellipsoid in shape. fruits usually 4 dry nutlets. the nutlets are sparsely hairy, tuberculate or smooth. the seeds are very scented with or without endosperm. the seeds of e. eriostachya is harvested in month july-september. all the body parts are used as a medicine. elsholtzia sps are used to treat cuts and burns by the people of lahaul and spiti (melkani et al., 1994). materials and methods: the seeds of elsholtzia eriostachya were collected from the wild and separated manually. the seeds were air dried for a fortnight and were stored in plastic air tight jars for further studies. seeds of this medicinal plant species were collected from pattan valley located in himachal pradesh, during august-september.seed viabil i ty was determined, qualitatively using a biochemical test “topographical tetrazolium test”. in this reduction process, the living cells are made visible by the reduction of an indicator. the indicator used is a colourless solution of 2,3,5-triphenyl tetrazolium chloride. the seeds were surface sterilized with 0.1% aqueous solution of mercuric chloride for 3 min. thereafter, they were washed thoroughly under tap water and soaked in distilled owater for 24 h at 25±2 c. thereafter, the seeds were cut off 1/3rd at the broad end opposite the radicle in order to expose the embryos. then the seeds were soaked in 0.1% aqueous osolution of ttc at 25± 2 c in dark. after 24 h, qualitative viability was determined by counting the coloured embryos. seeds having a completely stained embryo were considered viable. the experiment was done in triplicate taking 30 seeds of each species studied. the measurements were taken as percent viability. results and discussion: the viability status was assessed after a regular interval of 6 months and up to a storage period of 24-months.freshly harvested seeds of e. eriostachya exhibited 100% viability when incubated with 0.1% ttc solution for 24 h in dark. the described viability (100%) status was maintained for a period of 6 months and thereafter, a slow but steady decline in viability was observed. after 6, 12, 18 and 24-month storage, a 2, 8, 14 and 18% decrease in seed viability was recorded as compared to freshly harvested seeds. the freshly harvested seeds exhibited 100% viability, while 6, 12, 18 and 24-month storage seeds showed 98, 92, 86 and 82% viability respectively (fig. 1). the essential oil of elsholtzia plants exhibited antibacterial and antifungal properties (bestmann et al., 1997). essential oils extracted from e. splendens possess good antibacterial as well as anti-inammatory activities against acne-inducing bacteria, whereas inducing no cytotoxicity with human cell lines (kim et al., 2008). e. splendens also possesses antioxidant effect (jeong et al., 2005). thus this is a very important medicinal species and possesses a high viability status which is maintained for a storage period of 24 months. if proper research is done on this medicinal plant, then it would be a good alternate in the treatment of many diseases. fig.1 references 1. bestmann h.j., rauscher j., vostrowsky o., pant a.k. and mathela c.s. 1997. the volatile constituents of elsholtzia ava. planta medica. 63(1): 88-90. 2. jeong j.h., sohn h.o., shin h.j., hyun h.c., lee d.w. and limh.b. 2005. biological activities of avor components extracted from elsholtzia ciliate and elsholtzia splendens.j. kor. soc.tobacco sci. 27: 19-30. 3. kim s.s., jeong h.o., jeong s.p.,tai h.o., pil y.y., kim s.c.,lee h.n. and chang g.h. 2008. chemical composition and biological activities of elsholtzia splendens essential oil. j. appl biol. chem. 51(2): 69-72. 4. melkani a. b., beauchamp p.s., dev v., whalen c., mathela c.s. and dev. v. 1994. rosefuran epoxide from elsholtzia densa benth. j. essen. oil res. 6(5): 475-479. storage dependent changes in the viability status of seeds of elsholtzia eriostachya (benth.), a medicinal herb of pattan valley of lahaul and spiti, himachal pradesh original research paper vivek kumar mlsm pg college, sundernagar, mandi, h. p. 175018 botany elsholtzia eriostachya (benth.) is an important medicinal herb which is present in a cold desert of himchal pradesh . the elsholtzia sps. is used to treat cuts and burns by the native population of lahaul and spiti. all the parts of the plant is used as medicine. the present study is based upon assessment storage dependent changes of viability status of seeds of this medicinal plant. abstract keywords : medicinal plant, storage, population, viabilty, seed volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 38 x gjra global journal for research analysis 74.nafia zahidi online.cdr introduction ice cream is undoubtedly one of the most popular and favorite food products in mumbai among children and adults especially during summer season. several brands of ice cream in a variety of avors are marketed here. quality of ice cream depends on many intrinsic and extrinsic factors. possible sources of microorganisms in ice creams have been reported to include raw materials used for the composition of ice cream-mix, such as milk and milk powder, cream, avouring and colouring substances and sanitizer (verma, 1972; bathla and rao, 1973) and from contaminated air during processing (gomez, 1969).processes applied during its production are thought to prevent and eliminate most of the microbiological hazards associated with its consumption. pasteurization is most commonly applied heat treatment in the dairy industry which can destroy most pathogenic bacteria in the milk used for the preparation of ice cream. the subsequent processes that subject the mixtures to freezing temperature inhibit the growth of any remaining ora. also, as automatic machines are used for making ice-cream in dairy industry, the chance of contamination through direct hand manipulation is also drastically reduced. however, a milk-based product, ice cream is a good medium for microbial growth due to its high nutrient value, near neutral ph value and long periods of storage (bell, c. et al,1998). numerous health hazards are persistent due to reasons like contamination during the product handling as well as unsanitary conditions observed during frozen storage. many psychrophiles and psychrotolerant spoilage microorganisms (bacillus, micrococcus, pseudomonas) and pathogens like streptococcus, staphylococcus aureus, salmonella, shigella, listeria, campylobacter and brucella are generally present in ice cream. (jayjm, 1992). many food poisoning cases are associated with the consumption of such contaminated products. therefore, it is necessary to ascertain whether the ice-cream produced and distributed is hygienically safe, without any public health hazard. the present study was designed to determine the microbial quality of ice cream produced and sold by ve large scale manufacturers in mumbai city, and assess the potential risk to public health. materials and methods sample collection: a total of 20 different samples of ice-creams were collected for this study. 5 different brands produced by large-scale manufacturers in mumbai were bought from the local market. all samples were transported in an insulated container packed in ice and brought to the laboratory within half an hour and tested immediately for microbial quality. preparation of sample for analysis: prior to analysis, ice creams were kept in water bath at 45℃ for 5 min. after thawing ,1gm of liquid ice cream was transferred -1into a sterile tube. 10 dilution of the melted ice cream sample was made using sterile 0.1% peptone water and used for the detection of various pathogenic microbes by the following tests: detection of staphylococci: 0.1 ml aliquot of the diluted ice cream was spread on sterile salt mannitol agar (sma) and 0incubated at 37 c for 24 hours. yellow colonies were gram stained and checked for production of coagulase and catalase enzyme. detection of e.coli: 0.1 ml aliquot of the diluted ice cream was 0spread on sterile mac conkey's agar and incubated at 37 c for 24 hours. pink colored colonies were gram stained and checked for production of indole using tryptone water. (salle, a.j.,1984). colonies were also inoculated in triple sugar iron medium (tsi) (salle, a.j.,1984). detection of pseudomonas: 0.1 ml aliquot of the diluted ice cream was spread on sterile cetrimide agar and incubated at 037 c for 24 hours. colonies were gram stained. detection of shigella and salmonella: 0.1 ml aliquot of the diluted ice cream was spread on salmonella shigella agar 0and incubated at 37 c for 24 hours. colorless non-lactose fermenting colonies were gram stained, checked for motility and inoculated in tsi medium. results were compared with the requirements given in the specications as per bis (is:2804 – 1964). (indian standards 2002). according to these regulations, any frozen confection for sale should not contain any pathogens. salmonella and other pathogens should be absent. results the results obtained on performing bacteriological tests to detect pathogens are depicted in table 1 detection of pathogens in icecreams produced by large-scale manufacturers in mumbai city. original research paper s. dugal department of microbiology, sophia college (autonomous), maharashtra400026.india microbiology a study of the microbial quality of ice cream serves to indicate whether or not manufacturers employ proper sanitary procedures in the preparation of these products and the potential risk of acquiring food borne pathogens on their consumption. the present study was undertaken to assess if the bacteriological quality of ice creams sold by ve large-scale manufacturers in mumbai city conformed to microbial standards and were free of pathogenic bacteria. tests were carried out for the detection of staphylococci, e.coli, pseudomonas, shigella and salmonella. while most of the ice cream samples produced by four manufacturers showed presence of these organisms, only one of the commercially available brand of ice cream conformed to the accepted standards. e.coli, a faecal coliform was found to be the most common pathogen present. abstract keywords : ice cream, staphylococcus aureus, e.coli, shigella, mumbai. radhika dashottar department of microbiology, sophia college (autonomous), maharashtra400026.india naa zahidi* department of microbiology, sophia college (autonomous), maharashtra400026.india *corresponding author 8 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 1: presence of pathogenic bacteria in ve popular commercially available ice cream brands. absent + present bacteriological examination revealed that only one of the brands 'k', did not show presence of any pathogens. table 2: percentage of samples of each brand of ice cream that tested positive for pathogens the order of prevalence of pathogens in samples tested could be given as: e.coli >s.aureus > pseudomonas >shigella e.coli, being the most common pathogen, indicates the high risk of diarrhoea on consumption of these ice-creams. discussion in the current study, the microbiological surveillance ndings revealed that four out of ve ice cream brands collected during january 2020 from mumbai city showed the presence of pathogenic organisms and were found to be unsatisfactory and unt for consumption. this may indicate the bad quality of ingredients such as avors, coloring agents and fruits which are added to the mix after pasteurization or air incorporation. the quality of icecream also suffers when stored for extended periods (james m., 1978). the presence of shigella and coliforms like e.coli indicates possible faecal contamination. this suggests the possibility of other intestinal pathogens of also being present, though salmonella was absent in all samples tested. the presence of coliforms in the ice creams may pose a potential risk for public health, especially for vulnerable groups such as children. detection of pseudomonas indicates that these ice creams could have got contaminated due to handling. pseudomonas survive at low temperatures and being opportunistic pathogens, can potentially affect any individual with a low immunity. staphylococci enter from food handlers who may have an acute infection or from healthy carriers who harbor the organisms in their nose or throat. it is also due to improperly stored product and use of bare hands during preparation. the presence of s. aureus in some samples can pose a risk of food intoxication to the consumer due to the release of enterotoxins (frazier wc., 1958). conclusion from the current study, it can be concluded that except for one brand, since all other brands of ice creams tested failed to conform to the standards it strongly suggests the possibility of acquiring food-borne pathogens on consumption of these frozen products. much attention is needed to apply aspects of microbiological quality control for attaining desired safety margins and giving assurance that the ice cream received by a consumer is pure and of good quality. to ensure that the production, handling, processing, distribution and storage of ice cream is maintained under strict hygienic control, effective legislation needs to be enacted and enforced. also, relevant public authorities should inspect manufacturing process more frequently. conict of interest: none. references 1. bathla, j.m. and y.s. rao., 1973. microbial quality of ingredients in relation to that of ice cream. j. res. sci., 22: 59-66. 2. bell, c. & kyriakides. listeria: a practical approach to the organism and its control in foods. blackie academic & professional. london. 1998. 3. frazier, w. c., and westhoff, d. c., 1958, food microbiology. 1sted., mc grawhill inc.; new delhi, pg. 112. 4. gomez, a., 1969. microbial content and hygienic conditions of ice cream sold in leon alimentaria, 6: 21-25. 5. indian standards 2002. (1964). specications for icecream. bureau of indian standards, new delhi. 6. james, m., and jay, j. m., 1978, indices of food sanitary quality and microbiological standards and criteria. modern food microbiology, 2nded. pg. 311. 7. jay jm. modern food microbiology, fourth edition, chapman & hall inc. new york: 1992. 8. salle, a.j. fundamental principles of bacteriology tata mcgraw-hill, 1984. 9. verma, g.s., 1972. bacteria quality of some ingredients used in the manufacture of ice cream. ind. j. anim. res., 6: 27-30. ice cream brands staphylococci e.coli pseudomonas shigella k a + + m + + + + c + + h + + + ice cream brands staph. e.coli pseudomonas shig. k nil nil nil nil a 50% 50% nil nil m 25% 25% 25% 25% c nil 100% 25% nil h 25% 75% 25% nil x 9gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: foot infections are a major source of morbidity and a leading cause of hospitalization for persons with diabetes. ulceration,infection,gangrene,amputation are signicant complications of diabetic foot.charcot foot(neuropathic osteodystrophy)is another serious complication of long standing diabetes.it is a progressive condition characterized by joint dislocations,pathologic fractures and severe destruction of pedal architecture,which can lead to limb threatening conditions.five major pedal complications of diabetes are: 1) diabetic foot ulcer 2) diabetic foot infection 3) diabetic charcot foot 4) diabetic foot ischemia 5) deformities materials and methods : cross sectional observational study of 25 patients with diabetic foot admitted in tertiary care hospital during the period of 6 months.pediatric patients have been excluded from study.evaluation n management done by classifying the disease according to wegner's classication for diabetic foot. magitt-wegner classication of foot ulcers(table 1) patients had been taken randomly from different wards in hospital.data collected by taking proper history and clinical examination of foot,wound or ulcer.age,sex,duration and type of diabetes,examination ndingd,grade,investigation including blood sugar,swabs from ulcer,x ray of foot and treatment carried out were recorded. age incidence in diabetic foot(table 2) incidence of diabetic foot according to gender(table 3) diabetic foot infection according to cause (table 4) grading as per wegner's classication(table 5) culture and sensitivity(table 6) results: in present study ,limbs were preserved in 12 out of 25 surgically treated diabetic foot patients.13(56%) out of 25 cases despite of proper medical management and repeated debridment had to undergo amputation due to gangrene and uncontrolled fulminant infections. in a study conducted by dr. a.h khan et al52(200 patients), 70% required debridment,out of which 48.5% undergo skin grafting and rest 30% required amputation of different levels. in a study(100 patients) conducted bt dr.rooh ul muqim et al51,48% 0f patients required amputation. modalities of treatment(table 7) management of 25 cases of diabetic foot problems original research paper dr sandipkumar chaudhari* (ms, fmas, fiages. fccs) *corresponding author general surgery keywords : diabetic foot,amputation,debridment,dressing,antibiotics volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra grade description of the ulcer 0 pre or post ulcerative lesion completely epithelized 1 supercial,full thicknessulcer limited to the dermis,not extending to subcutis 2 ulcer of the skin extending through the subcutis with exposed tendon or bone without osteomyelitis or abscess formation 3 deep ulcers with osteomyelitis or abscess formation 4 localised gangrene of the toes or the forefoot 5 foot with extensive gangrene age(years) no.of cases percentages upto 40 1 4% 41-50 10 40% 51-60 4 16% 61-70 6 24% 71-80 4 16% total 25 100% sex no.of cases percentages male 18 72% female 7 28% total 25 100 causes no.cases percantages infective 15 60% ischemic 6 24% neuropathy 2 8% infective + ischemic 1 4% infective +neuropathy 1 4% total 25 100% present study dr.rooh ul muqim et al study grade no.of patients percentages no.of patients percentages 0 0 0% 6 6% 1 1 4% 14 14% 2 3 12% 25 25% 3 9 36% 30 30% 5 4 16% 4 4% organism cases percentages staphyococcus 11 44% pseudomonas 6 24% streptococcus 1 4% klebsiella 3 12% no growth 4 16% present study dr.a.h.khan et al study no. of cases percetages no. of cases percentages dr chirag chaudhary ms ortho. 44 x gjra global journal for research analysis amputation levels (table 8) conclusion: we can save maximum number of limbs in diabtic foot infections with early recognization of infection and treatment ,patient's education about foot infection and proper care,aggressive use of antibiotics and repeated debridment when required.due to complexity and multifactorial pathogenesis of diabetic foot problems,despite sophisticated investigations and treatment modalities amputation rate is still higher. references: 1. evaluation and management of diabetic foot according to wegner’s classication a study of 100 cases rooh-ul-muqim ,samson grifn,mukhtar ahmed 2. approach to managing diabetic foot complications,a study of 200 cases khan a.h.1,bajwa g.r 3. a study-steps for avoiding foot ulcers by ramya,kannan 2007 4. incidence,outcomes,and cost of foot ulcers in patients with diabetes by dr.scott d.ramsay 5. a comparison of two diabetic foot ulcer classication systems the wegner’s and the university of texas wound classication systems by dr.samson oyibo 6. dinh t,pham h veves a,emerging treatments in diabetic wound care,wounds 2002;14 : 2-10 7. pinzur ms.amputations in the diabetic foot.in boulton ajm,rayman g(eds),the foot in diabetes.4th edn.chichester : wiley, 2000 ;308-322. 8. lipsky ba,berendt ar,deery hg,et al. diagnosis and treatment of diabetic foot infections,clin infect dis 2004 ;39:885-910 9. saunders lj,mrdjencovich d,anatomical patterns of bone and joint destruction in neuropthic diabetics.diabets 1991 ; 40 :529a 10. boulton ajm,gries fa,jervell ja.guidelines for the diagnosis and outpatient management of diabetic peripheral neuopathy.diabet med 1998 :15 : 508-514 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra incision & drainage 2 8% debridment 1 4% 43 21.5% stg + debridment 9 36% 97 48.5% amputation 11 44% 60 30% amputation + stg 2 8% total 25 100% 200 100% present study dr.rooh ul muqim study prodedure no.of cases percentage no.of cases percentage toe 4 31% 32 66.6% transmeta tasal 3 23% syme's 0 0% 5 10.4& below knee 3 23% 11 22.9% above knee 3 23 % total 13 100% 48 100% x 45gjra global journal for research analysis introduction: primary hypertension is the most common type of hypertension, affecting 95% of hypertensive patients. it has no identiable cause. it is the primary cause of stroke, coronary artery disease and sudden cardiac death. in worldwide, the majority of diagnosed hypertensive patients are inadequately controlled. approximately 20% of the worlds adults are estimated to have hypertension, when hypertension is dened as blood pressure in excess of 140/90mm hg. the prevalence dramatically increases in patients older than 60 years. in many countries , 50% of individuals in this age group have hypertension. world wide approximately one billion people have hypertension, contributing to more than 7.1million deaths per year. materials and methods: this is a hospital based cross sectional study in which 200 hypertension patients reported in national institute of siddha are selected by checking their blood pressure, patients are given with a set of questionnaire about their personal history, such as food habits, hobbies, occupational and socioec onomic status, level of stress, depression, treatment history , family history and also their disease history this study was approved by institutional ethical comity of national institute of siddha , and registered in clinical trials registry in india. results table 1 age distribution: distribution of age in hypertension patients: in 200 patients , 7% are included in the age group of 25-40, 17.5% are 41-50age group, 30.5% are 51-60 age group and 12% are above 70 age group. table 2: socio economic status distribution of socio economic status in hypertension patients: out of 200 patients 42% are from poor family, 47% are from middle class family, then only 11%of patients are from upper class . cross sectional study on “ kuruthlazhalnoi” (hypertension) reporting in national institute of siddha opd original research paper dr. s. priyadarshini* second year pg scholar, department of maruthuvam, national institute of siddha ,tambaram sanatorium, chennai -47. *corresponding author ayurveda many disease are emerging as a trend of life style modications due to stress, secondary life style and food habits , one among them hypertension. it is an important public health problem in both economically developed and developing nations.kuruthiazhalnoi is the pitham dominant disease which is caused due to imbalance of pitham in human body due to dietary modications. this condition may be comparable with hypertension in modern text. this study was a hospital based cross-sectional study conducted in nis opd among 200 subjects selected using non-randomized sampling method. hypertension was signicantly higher in individuals more than 35 years and who take alcohol, smoking and in subjects with raised cholesterol level. in this observational study the result shows that 40.5% (81patients) got improved overall there was both reduction of symptoms and blood pressure in siddha with allopathy medication, 6%(12patients) not improved ,then 53.5%(107patients) are not having awareness about the treatment of hypertension in siddha at nis. abstract keywords : hypertension, kuruthiazhalnoi,pitham, a cross sectional study. dr. h. vethamerlinkumari associate professor , department of maruthuvam, national institute of siddha, tamabaram sanatorium, chennai -47. dr. k. manickavasakam head of the department& former director, department of maruthuvam, national institute of siddha, tambaram sanatorium, chennai-47. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra subramaniyan. m senior research ofcer (statistics),national institute of siddha, tambaram sanatorium,chennai-47 dr. v. banumathi former director, national institute of siddha, tambaram sanatorium, chennai-47. age no of patients percentage 2540 14 7% 41-50 35 17.5% 51-60 61 30.5% 61-70 66 33% above70 24 12% economic status no of patients percentage poor 84 42% middle 94 47% upper 22 11% 14 x gjra global journal for research analysis table 3 – nature of living: distribution of hypertension patients according to nature of living: out of 200 patients , 71% are from urban area and 29% are from rural area. table 4 – dietary habits: distributions of hypertension patients according to dietary habits: out of 200 patient 80.5% are non-vegetarian,only 19.5% are vegetarian. table 5 occupational history: distribution of hypertension patients according to occupational history: out of 200 patients 17% patients are in sedentary work,10% are in eld work,27% are in eld work with physical activity, and 33% are in house hold work and 13% of patients are retired people. table 6 – personal habits: distribution of hypertension patients according to personal habits: out of 200 patients, 3% patients are smokers , 10.5% patients had the habit of smoking with alcohol, 0.5% patients had the habit of smoking alcohol and tobacco chewing, 5.5% patients had the habit of alcohol, 0.5% patients had the habit of alcohol with tobacco chewing, 1.5% patients had the habit of tobacco chewing and 78%patients were not having no other addictions. table 7 – psychological evaluation: distribution of hypertension patients accoding to psychological evaluation: out of 200 patients, 5.5% of patients having stress, 3% of patients having depression, 6.5% of patients having emotional behaviour, 1.5% of patients having stress with depression, 3.5% of patients having stress with emotional behaviour, 4.5% of patients having stress , depression and emotional behaviour and 75.5% of patients not having any other psychological problems. table 8 – body mass index: distribution of hypertension patients accoding to body mass index: volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra nature of living no of patients percentage urban 142 71% rural 58 29% diet no of patients percentage vegetarian 39 19.5% non veg 161 80.5% occupation no of patients percentage sedentary work 34 17% field work 20 10% field work with physical labour 54 27% home maker 66 33% retired 26 13% habits no of patients percentage smoking 6 3% smoking &alcohol 21 10.5% smoking alcihol &tobocco 1 0.5% alcohol 11 5.5% alcohol&tobocco 1 0.5% tobocco 1 0.5% betel nut 3 1.5% no bad habits 156 78% psychological evalution no of patients percentage stress 11 5.5 depression 6 3 emotional behaviour 13 6.5 stress &depression 3 1.5 stress& emotional 7 3.5 stress, depression& emotional behaviour 9 4.5 no psychological illness 151 75.5 bmi no of patients percentage under weight 3 1.5% normal 70 35% over weight 94 47% obese 1 24 12% obese 2 9 4.5% x 15gjra global journal for research analysis out of 200 patients 1.5% are comes under weight and their bmi is 17-18.5, 35% are normal weight and their bmi is18.5-25,47% are comes under over weight and their bmi is 25-30, 12% are comes under obese class 1 and their bmi is 30-35 and only 4.5%of patients are obese class 2 and their bmi is 35-40. table 9 – associated disease : distribution of hypertension patients according to associa ted disease: out of 200 patients, 42.5% of patients are having diabetes mellitus, 25 % of patients having hyperlipidemia, 12.5% of patients having ischemic heart disease, and 5% of patients having chronic kidney disease. table 10 – treatment history: distribution of hypertension patients according to treatment history: out of 200 patients , 50% of patients taking allopathy treatment , 37.5% of patients taking siddha with allopathy treatment , 9% of patients taking siddha treatment and 3.5% of patients are not taking any treatment. table 11 – improvement history : distribution of hypertension patients according to improvement: out of 200 patients, 40.5% of patients are improved in siddha with allopathy treatment , and only 6% of patients not improved , 53.5% of patients not having awareness in siddha treatment. discussion: high blood pressure (bp) is ranked as the third most important risk factor for attributable burden of disease in south asia (2010) . hypertension (htn) exerts a substantial public health burden on cardiovascular health status and healthcare systems in india . htn is directly responsible for 57% of all stroke deaths and 24% of all coronary heart disease (chd) deaths in india . the who rates htn as one of the most important causes of premature death worldwide . the global and regional burden of disease and risk factors study (2001), in a systematic analysis of population health data for attributable deaths and attributable disease burden, has ranked htn in south asia as second only to child underweight for age . in an analysis of worldwide data for the global burden of htn, 20.6% of indian men and 20.9% of indian women were suffering from htn in 2005 . the rates for htn in percentage are projected to go up to 22.9 and 23.6 for indian men and women, respectively by 2025 . recent studies from india have shown the prevalence of htn to be 25% in urban and 10% in rural people in india . according to the who 2008 estimates, the prevalence of raised bp in indians was 32.5% (33.2% in men and 31.7% in women) . however, only about 25.6% of treated patients had their bp under control, in a multicenter study from india on awareness, treatment, and adequacy of control of htn . out of 200 patients 63.5% of patients comes under the age category of 51-70, and about 57% are males and 43% of patients female. 27% of patients are in eld work with physical labour is the trending pattern of occupation. another signicant nding is 47% of patients are middle class, 80.5% are non-vegetarians, only 22% of patients having smoke, alcohol, tobacco and betel nut chewing habits and 24.5% of patients having psychological problems, 47% are over weight, 42.5% of pat ients having diabetes , 25% having hyperlipidemia, 12.5% having ischemic heart disease, 5% having chronic kidney disease. 50% of patients taking allopathy treatment, 37.5% of patients taking siddha with allopathy treatment, only 9% of patients taking siddha treatment. and 40.5%of patients improved in siddha with allopathy treatment and 6% not improved , 107 patients not having awareness in siddha treatment. conclusion: in this observational study the result shows that 40.5% (81patients) get improved overall there was both reduction of symptoms and blood pressure in siddha with allopathy medica t ion , 6%(12pat ien ts ) no t improved , then 53.5%(107patients) are not having awareness about the treatment of hypertension in siddha at nis. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra associated disease no of patients percentage diabetes mellitus 85 42.5% hyperlipidemia 50 25% ischemic heart disease 25 12.5% chronic kidney disease 10 5% treatment history no of patients percentage allopathy 100 50% siddha 18 9% allopathy with siddha 75 37.5% no treatment 7 3.5% improvement history no of patients percentage improvement 81 40.5% no improvement 12 6% unknown cases 107 53.5% 16 x gjra global journal for research analysis references: 1. ka.na.kuppusamy mudhaliyar , siddha maruthuvam pothu, pg.no 214-219. 2. chobanian av, bakris gl, black hr, et al. the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the jnc 7 report. jama, 2003, 289(19): 2560-2572. 3. israeli e, korzets z, tekes-manova d, et al. blood-pressure categories in adolescence predict development of hypertension in accordance with the european guidelines. american journal of hypertension, 2007, 20(6): 705-709. 4. elliott wj, black hr. prehypertension. nat clin pract cardiovasc med, 2007,4(10): 538548. 5. wu s, huang z, yang x, et al. cardiovascular events in a prehypertensive chinese population: four-year follow-up study. international journal of cardiology, 2013, 167(5): 2196-2199 6. 5. do carmo rocha j, bustamante teixeira mt, azevedo e silva g, et al. prevalence of prehypertension and associated factors in women. investigación y educación en enfermería, 2014, 32(3): 471-479. 7. davidson clinical medicine. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 17gjra global journal for research analysis introduction in urban india stroke accounts for 1% mortality of all hospital admissions, 4% in all medical cases and about 20% in all disorders of central nervous system. risk factor for stroke inc ludes diabetes , hyper tension, smoking and hyperlipidemia and these have been linked to abnormalities of haematology and coagulation such as increased brinogen. stroke is dened as an abrupt neurologic decit that is at tributable to focal vascular cause. risk factors for stroke are hypertension, atr ial bri l lat ion, carot id stenosis, hyperlipidemia, diabetes, myocardial infarction, atrial myxomas and smoking. fibrinogen is a soluble plasma glycoprotein that consists of three nonidentical pairs of polypeptide chains chains). in the rst phase of thrombus formation soluble brinogen is converted into brin peptides initiate a process in which brin monomers begin to gel. these brin monomers polymerise to form brin polymers. this process continues and elongation of polymers causes formation of protobrils. once a critical mass of long proto brils is established, the protobrils form lateral contacts with other protobrils thereby forming brin clot. fibrin clot thereby potentiates formation of thrombosis. epidemiological observations indicate that high plasma brinogen levels strongly correlate with the frequency of two major thrombotic complications of atherosclerosis, stroke as well as myocardial infarction. thrombosis is increasingly recognized as a central mechanism in stroke and myocardial infarction, and brinogen is believed to be involved in events thought to play a major role in thrombosis. therefore elucidation of the relationship between brinogen and thrombosis may strengthen the predictive value of this protein and suggest new treatment in management of stroke. hence this study is designed to investigate the association between plasma brinogen levels and acute stroke. methodology the present study was a cross sectional study done in the medicine ward/icu. plasma brinogen level was done of 50 patients presenting with acute stroke admitted in medicine ward/i.c.u of sree balaji medical college &hospital from january 2019 to july 2019. method of collection of data: the study was carried out on 50 consecutive patients admitted to medicine ward/i.c.u of sree balaji medical college& hospital, chennai with acute stroke within 24 hour of symptoms. detailed history were taken to nd out the risk factors such as hypertension, diabetes, smoking and overweight. hypertension was diagnosed by jnc viii criteria. diabetes was diagnosed by american diabetes association criteria. smoking was recorded in terms of number of cigarette pack years smoked. thorough general and systemic examination was carried out. in addition to routine investigations as per standard protocol in the evaluation of stroke patient, fasting plasma brinogen level was estimated. patients were followed up till they were discharged from the hospital. inclusion criteria: all patients fullling all of the below criteria were included in the study 1) patients presenting with acute stroke within 24 hours of onset of symptoms & ct/mri scan. shows cerebral infarct or haemorrhage. 2) patients willing to give informed written consent. patients with evidence of uremia, infection, active hepatic disease, active hepatic disease, undergone surgery in last three months and not willing to give informed written consent were excluded from the study. detailed history, clinical examination and relevant laboratory investigations were done as per proforma.fasting plasma a study on fibrinogen levels in patients of acute stroke original research paper dr. g. venkat sai* junior resident, department of general medicine , sree balaji medical college , chennai, tamil nadu. * corresponding author x 107gjra global journal for research analysis general medicine introduction: risk factor for stroke includes diabetes, hypertension, smoking and hyperlipidemia and these have been linked to abnormalities of haematology and coagulation such as increased brinogen. the present study is designed to investigate the association between plasma brinogen levels and acute stroke. methodology: the present study was a cross sectional study done in the medicine ward/icu of a tertiary care hospital. plasma brinogen level was done of 50 patients presenting with acute stroke admitted in medicine ward/i.c.u of sree balaji medical college& hospital. detailed history was taken to nd out the risk factors such as hypertension, diabetes, smoking and overweight. in addition to routine investigations as per standard protocol in the evaluation of stroke patient, fasting plasma brinogen level was estimated. results: the mean age in the present study was 58.52 years. the maximum numbers of patients were in the age group 60-69 years. in 86% of cases were having higher brinogen level. there were 23(46%) smokers among patients. non smokers, normotensives, non obese and non diabetics had higher brinogen levels than smokers which were not statistically signicant. conclusion: mean brinogen level was lower in patients of acute stroke with any of risk factors like smoking, hypertension, diabetes and obese than in patients of acute stroke without any of these risk factors. this difference was not statistically signicant in this study but further large study can be planned to prove this. abstract keywords : acute stroke, fibrinogen, hypertension, diabetes volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. n. n. anand professor, department of general medicine , sree balaji medical college , chennai, tamil nadu. l ( aa bb and 108 x gjra global journal for research analysis brinogen was estimated in patients and age, sex and risk matched controls.the plasma brinogen was measured quantitatively by clauss method. venous blood was collected in an evacuated siliconized blood collection tube containing 1 volume 0.11mol/lt of sodium citrate (3.8%) and 9 volumes of whole blood, which was centrifuged for 15 min at rcf of 2000g.the buffer which was provided in the dade behring brinogen estimation kit was used to prepare 1:10 dilution of patient's plasma sample 0.2ml diluted (50µl) citrated plasma sample was incubated for 1 minute, then 25µl of thrombin reagent was added at room temperature 0 and clotting time was then determined at 37 centigrade using a coagulation instrument. results there total 50 patients presented with acute stroke within 24 hours of onset of symptoms & ct/mri scan and fullling inclusion criteria. this all patients were included in the study. table 1: age wise and brinogen level wise distribution of cases (n=50) table 2: gender wise distribution of cases and their mean brinogen level (n=50) table 3: relation of different risk factors with mean brinogen level the mean age in the present study was 58.52 years. the youngest patient was of age 35 years. the oldest patient was of age 84 years. the maximum numbers of patients were in the age group 60-69 years. in the present study minimum plasma brinogen level was 180mg/dl and maximum was 850mg/dl. normal brinogen value is 150-400. in 86% of cases were having higher brinogen level. among 50 patients studied, 62% were male and 38% were female. males had mean brinogen of 595 and females had mean brinogen of 641. this difference was not statistically signicant. (p-value > 0.05) in the present study there were total 44 patients were having ischemic strokes and their mean brinogen level was 615 mg% and there were total 6 patients were having haemorrhagic strokes and their mean brinogen level was 588 mg%. there were 23(46%) smokers among patients. non smokers had higher brinogen levels than smokers which were not statistically signicant.among normotensive patients mean brinogen level was higher than hypertensive patients, mean values in hypertensive was 563 whereas it is 648 in patients who are normotensive. this difference was not statistically signicant. in present study non diabetics had higher brinogen levels which were not statistically signicant. in patients who were obese, mean brinogen level was 597 and in non obese patients, mean brinogen level was 632. non obese patients had higher brinogen level than obese individuals. the difference was not statistically signicant. discussion the present study involved 50 patients presenting with acute stroke admitted in medicine ward/i.c.u. the mean brinogen level was 615 mg% in ischemic group. mistry pp et al., in their study involving 56 patients admitted in the hospital within 24 hours of onset of symptoms. the levels were found to be raised signicantly (531.73mg %) compared to those of the age and sex matched control group (445.78mg %). when the levels of plasma brinogen in stroke group with one risk factor were compared to those of individuals with comparable control group with same risk factor, a signicant difference was observed. hazra b et al., in their study involving 33 patients of cerebral thrombosis and 30 patients with cerebral hemorrhage admitted within 24 hours of onset of stroke concluded that the mean plasma brinogen concentration in patients of cerebral thrombosis (378.67 mg/dl) is signicantly higher when in the control group (216.67). variation in the level of brinogen in the above studies may be due to variation in ethnicity or the method of brinogen assay or may be due to age group and sex of the patient selected for the study. aj lee and tw maede have shown that brinogen level increases with age. this study also demonstrates an increasing trend of brinogen with age. fibrinolytic activity reduces as age advances because of, as age advances there is change in orientation of gpiia/iiib receptor causing decreased brinolytic activity which accounts for increased plasma brinogen levels as age advances. it is likely that mutation accumulation of plasma brinogen plays a signicant role in the changes of brinogen with age. the increase of variance with age is the product of unrepaired evolutional damage in different levels of organization, and the mutations causes increased brinogen levels as age advances. aj lee and tw maede11 have shown males have higher brinogen when compared to females. this study has shown that brinogen was increased in females than males amongst higher brinolytic activity in females explained the lower brinogen levels in females when compared to males. ernst e has demonstrated that smoking is associated with increased plasma brinogen levels. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra variables no. (%) age group (in years) 30-39 3 (6.0) 40-49 11 (22.0) 50-59 11 (22.0) 60-69 15 (30.0) >70 10 (20.0) fibrinogen level (mg/dl) less than 200 2 (4.0) 200-400 5 (10.0) 400-800 43 (86.0) gender no. (%) mean +sd p-value males 31 (62.0) 595.16± 195.26 0.40477 females 19 (38.0) 641.05±173.46 patients no.mean(mg%) brinogen p-value smoking smokers 23 596.09±204.02 0.539199 non smokers 27 629.26±175.32 hypertension hypertensive 21 563.81± 206.09 0.113364 normotensive 29 648.62±165.55 diabetes diabetic 15 545.33±210.84 0.0907205 non diabetic 35 643.43± 171.94 bmi >30 9 597.78±169.02 0.613588 <30 41 632.16±186.56 this study has shown increased brinogen levels in patients amongst smokers as compared to nonsmokers which was not statistically signicant. other studies have demonstrated that in smokers, the plasma brinogen is elevated because, smoking activates lung macrophages which releases il-4 which increases brinogen synthesis14smoking decreases brinolytic activity. smoking causes endothelial damage resulting in activation of coagulation system and release clotting factors. anjula jain et al has demonstrated brinogen levels are higher in hypertensives. lee aj has demonstrated plasma brinogen was higher among hypertensive. in this study hypertensive patients had higher brinogen than normotensives which was not statistically signicant. several pausible mechanisms could explain an observed association between elevated brinogen levels and hypertension, relation of brinogen to increased viscosity and peripheral vascular resistance. hyperinsulinemia and insulin resistance is common amongst hypertensive and hyperinsulinemiais known to cause decreased brinolytic activity. hence increased brinogen levels in hypertensives. markers of inammation, such as il-6 and il-8 are elevated in hypertension and causes reduced consumption of brinogen, thereby contributing to increased plasma brinogen in hypertension, increased platelet activation, increased activity of the coagulation system and decreased function of the brinolytic system. meade tw and ernst e have shown that obese individuals have higher brinogen levels. obese in-dividuals had higher brinogen levels compared to non-obese patients which were not statistically signicant. the mechanisms underlying increased plasma brinogen in patients who had over weight are, there is a positive association between obesity (skin fold t h i c k n e s s ) a n d p l a s m a i n s u l i n c o n c e n t r a t i o n , hyperinsulinemia thereby stimulates brinogen synthesis. it is possible that the interaction between obesity and physical inactivity may promote dyslipidaemia and increased plasma brinogen. in this study diabetics had higher brinogen than non diabetics.the exact mechanism of increased brinogen levels in diabetics is unknown, possible mechanisms include, insulin stimulates cholesterol synthesis in smooth muscle cells and macrophages of the arterial walls, stimulates the proliferation and migration of smooth muscle cells. it also enhances the formation of brinogen. endothelial dysfunction which is common in diabetics, which causes decreased brinolytic activity and hence increased plasma brinogen levels. the plasma glucagon concentration is positively related to the plasma brinogen concentration. thus,brinogen production is markedly enhanced in diabetic patients, and this alterationis likely to determine the observed hyperbrinogenemia in these patients. hyperglucagonemia may contribute to the increased brinogen production. thus, insulin concentrations (and probably also glucose proles) may need to be maintained at the lowest attainable level in type 2 diabetes to prevent increased brinogen synthesis and concentrations. conclusion the maximum numbers of patients of acute stroke were in the age group 60-69 years. mean brinogen level was lower in patients of acute stroke with any of risk factors like smoking, hypertension, diabetes and obese than in patients of acute stroke without any of these risk factors. this difference was not statistically signicant in this study but further large study can be planned to prove this. references 1. lee aj, lowe gd, woodward m, pedoe th. fibrinogen in relation to personal history of prevalent hypertension, diabetes, stroke, intermittent claudication, coronary heart disease and family history. the scottish heart health study. br heart j 1993; 69:338-342. 2. fu a and nair s k. age effect on brinogen and albumin synthesis in humans. am j physiolendocrinolmetab 1998; 275: 1023-1030. 3. ernst e. regional variations in plasma brinogen levels. ann of internal medicine 1991;115(4):329-330. 4. meade tw, chakrabarti r, haines ap, north wr, stirling y. characteristics affecting brinolytic activity and plasma brinogen concentration. bmj 1979; 1: 153-56. 5. lip gyh. fibrinogen and cardiovascular disorders. qjm 1995; 88: 153-6. 6. anjula jain, hl gupta shashi narayan. hyper brinogenemia in patients of diabetes mellitus in relation to glycemic control and urinary albumin excretion rate. japi 2001;49:227-230. 7. sechi la, zingaro l, catena c, casaccio d, marchi se. relationship of brinogen levels and hemostatic abnormalities with organ damage in hypertension. hypertension 2000;36:978. 8. meade tw, chakrabarti r, haines ap, north wr, stirling y. characteristics affecting brinolytic activity and plasma brinogen concentration. bmj 1979; 1: 153-56. 9. barazzoni r, zanetti mg. kiwanuka de, carraro p, tiengo a, tessari p. increased brinogen production in type 2 diabetic patients without detectable vascular complications: correlation with plasma glucagon concentrations. the journal of clinical endocrinology and meta bolism2000;85:3121-3125. 10. mistry p, chawla kp, rai hp, jaiswal p. plasma brinogen levels in stroke. j postgrad med 1990;36:1-4 11. smith ws, johnston sc, easton jd. cerebrovascular diseases. in: kasper dl, faucias, longo dl, braunwald e, hauser sl, jameson lj, editors. i larrison’s principles of in ternal medicine. vol2.16th edn. new york: mcgraw hill;2005.p.2372-2393. 12. rand ml, murray rk. hemostasis and thrombosis. in: murray k, granner dk, mayes pa, rodwell vw, editors. har-per’s illustrated biochemistry. vol.1. 26th edn. new delhi: mcgraw hill; 2003.p.598-608. 13. diminno g, mancini m. measuring plasma brinogen to predict stroke and myocardial infarction. arteriosclerosis 1990; 10:1-7. 14. hazra b, sengupta n, saha sk, guha s, das b, banerjee ar. a study of plasma brinogen level in acute stroke patients in calcutta. indian journal of physiology and allied sciences 1997;51:76-80. x 109gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: the leading cause of death worldwide is coronary artery disease1. in 2015 coronary artery disease accounted for 7.2 million deaths world wide2,3, 80% of which were in low income countries like india4. it has been estimated that by 2020, 2.6 million indians are predicted to die because to coronary artery disease5.indians are prone to get coronary artery disease at an earlier age compared to people in developed countries because of the high prevalence of risk factors like diabetes and hypertension6,7. st segment elevation myocardial infarction is most common type of acute coronary event contributing 60.6% of overall incidence of acute coronary syndrome in indian population8.the overall mortality in stemi is approximately 4 to 7 % or even less in the published clinical trials. however this is not the case in the real world situation9,10 .this is because the patients enrolled in the randomized trials are selected ones and represented low-risk subgroup. therefore the results of these trials are not applicable to 50% of patients in clinical practice11. a realistic view can be obtained from registry data. in india, create registry data recorded an in-hospital mortality rate of 7.9% and 30 day mortality rate of about 8.6%, which included both patients with unstable angina and ami. v.jacob jose and satya n. gupta from vellore (tamilnadu), observed 16.9% in hospital mortality amongst the south indian population following stemi 12. hyponatremia is a common electrolyte disorder amongst the inpatients in hospital 13,14,15,,16,especially with cardiac failure, cirrhosis or nephrotic syndrome. hyponatremia plays a major role in prediction of cardiovascular mortality amongst patients with cardiac failure17,18,19.the neurohormonal activation accompanying an acute myocardial infarction is similar to the one which accompanies a cardiac failure20. hyponatremia is common after myocardial infarction21, and a rise in plasma sodium concentration accompanies clinical improvement in patient22.the prognostic importance of hyponatremia in a case of chronic heart failure is very well established whereas its importance acute myocardial infarction is lacking 23,24,25, the study was conducted to determine the prognostic importance and usefulness of hyponatremia for predicting short term survival in a case of acute st segment elevation mi. aims & objectives : 1. to study the prevalence of low ejection fraction in a case of acute st segment elevation myocardial infarction. 2. to study the relationship between severity of low ejection fraction and short term mortality. 3. to determine the prognostic importance of low ejection fraction in a case of acute st segment elevation myocardial infarction. 4. to assess the usefulness of low ejection fraction as an independent risk factor in predicting short term mortality. materials & method: 50 subjects admitted in the icu of sree balaji medical college & hospital between november 2017 to july 2019., with acute st segment elevation myocardial infarction (stemi) were studied in a prospective manner. study design: 1) single centred 2) prospective 3) follow up study acute stemi was diagnosed according to the following criteria diagnosis of stemi: 1. presence of chest pain of >20min duration and 2. st segment elevation of >1mm in atleast two standard limb leads or >2mm in atleast two contiguous precordial leads or new onset of left bundle branch block and / or 3. elevated cardiac biomarkers. study participants: inclusion criteria: patients who presented within 12 hrs of onset of symptoms, with electrocardiographic evidence of stemi,elevated cardiac biomarkers and received a thrombolytic therapy with streptokinase were included in the study. exclusion criteria : 1. patients with non stemi or unstable angina. 2. people with previous history of coronary artery disease. 3. people with previous history of arrhythmias. 4. people with previous history of cardiomyopathy or heart failure. 5. people with previous diuretic use. 6. people with cirrhosis of liver,renaldisease, hypothyr oidism. 7. serum creatinine > 2mg% , blood urea > 60mg/dl. patients who fullled the above inclusion criteria and not having any of the above said exclusion criteria were included in the study as a participant. results table 1 low ejection fraction predictor of short term mortality in case of acute st segment elevation myocardial infarction (stemi) original research paper dr. shweta sureshbabu saritha junior resident , sree balaji medical college and hospital x 51gjra global journal for research analysis general medicine keywords : dr. k. shanmuganandan* professor, department of general medicine, sree balaji medical college & hospital, chennai *corresponding author dr. suresh kanna assistant professor,department of general medicine, sree balaji medical college & hospital, chennai volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra n mean sd sem ef hypo 14 42.500 9.1041 2.4332 nomal 36 52.972 9.6525 1.6087 52 x gjra global journal for research analysis table 2 a s s o c i at i o n o f e j e c t i o n f r a c t i o n a n d hyponatremia discussion: in acute myocardial infarction the development of hyponatremia is a marker that probably incorporates different prognostic entities,including severe left ventricular dysfunction,hemodynamic alterations,and the extent of neurohormonal activation. goldberg a66 et al studied 1047 patients with acute st elevation mi, without past history of heart failure.it was found that hyponatremia on admission or early development of hyponatremia was independently associated with short term mortality association between hyponatremia and ejection fraction the mean ejection fraction was lower among patients who presented with hyponatremia (mean ef 43.33%) or developed hyponatremia within 72 hours(mean ef 47.33%) when compared to patients with normal sodium levels(mean ef 54.4%). our results were consistent with the study conducted by goldberg a ,hammerman h et al, were the mean ef among patients with normal sodium levels,hyponatremia on admission and hyponatremia within 72 hours was 47%,42% and 42% respectively conclusion : there is signicant role of acute mortality in patients with low ejection fraction in case of acute st segment elevation myocardial infarction. references : 1. lopez ad, mathers cd, ezatti m, et al .global and regional burden of disease and risk factors2001: systematic analysis of population health data, lancet 2006;367:1747-57 2. castelli wp.epidemiology of coronary heart disease; the framingham study. am j med 1984 : 27 : 4 – 12. 3. roger’s wj, canto jg et.al., temporal trends in the treatment of over 1.5 million patients with myocardial infarction in the us from 1990 through 1999. the national registry of myocardial infarction 1,2&3. j.am.coll cardiol 36 ; 2056;2000. 4 . reddy ks, cardiovascular disease in non -western countries nengl j med 2004;350(24):2438-40 5 . ghaffer a, reddy ks, singhi m. burden of noncommunicable diseases in south asia bmj 2004; 328:807-10 6 . mohan v , deepa r, rani ss, premlatha g. prevalence coronary artery disease and its relationship to lipids in selected population in south india .the chennai urban population study (cups no 5) j am coll cardiol 2001;38:682-87 7 . joshi p, islam s,paisp,etal. risk factors for early myocardial infarction in south asians compared with individuals in other countries jama 2007;297:286-9 8 . pais p, xavier d, gupta r, et al .treatment and outcome of acute coronary syndrome in india the (create):a prospective analysis of registry data lancet 2008;371:1435-42 9. brown n, young t, gray d etal. inpatient deaths from acute myocardial infarction 1982-1992: analysis of data in nottingham heart attack register bmj1997;315:159-164 10. every nr, freiderick pd, robinson m, et al .a comparison of the national registry of myocardial infarction -2 with the co-operative cardiovascular project j am coll cardiol 1999;33:1886-94 11. zeymeru , senges j. why do we need prospective registries in patients with myocardial infarction eu heart j 2003;24:1611-12 12. v jacob jose ,satya n gupta et al morbidity and mortality of acute st segment elevation myocardial infarction in the current era indian heart j2004;56:210-14 13. upadhyay a, jaber bl, madias ne. incidence and prevalence of hyponatremia. am j med. 2006;119(7 suppl 1):s30-s35. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra f sin t df sin mean std ef equal variances assumed .254 .616 -3.497 48 .001 -10.4 722 2.99 45 -16.49 30 -4.4 515 introduction: acute pharyngitis is dened as an infection of the pharynx and/or tonsils. it is a very common pathology among children and adolescents. although viruses cause most acute phar yngitis episodes, group a streptococcus (gabhs) causes 37% of cases of acute pharyngitis in children older than 5 years [1]. other bacterial causes of pharyngitis are group c streptococcus (5% of total cases), c. pneumoniae (1%), m. pneumoniae (1%) and anaerobic species (1%). between viruses rhinovirus, coronavirus and adenovirus account for the 30% of the total cases, epstein barr virus for 1%, inuenza and parainuenza virus for about 4% [2]. the incidence of acute pharyngitis peaks in childhood and adolescence with approximately 50 percent of all cases occurring before age 18 [3,4]. among adults, most cases of acute pharyngitis occur by age 40 and incidence declines thereafter [3]. approximately 5% to 15% of adult cases are caused by gabhs (group a β hemolytic streptococcus). in some patients, it can be important to identify an infectious cause other than gabhs (for example, gonococcal pharyngitis, epstein– barr virus, and acute hiv infection), but in the vast majority of cases, acute pharyngitis in an otherwise healthy adult is selflimited and rarely produces signicant sequelae [5]. clinical manifestations include sore throat and fever with sudden onset, red pharynx, enlarged tonsils covered with a yellow, blood-tinged exudate. there may be petechiae on the soft palate and posterior pharynx. the anterior cervical nodes are enlarged and swollen. headache and gastrointestinal symptoms (vomiting and abdominal pain) are frequent. this study was initiated to analyse the infective prole of patients with throat infections children vs adults. materials and method: patients with throat infections coming to regional hospital bilaspur from surrounding rural areas of bilaspur, solan, hamirpur and mandi districts, constituted the study subjects. a total of 40 subjects with acute/chronic infection and age group 1–17 years and 19–33 years were included in the study. for each included patient, a physician obtained a history, performed a clinical examination, throat swabs from all the patients were collected for culture. throat cultures were incubated on 2 blood agar plates in anaerobia without inhibitor and were read after 48 hours. physicians prescribed antibiotic treatment within 48 hours in patients with a positive throat culture. results: a total of 40 patients from clinically chronic or acute throat infection were tested and analyzed. of them, 20 were children with age group 1-17 yrs and 20 were adult with 19-33 yrs of age. out of 20 children 8(40%) were male and 12 (60%) were female. out of 22 adult patients 9(45%) male and 11(55%). all 20 (100%) children had microbial growth and out of 20 adult patients 18 (90%) had microbial growth (no growth was present in 2 female patients). (table 1). in children (figure-1), the most frequent bacterial isolates were staphylococcus aureus in 8 (40%), followed by pseudomonas aeruginosa in 6 (30%), enterococcus faecalis, klebsiella pneumonia, and citrobacter koseri in 1 (5%) patient each. in adults (figure-2), the most frequent bacterial isolate was pseudomonas aeruginosa in 9 (45%), followed by klebsiella pneumonia in 3 (15%), staphylococcus aureus in 2 (10%), serratia marcescens, escherichia coli, aeromonas hydrophila and morganella morganii in 1 (5%) patient each. acute pharyngitis was present in 16 (80%) children and 13 (65%) adults. out of 16 children with acute pharyngitis growth of staphylococcus aureus was abserved in 7 (43.7%), pseudomonas aeruginosa in 5 (31.2%) followed by staphylococcus epidermidis in 2 (12.5%), enterococcus fae calis and klebsiella pneumonia in 1 (6.25%) patient each. out of 13 adults with acute pharyngitis growth of pseudomonas aeruginosa was abserved in 5 (38.5%), klebsiella pneumonia in 2 (15.4%) followed by staphylococcus aureus, serratia marcescens, escherichia coli and morganella morganii in 1(7.7%) patient each [no growth in 2 (15.4%) patients] (figure 3). chronic pharyngitis was present in 4 (20%) children and 7 (35%) adults. out of 4 children with chronic pharyngitis growth of staphylococcus aureus, staphylococcus epidermidis, pseudomonas aeruginosa and citrobacter koseri was present a comparative study of infective profile of patients with throat infections in children vs adults original research paper dr ankur dharmani md pediatrics regional hospital, bilaspur, himachal pradesh, india medicine introduction: acute pharyngitis is dened as an infection of the pharynx and/or tonsils. clinical manifestations include sore throat and fever with sudden onset, red pharynx, enlarged tonsils covered with a yellow, blood-tinged exudate. headache and gastrointestinal symptoms (vomiting and abdominal pain) are frequent. aims and objective: to study the acute/chronic pharyngitis in children vs adults. materials and method: a total of 40 subjects with acute/chronic infection and age group 1–17 years and 19–33 years were included in the study. physicians prescribed antibiotic treatment in patients with a positive throat culture. results: in children the most frequent bacterial isolates were staphylococcus aureus in 8 (40%). in adults the most frequent bacterial isolate was pseudomonas aeruginosa in 9 (45%). acute pharyngitis was present in 16 (80%) children and 13 (65%) adults. chronic pharyngitis was present in 4 (20%) children and 7 (35%) adults. conclusion: in most of the throat swab of children staphylococcus aureus was observed, while in adult's isolates of pseudomonas aeruginosa was observed in most of the samples. abstract keywords : volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr sonia kashyap md internal medicine ddu hospital, shimla, himachal pradesh, india dr manjeet singh* ms ent regional hospital bilaspur himachal pradesh, india *corresponding author 12 x gjra global journal for research analysis in 1 (25%) patient each. out of 7 adults with chronic pharyngitis growth of pseudomonas aeruginosa was abserved in 4 (57.2%), followed by staphylococcus aureus, klebsiella pneumonia and aeromonas hydrophila in 1 (14.3%) patient each (figure 4) in children out of 8 s. aureus isolates, 7 (87.5%) were resistant to penicillin, 5 (62.5%) each to tmp/smx and clindamycin, 6 (75%) each for ciprooxacin and levooxacin, 1 (12.5%) to amoxy/clav. out of 3 staphylococcus epidermidis, 3 (100%) each were resistant to penicillin and tmp/smx, 1(33.3%) each were resistant to ciprooxacin, levooxacin, clindamycin and tetracyclin. out of 6 isolates of pseudomonas aeruginosa 1 (16.6%) each were resistant to ciprooxacin, levooxacin, ticar/clav, ceftazidime, cefopera/sul, and amoxy/clav. enterococcus faecalis was observed in 1 isolate, 1(100%) each were resistant to penicillin and ciprooxacin. klebsiella pneumonia was observed in 1 isolate, 1(100%) was resistant to ampicillin (table 1). in adults out of 8 s. aureus isolates 2 (100%) each were resistant to penicillin and ciprooxacin, and 1 (50 %) each were resistant to tmp/smx, levooxacin, and clindamycin. out of 9 isolates of pseudomonas aeruginosa 2 (22.2%) each were resistant to ticar/clav and imipenem, 1 (16.6%) each were resistant to ceftazidime, cefopera/sul and cefepime. out of 3 isolates of klebsiella pneumonia all the 3 (100%) were resistant to ampicillin, 1 (33.3%) each were resistant to pip/taz, cefopera/sul, and amoxy/clav. serratia marcescens, was observed in 1 isolate, 1(100%) was resistant to amoxy/clav. escherichia coli was observed in 1 isolate, 1(100%) each were resistant to ampicillin, ciprooxacin and levooxacin. 1 isolate morganella morganii was observed, 1(100%) each were resistant to ampicillin and amoxy/clav (table 2). discussion: acute pharyngitis is common in adults and children, accounting for ~5% of medical visits [6]. most cases are viral, benign, and self-limited. group a �-hemolytic streptococci (gabhs) is the most common bacterial etiology. among children of all ages who present with sore throat, the prevalence of gabhs has been estimated to be 37% (95% ci, 32– 43). streptococcal pharyngitis occurs at all ages but is most common among school-aged children and adolescents. it is rare in children younger than 3 years. in our study a total of 40 patients from clinically chronic or acute throat infection were tested and analyzed. of them, 20 were children with age group 1-17 yrs and 20 were adult with 19-33 yrs of age. out of 20 children 8(40%) were male and 12 (60%) were female. jeffrey a. linder et al [7]., included visits by children aged 3 to 17 years (because children younger than 3 years are unlikely to have gabhs pharyngitis) with a primary reason for visit of “symptoms referable to the throat” (reason for visit classication code 1455; 96% reported “soreness” or “pain” in the throat). culture of a throat swab on a sheep-blood agar plate remains the standard for the documentation of the presence of group a streptococci in the upper respiratory tract and for the conrmation of the clinical diagnosis of acute streptococcal pharyngitis [8] (a-ii). if done correctly, culture of a single throat swab on a blood agar plate has a sensitivity of 90%–95% for the detection of the presence of group a β-hemolytic streptococci in the pharynx [9] (a-ii). in our study e. coli was present in 1 (5%) adult, klebsiella pneumonia was present in 1 (5%) child. according to the study by livermore et al [10], in 2012 antibiotic resistance of e. coli and klebsiella spp. is highest in asia (≥60%), with rates of 10–30% in southern europe, and 5–10% in northern europe, australasia and north america. the antibiotic of choice for pharyngitis caused by gabhs is penicillin, which is narrowspectrum, inexpensive, and to which gabhs is universally susceptible. linder et al [7] including a total number of 4158 children with pharyngitis aged 3-17 years shows that physicians performed a gabhs test only in 63% of children with sore throat and prescribed antibiotics to 53% of children, exceeding the maximum expected prevalence of gabhs. there was a signicant difference in antibiotic prescriptions between children who had a gabhs test performed and those who did not: gabhs testing is associated with a lower rate of antibiotic prescribing. all the authors and national guidelines agree in suggesting penicillin as rst choice treatment, since gabhs remains universally susceptible to penicillin [11]. although penicillin v is the drug of choice, ampicillin or amoxicillin equally are effective and, due to the good taste, represent a suitable option in children [12]. amoxicillin is often used in place of penicillin v as oral therapy for young children; the efcacy appears to be equal. this choice is primarily related to acceptance of the taste of the suspension. erythromycin is a suitable alternative for patients allergic to penicillin. first generation cephalosporins are also acceptable for patients allergic to penicillin who do not manifest immediate-type hypersensitivity to b-lactam antibiotics. for the rare patient infected with an erythromycinresistant strain of group a streptococcus who is unable to tolerate b-lactam antibiotics, clindamycin is an appropriate alternative. conclusion: in most of the throat swab of children staphylococcus aureus was observed, while in adults isolates of pseudomonas aeruginosa was observed in most of the samples. correct diagnosis and treatment of pharyngitis are the key points to attain a judicious use of antibiotics, and to prevent suppurative and non suppurative sequelae. thus, prudentially, we believe that paediatricians should perform at least one microbiological test (radt or throat culture) in pharyngitis suspected for etiology, in order to make the correct diagnosis. akhnowledgement: first authors: dr ankur dharmani, dr sonia kashyap tables and figures: figure 1: bacterial isolates in children figure 2 : bacterial isolates in adults volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 13gjra global journal for research analysis figure 3: bacterial isolates in children vs adults with acute pharyngitis figure 4: bacterial isolates in children vs adults with chronic pharyngitis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 1: resistance pattern of antimicrobial agents (%) in children p a t/s cf l t/c cfz c/s cp a/c cd t staphylococcus aureus (n=8) 7 (87.5%) 5 (62.5%) 6 (75%) 6 (75%) 1 (12.5%) 5 (62.5%) staphylococcus epidermidis (n=3) 3 (100%) 3(100%) 1(33.3%) 1(33.3%) 1(33.3%) 1(33.3%) pseudomonas aeruginosa (n=6) 1 (16.6%) 1 (16.6%) 1 (16.6%) 1 (16.6%) 1 (16.6%) 1 (16.6%) 1 (16.6%) enterococcus faecalis (n=1) 1(100%) 1(100%) klebsiella pneumonia (n=1) 1(100%) p: penicillin, a : ampicillin, t/s: tmp/smx, g: gentamycin, cf: ciprooxacin, l: levooxacin, p/t: pip/taz, t/c: ticar/clav, cfz: ceftazidime, c/s: cefopera/sul, ak: amikacin, ip: imipenem, cp: cefepime, a/c: amoxy/clav, lz:linezolid, cd: clindamycin, t : tetracyclin p: penicillin, a : ampicillin, t/s: tmp/smx, g: gentamycin, cf: ciprooxacin, l: levooxacin, p/t: pip/taz, t/c: ticar/clav, cfz: ceftazidime, c/s: cefopera/sul, ak: amikacin, ip: imipenem, cp: cefepime, a/c: amoxy/clav, lz:linezolid, cd: clindamycin, t : tetracyclin table 2: resistance pattern of antimicrobial agents (%) in children p a t/s cf l p/t t/c cfz c/s ip cp a/c cd staphylococcus aureus(n=2) 2(100%) 1(50 %) 2(100%) 1 (50 %) 1 (50 %) pseudomonas aeruginosa (n=9) 2(22.2%) 1(16.6%) 1(16.6%) 2(22.2%) 1(16.6%) klebsiella pneumoniae (n=3) 3(100%) 1(33.3%) 1(33.3%) 1(33.3%) serratia marcescens (n=1) 1(100%) escherichia coli (n=1) 1(100%) 1(100%) 1 (100%) morganella morganii (n=1) 1(100%) 1(100%) references 1. shaikh n, leonard e, martin jm. prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis. pediatrics. 2010;126:e557–64. 2. bisno al. acute pharyngitis. n engl j med. 2001;344:205–11. 3. andrém, odenholt i, schwan a, axelsson i, eriksson m, hoffman m, mölstad s, runehagen a, lundborg cs, wahlström r, swedish study group on antibiotic use. upper respiratory tract infections in general practice: diagnosis, antibiotic prescribing, duration of symptoms and use of diagnostic tests. scand j infect dis. 2002;34(12):880. 4. danchin mh, rogers s, kelpie l, selvaraj g, curtis n, carlin jb, nolan tm, carapetis jr. burden of acute sore throat and group a streptococcal pharyngitis in school-aged children and their families in australia. pediatrics. 2007;120(5):950. 5. snow v, christel mp, richelle jc, hoffman jr, principles of appropriate antibiotic use for acute pharyngitis in adults. ann intern med. 2001;134:506508. 6. armstrong gl, pinner rw. outpatient visits for infectious diseases in the united states, 1980 through 1996. arch intern med. 1999;159:2531-2536. 7. linder ja, bates dw, lee gm et al., antibiotic treatment of children with sore throat. jama. 2005;294(18):2315-2322. 8. breese bb, disney fa. the accuracy of diagnosis of beta-streptococcal infections on clinical grounds, j pediatr, 1954, vol. 44 (pg. 670-3). 9. gerber ma. comparison of throat cultures and rapid strep tests for diagnosis of streptococcal pharyngitis, pediatr infect dis j, 1989, vol. 8 (pg. 820-4). 10. livermore d. (2012) current epidemiology and growing resistance of gramnegative pathogens. korean j intern med 27: 128–142. 11. gerber ma. nelson, textbook of pediatrics, international editions. 18. vol. 182. 2007. group a streptococcus; pp. 1135–39. 12. american academy of pediatrics, committee on infectious diseases. red book: report of the committee on infectious diseases. 27. elk. grove village; 2006. 14 x gjra global journal for research analysis 25.dr pankaj kumar.cdr introduction: identication means xing the individuality of a person. unidentied or unclaimed dead body means body of a deceased person , if such body has no relative or if it is not claimed by any of his relatives within 48 hrs. of his death. as and when a dead body recovered by the police is unidentied or unclaimed, the police ofcer make inquiry under section 174(14) and send it for medico-legal autopsy. the unknown body brought for autopsy is preserved in the mortuary for 72hrs from the time it came to the mortuary. if there is no claim for the body even after 72 hrs., the police ofcers are legally authorised to dispose off the body. the aim of this study is to ascertain the cause of death and other parameters in the unknown/unclaimed victim. however, the problem of nding the cause of death in unknown body get aggravated when the bodies recovered are either in decomposed form or crushed state. post-mortem examination act as one of the investigative tool that helps in positive identication of the deceased, determination of time since death, cause of death, manner of death, time between injury and death, and to recover clues from the body. material and methods: unidentied bodies brought for post-mortem examination to the mortuary of dept. of forensic medicine & toxicology, nmch, patna, during the period of jan 2016 to dec 2017 comprise material for the study. data regarding these cases were compiled from pm reports, inquest paper, detailed hist ory elicited from concerned i.o. at the time of autopsy. observation & results: a total of 829 bodies (409 cases in 2016 and 420 cases in 2017) were brought for pm examination to the mortuary of fmt dept. nmch, patna during the study period of two years (jan2016dec2017). of these unknown/unidentied cases were 124 (67 cases in 2017 and 57 cases in 2017) comprising 14.95% of total cases (16% in 2016 and 14% in 2017). the present work was done on 124 cases, of which, 103 cases were brought directly from the nmch hospital while the rest were referred from nearby hospitals. gender wise distribution shows, there were 83 cases (66.93%) of male and female contributed 33.06% (41cases) of the total cases studied. opinion regarding the cause of death was given at the time of autopsy in 114 cases (91.9%) while in the remaining 10 cases (8.06%), additional investigations were required; so the opinion was kept reserved and viscera was send for histopathology and chemical analysis in the concerned fsl. till the date, out of these 10 cases, 5 cases were reported to be positive for the presence of poisonous substances by the fsl while the reports of rest 5 cases were still awaited. on including these 5 conrmed cases of poisoning in the study, there were total of 119 cases, where nal opinion to the cause of death were available, of which 40 deaths (32.25%) were natural and the rest 79 cases (63.70%)were that of unnatural deaths. among all the 40 natural deaths (32.25%), lung disease (acute/chronic) comprising 32 cases (80%) predominated the cause of death followed by coronary artery disease in 3 cases (7.5%) and hepatic disease in 2 cases (5%). the cause of death was others (including heat stroke, hypothermia etc.) in 3 cases (7.5%). table 3 shows that among 124 unidentied cases studied, road trafc/rail accident were most common (21.77%) cause of death. strangulation accounted for 13 cases(10.48%), electrocution in 2 cases (1.6%) and gun shot in 1 case(0.8%). drowning was the cause of death in 26 cases (20.96%)and poisoning and not known account for 5 cases(4.03%) each. among all unnatural, accidental deaths (including rta, rail accidents)were most common (55cases,69.62%) manner of death followed by homicidal 19 cases,24.05%{comprising of strangulation(13 cases,13.48%), gunshot(1case,0.8%) & trauma(5cases, 4.03%)} and suicidal 5 cases[6.32%] comprising all cases of poisoning only. the cases from the rural area constitute 62.09% (77cases) whereas the remaining 47cases (37.9%) were belonging to urban area. table 1: pattern of cause of death in unclaimed/ unidentified /unknown dead bodies : a two year retrospective study. original research paper dr. radha raman singh associate professor, fmt dept., nalanda medical college and hospital (nmch), patna. x 13gjra global journal for research analysis forensic medicine patna is one of the largest city (both in terms of population and area) as well as the capital city of bihar. every year thousands of people from different regions of bihar throng to the capital city in search of job. when these people die without any identifying document, it is very difcult to establish their identity and cause of death as their past medical and other histories are not known. the present 2 yrs. of retrospective study was undertaken to nd the cause of death and its pattern in unknown/unidentied/ unclaimed dead bodies brought for autopsy at nalanda medical college & hospital (nmch), patna, between jan 2016 to dec 2017. a total of 829 cases were brought for medico-legal autopsy of which unknown cases accounted for about 14.95%. the manner of death was certied as natural in 32.25% of cases in which chest and abdominal disease combined were mainly responsible with a predominant pathology in the lungs (80% cases). of all unnatural deaths (63.70%), road/rail accident injuries were most common (21.77%) cause of death followed by drowning (20.96%). there was a clear predominance of males cases (66.93%) over female one. the government should take initiatives at large to prevent unnatural deaths in unidentied or unknown persons. the study suggest an urgent need for creation of a national missing person database as well as dna database to aid the identication of unidentied/unclaimed/unknown bodies. abstract keywords : unknown, unclaimed, unidentied, death, autopsy, pattern. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. pankaj kumar* associate professor, fmt dept., patna medical college and hospital (pmch), patna. *corresponding author dr. ranvir ranjan jr iii (pg), fmt dept., pmch, patna. manner of death (among unnatural deaths) no of cases % 1)homicidal (strangulation, gunshot, trauma) 13+5+1=19 24.05 2)suicidal(poisoning) 5 6.32 3)accidental(rta+ rail accidents ,drowning , electrocution) 27+2+26=55 69.62 total 79 100 14 x gjra global journal for research analysis table 2: table3: pie-chart 1: pie-chart 2: pie-chart 3: bar chart 1: distribution of known vs. unknown cases during 2016 & 2017 discussion: unidentied cases brought for pm examination at nmch account for although less no of cases but were very signicant one. most of the cases among unnatural deaths were due to road/rail accidents probably because i) beggers and destitudes reside at the road side and are usually physically challenged ii) hit and run accidents with crushing of head and face, hindering identication iii)body being dismem bered when run over by a heavy vehicle or train iv)a person being involved in a fatal accident just on arrival in a completely new place v) close proximity of the hospital to the national highway, gandhi setu and patna junction which because of being in capital are highly crowded. the rta was followed by drowning which can be attributed to the closeness of the hospital to the river ganges. among unnatural deaths , the lung pathology predominated and rural cases exceeded the urban one. conclusion: the ndings of our study revealed that road/rail accidents is most important cause of mortality in unknown cases in the study area. male were most affected population and most of the cases belong to rural area. as far as manner of death is concerned, accidental was most common followed by homicidal and suicidal. more deep studies are required to nd the actual cause of accident for preventing its effects on morbidity and mortality, which will in turn help in providing better health care facilities to the homeless. apart from it, effort should also be made by the police to present the unknown/unclaimed bodies for autopsy without delay so that the decomposition and other artefacts do not set in and obscure the valuable ndings regarding the cause and manner of death besides the identication. along with publishing missing notices in dailies by police personnel, the simple technique of preserving records like colour photographs{of dead body as well as clothes}, marks of identications (at least 2), tattoos, scars, deformities, dental records, whole body radiographs{to reveal old fracture or implants}, ngerprints, dna analysis(by preserving sternum), blood samples for cross matching, pulp of ngers ( preserved in formalin) also help a lot in identifying the deceased even years after their deaths/post-mortem. declaration of conflicting interests: none declared funding: this research received no specic grants from any funding agency in the public, commercial, or not for prot sectors. references: 1. vij k. textbook of forensic medicine & toxicology, principles and practice , 5th edition ,india; el sevier:2018 p35-37. 2. reddy ksn: the essential of forensic medicine and toxicology 28th ed, hyderabad,india , page 112-113. 3. job c, determination of cause of death in decomposed bodiesa regional study.indian academy for medicine 2009,31(1):11-17. 4. kumar a, tyagi a, aggarwal nk, sex determination using adult talus and calcaneum bones. j forensic medicine & toxicology,2009,12(1): 04-12. 5. shepherd r,guidelines for autopsy and exhumation, simpson`s forensic medicine 12th ed,london page 187-193. 6. kumar a, harish d, chavali kh, singh a,pattern of cause of death in unknown dead bodies : a three year study in a tertiary care hospital. j indian academy of forensic medicine oct-dec 2012;34(4). volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra causes of deaths (natural) no of cases % 1.lung ds (acute/chronic) 32 80 2. coronary disease 3 7.5 3. hepatic disease 2 5 4. others 3 7.5 cause of deaths no of cases % 1.natural 40 32.25 2. road trafc/rail accidents 27 21.77 3. gunshot 1 0.8 4. trauma(head, abdominal, chest injuries) 5 4.3 5. drowning 26 20.96 6. strangulation 13 10.48 7. electrocution 2 1.6 8. poisoning 5 4.03 9. not known 5 4.03 1. introduction nowadays, pollution is the major issue in the universe. in case gas-powered lawn mowers due to the emission of gases it is responsible for pollution. also, the cost of fuel is increasing hence it is not efcient. traditionally, lawn mowers are often clunky pieces of machinery that involve a lot of strength and energy to use. these present and high-tech grass cutters, however, have been creatively designed to make the whole landscaping process much simpler and easier for the user. from robotic lawn mowers that can incredibly cut the grass for you to those that are cleverly powered by solar energy, these convenient and easy-to-use grass-cutting devices make straightening up your lawn more pleasing. the grass-cutters use cordless electric mowers, trimmers, and blowers powered by clean renewable energy generated by solar panels mounted on our trucks and trailers. we also use reel push mowers for smaller hard to access areas like pathways and parks. there's no oil, and no pollution. just clean air, less noise, and green grass [2]. the other objective is that the automatic lawn cutter has to differentiate between grass and concrete while monitoring its surroundings continuously. we wanted an ultrasonic sensor to sense if the lawn cutter was heading into an object. safety is the main concern while designing the lawn cutter. as it has blades we wanted our lawn cutter not to be in operating mode if it was being held in the air by the user. knowing that the user would be randomly holding the lawn cutter we needed a sensor to detect orientation. the accelerometer was hence used in lawn cutter so that it will not operate when user holds it. an automatic lawn cutter will relieve the consumer from mowing their own lawns and will reduce both environmental and noise pollution. 2. problem statement in the time where technology is merging with environmental awareness, consumers are looking for ways to contribute to the relief of their own carbon footprints. pollution is manmade and can be seen in our own daily lives, more specically in our own homes. gas powered lawnmower is in 90% of u.s. home and they create 5% of the total u.s. pollution. green technology initiatives are being supported by both the government and cooperates business. our new design for an old and outdated habit will help both the consumer and the environment [4,5]. in this paper, the solar-powered automatic grass cutter will relieve the consumer from mowing their own lawns and will reduce both environmental and noise pollution. this design is meant to be an alternate green option to the popular and environmentally hazardous gas-powered lawn mower. ultimately, the consumer will be doing more for the environment while doing less work in their daily lives. 3. objective the project aims at fabricating a grass cutting machine system that makes grass cutter motor running through the solar energy. the solar powered grass cutting machine is a robotic vehicle that is powered by solar energy which controlled by remote. in this system, we use the battery to power the vehicle movement motor and grass cutter motor. the solar panel is used to charge the battery along with battery charger so that there is no need of charging it externally. 4. literature review ashish kumar chaudhari, in this paper they have prepared manually handle device which is capable to cut the grass. this device consists of linear blades and it does not affect by climatic conditions. they have used following components for preparing grass cutter. the main objective of this paper is to move the grass cutter is different directions to prepare various designs as per requirements. by using link mechanism the height of the cut solar grass cutter original research paper mr. nikhil gupta department of mechanical engineering, aiimt college of engineering, greater noida mechanical engineering from time immemorial, the sun has been the major source of energy for life on earth. the solar energy was being used directly for purposes like drying clothes, curing agricultural produce, preserving food articles, etc. even today, the energy we originate from fuel-wood, petroleum, parafn, hydroelectricity and even our food originates obliquely from sun. solar energy is almost unbounded. the total energy we obtain from the sun far exceeds our energy demands. ever since the industrial revolutions human have been dependent on fuels, electricity and wind energy. for human enlargement in many countries there is study and trials are going on the solar energy and the wind energy, so we make our new concept solar powered grass cutting machine in these concept we cut grass s on the agricultural products or on small plants in lawns and gardens. remote controlled grass cutter can be described as the application of radio frequency to power a machine on which electric motor rotates which in turn rotates a blade which does the mowing of a grass [1,3]. abstract keywords : blade, grass, grass cutting machine, motor, solar energy fahad ali* department of mechanical engineering, aiimt college of engineering, greater noida *corresponding author injmamulhaque department of mechanical engineering, aiimt college of engineering, greater noida volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra kamal afzal department of mechanical engineering, aiimt college of engineering, greater noida kartikay gupta department of mechanical engineering, aiimt college of engineering, greater noida 110 x gjra global journal for research analysis can be adjusted. the unskilled labor can easily operate this device. they have prepared wireless grass cutter. there are two main components such as transmitter and receiver. transmitter continuously transmits the rays if any obstacle comes in front of grass cutter then the rays are reected back towards the receiver. the receiver receives the signals in the serial form encoder but microcontroller required parallel data for communication so receiver sends data to the decoder to convert data in the parallel form and then it passed to the microcontroller. they have used solar panel so it is not required to charge battery externally and a battery is continuously charged at the constant voltage when grass cutter is in working. the battery is charged in daytime by using the solar panel and it is stored so we can use grass cutter at night time also. because of two dc motor, both forward and backward motion of grasscutter can simultaneously possible. ashish kumar chaudhari , in this paper author explained that solar plate which is placed above the grass cutter generates solar energy and use this energy for working the grass cutter. also, using driver circuit for 925 | page controlling the speed of the motor as per the requirement. solar panels, batteries, dc motor, solar charger, circuitry, and blades these components are used for preparing grass cutter. for preventing the battery from overcharging and the over-discharging regulator is placed into the system and it should be placed in series. they have provided lcd display unit which displays voltage generated during solar rays trapping. due to seasonal conditions if the battery is not charged they can provide the power bank to charge the battery instantly. pankaj malviya, author prepared manually handle device. the battery can be charged by using solar panel as well as external power supply and dc motor which is controllable is used for changing the direction of grass cutter as per need are used. the most modern regulator is used for preventing overcharging and discharging of the battery which saves span of the battery. due to industrialization, more electricity is required for various industrial applications and electrical gadgets so solar energy is the best alternative for electricity. solar panel, battery, dc motor, solar charger these components are used for fabrication of grass cutter. they have used less number of moving components so there is less maintenance. this grass cutter will give much more physical exercise to the operator and it will easily handle. praful p. ulhe, in this paper they have prepared manually operated grass cutter with spiral roller blades due to spiral blades increases the efciency of cutting. for adjusting the height reel cutter is component placed on grass cutter. this grass cutter used to cut the grass uniformly and also it can cut the different types grasses. the battery can be charged during working conditions and it also having ac charging. for the collection of cutting grass cutting box is placed over grass cutter so the cut grass put on the lawn. it is having light in weight and compact in design. t. karthick, in this paper author fabricated grass cutting machine with rotary blades by using solar energy. the solar energy is trapped in the photovoltaic cell to generate electricity. the cells may be grouped in the form of panels or arrays. solar panel is placed such that to absorb high intensity from sun and it will incline at 450. the main function of solar charger is increased current during batteries are charging and also disconnect when they are fully charged. circuit's breakers are used to start or stop the motor. by considering ground clearance they can adjust the height of grass. tanimola, author developed solar powered lawn mower. they found various results which are listed below, sample plotheight grass before movingheight grass after moving expected height of grass after moving elephant grass 224 90 100 stubborn grass 234 92 100 spare grass 111 70 80 carpet grass 70.5 56.5 50 the average height of grasses after moving was lesser than the expected after the machine have been adjusted to a height for four species of grasses. less time required for cutting the grass. the efciency is also increases. ms. lanka priyanka, in this paper they have fabricated solar powered grass cutting machine with tempered blades are attached to this grass cutter. this grass cutter is manually operated as well as automatic operated. the materials commonly used gi sheet, motor, wheel, al sheet, switch, wire, square pipe and insulating material. the components used are comparator, rechargeable battery, relay, temperature sensor, dc motor. the voltage generated by using solar panel displayed on lcd display unit. dipin.a , they prepared solar powered vision based robotic lawn mower which operated manually with less efforts. the predetermined program feed into the system and the robot moves as per predetermine pattern with the help of matlab programming as well as camera installed over the robot structure. robots which is produced for reducing the human efforts also detects human and objects which is come in front of robot. therefore it protects the equipment form damage and also reducing risk on human. the robot cut the grass in different direction for making different design patterns as specied by human. sachin prabha the writer fabricate solar grass cutter machine for reducing human work and also consume non renewable sources of energy on the earth surface. by using solar panel the energy is acquire from sun and store it into batteries and uses this energy as per the requirement. all this functions are proceeding according to prescribed time by proper monitoring. a specic mechanism provide for protection of batteries from extra charging which increases life span of batteries. it can also be used for small scale for gardening. 5. components used: 1. dc motor 2 rotating the wheel 2. dc motor 1 rotating the blade 3. wheel 4 moving the robot 4. battery 1 power supply for motors 5. solar panel 1 power supply for batteries 6. collapsible blade 3 high carbon steel resist wear 6. conclusion it consumes non-renewable sources of energy so total energy received from sun far exceeds our energy demand. it meant to be an alternate green option to the popular and environment hazardous gas-powered lawn mower and reduces human effort. the nons killed person also handles it easily. by using simple switches or by predetermine programming it can be easily handled and control within less time span. we have made it automated by providing sensors. therefore, it is highly efcient and accurate. therefore equipment should be protected from damage and reduces risk on a human. 7. final product fig.1 front view of product volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 111gjra global journal for research analysis fig. 2 side view of product 8. applications ÿ it can be used in gardens for cutting the grass evenly. ÿ also it can be used in college campus. ÿ it is useful in lawns. ÿ it can be efciently used in agriculture areas. ÿ it can used for cutting the grass of particular area of play grounds. e.g:-cricket, football playgrounds etc. ÿ military applications references [1] "smart solar grass cutter robot for grass trimming" by ashish kumar chaudhari, yuvraj sahu, pramod kumar sahu, subhash chandra verma [2] "design and implementation of automatic lawn cutter" by pratik patil, ashwini bhosale, prof. sheetal jagtap. [3] bravo, r., “tired from mowing the lawn”, journal of pediatric health care, 24: 2010, 123–126. [4] scherer, e. “humanoid robots for human life support”, proceedings of ifac conference on supplemental ways for improving international stability through automation 15-17 june 2006, ed. p. kopacek, 101 – 105, elsevier. [5] pansire, d.g. “self-propelled self-guiding lawn mower.” u.s. patent 4, 1980, 180,964. [8] reid, j.f., zhang. q., noguchi, n., and dickson, m. “agricultural automatic guidance research in north america.” computers and electronics in agriculture. vol. 25, 2000, pp. 155-167. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 112 x gjra global journal for research analysis support the decision taken by the government: the government of bharatiya janata party led by shri narendra modi, the prime minister of india decided to repeal sections 370 and 35 (a) of kashmir on august 5, 2019. in support of this decision, the present home minister of this government shri amit shah said in parliament, "we are making a historic decision. that decision could not be taken by governments that have come in the last 70 years.” he further said that the past 70 years ago, the state of jammu and kashmir was given the status of a separate state under section 370 was a historical mistake. we are repairing that mistake. in this decision, they divided the state of jammu & kashmir by strengthening the status of the constituent state of jammu & kashmir. with this decision, jammu & kashmir thended as the 29 constituency of the indian union. jammu kashmir and ladakh were created as the two union territories. ladakh union territory will not have assembly status. in support of this decision, shri amit shah said that this is an important decision in the interest of the people of jammu & kashmir. particularly, the people of kashmir valley will come in the mainstream due to this decision. similarly, according to him, entrepreneurs in jammu and kashmir will buy land and set up industries. it will benet the masses of jammu and kashmir; they will get jobs in a large scale. establishment of various educational institutes will provide better educational facilities to the children. the right to information act will apply. reservation for the people belong to scheduled caste can be taken further. there, women will have the same rights as the other indian women in the wealth of their father. corruption of wasting money given to political parties in jammu & kashmir, e.g. pdp, the national conference by the central government in the last 70 years would prevent. in this way, this decision is supported by the existing government. did constitutional provisions & code comply while repealing article 370? on may 27, 1949, the new article 307 was added to the constituent assembly, which was later referred to as section 370 (article 370). therefore, this state was given special powers than states of india. as a result, no one else outside this state can permanently reside in jammu & kashmir and cannot buy property there. this made jammu & kashmir a part of india, but its relationship with india was bridged by the section 370. it was through this bridge that the national leaders of india tied jammu and kashmir as an integral part of india. because if it were to be repealed permanently, according to the original law, it would have to pass the resolution in the assembly of jammu & kashmir. it was only after this that a constitutional provision was made that parliament would decide on it. but, has the existing government decided to repeal article 370 as per the constitutional provision? this important question arises here. but, the assembly of jammu & kashmir did not exist at the time of this decision. therefore, the question of consent of the legislative assembly does not arise. the central government has requested parliament to repeal article 370 through the governor of jammu & kashmir. the governor of constituent state is the representative of the central government; s/he does not represent the people of the constituent state. therefore, the governor's request to the central government is inconsistent with the constitutional provision. accordingly, the members of parliament should be given copies of the bill at least two days before the amendment of the bill was tabled in parliament, but only a few minutes before such an important bill was presented in the parliament. therefore, members of the opposition party could not express their strong intellectual views while discussing the bill. this is contrary to the democracy and the constitutional code. it is not in the constitutional practice to get the bill passed by the ruling party on the strength of its majority. it is harmful to democracy. this proves that the ruling government did not comply with the constitutional provisions and codes while taking this decision. future results: fatal to the federal system: the manner in which the existing government repealed article 370 and section 35 (a), which abolished the status of the state of jammu & kashmir as a constituent state and converted it into two union territories, is extremely dangerous to the federal system of india. because, further, the central government can alter the territory of any constituent state without the consent of that state or a constituent state may be terminated so that in future there may be a dispute of constituent state against central government. the people of jammu & kashmir have lost their faith: in the last 70 years, the bridge which was created by article future consequences of abolition of article 370 of jammu & kashmir original research paper dr pradip t wakode head, department of political science smt radhabai sarda arts, commerce & science college, anjangaon surji, dist amravati (ms),444705 x 23gjra global journal for research analysis political science the present research paper throws light on consequences of deletion of article 370 and 35 (a) about jammu and kashmir and 35 (a) by the existing government of bharatiya janata party on august 5, 2019. in the same decision, while terminating the status of jammu & kashmir as a constituent state of the indian federal state into two union territory states i.e. jammu kashmir and ladakh, has the existing government complied with the constitutional provisions and code? likewise, was this decision worthwhile in the current situation? the research article examines a thorough overview of the impact of this decision on the people of kashmir as well as on india and international affair. the reasons given by the present government in support of this decision i.e. it is because of the repeal of this clause that the people of jammu and kashmir would come in the mainstream. indian national security advisor, shri ajit dowal said that the decision was supported by 92 per cent of the people living in kashmir valley. the government said that the industrial development of jammu and kashmir, the development of the backward classes as well as the dalits and tribals would take pickup and women would get judicial rights. jammu and kashmir will be free from corruption. there will be an increase in the growth rate. the review is conducted in the present article. the ndings presented in the research paper presented. was there really a demand for the people of the country to repeal article 30 and 35 (a) of jammu and kashmir? or was it the need of the bharatiya janata party and the pro-hindu organizations that were involved in the government? what are the national benets of this decision? it has also reviewed the ndings regarding the political benets of the bharatiya janata party. abstract keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 24 x gjra global journal for research analysis 370 and section 35 (a) clause between india and jammu & kashmir collapsed so, in future, the people of kashmir valley will alienate from india. their belief in the indian adminis trative system has lost. because, the manner in which the present government took the decision secretly; the people of kashmir believe that the ruling government has deceived them. therefore, bringing them into the mainstream will not be possible. dangerous to indian democracy: the decision taken by the ruling government to repeal article 370 and section 35 (a) of jammu & kashmir without showing any transparency, without following the constitutional provision & code, without taking the opposition party in faith, without giving enough time to discuss it in the house has proved to be deadly to indian democracy. internationalization of kashmir's question: the problem of jammu & kashmir has been limited between india and pakistan for the last 70 years. the abolition of article 370 has given pakistan an opportunity to internationalize the issue. the risk of world war: people in the world are aware that the problem of jammu & kashmir is the most sensitive issue which can be the cause of world war. india and pakistan are both nuclear armed nations and defense ministers of both the countries have threatened each other for nuclear war. hence, an atmosphere of fear has created in the world. violation of simla agreement: according to the simla agreement between india and pakistan, it was decided to resolve the issue through the discussion between india and pakistan. the unilateral decision by the ruling government of india gave pakistan an opportunity to blame india to break the simla contract. human rights' violation: since the decision taken by the present government on kashmir on august 5, 2019, section 144 has been imposed to control the livelihood of the people of kashmir. they will neither be able to open shops or go to work nor meet each other. mobile and internet services are closed; no one can go to their places of worship for prayers; no medical facilities are available if someone becomes ill. if someone dies, not more than four or ve persons can gather together for funeral rites. by imposing such strict restrictions on the people of jammu & kashmir, their human right is being violated. conclusion: the state of jammu & kashmir has achieved the status of an independent state under sections 370 and 35 (a) during the last 70 years. this kind of status has also been received by the north-east constituents of the indian union. the demand for the elimination of the status of a separate constituency of jammu & kashmir has never been demanded by the indian people through movement or any other way in the last 70 years. but there has always been an urge to cancel the section 370 of jammu & kashmir from the hinduist parties & organisations such as bharatiya janata party, the old jana sangh and rashtriya swayamsevak sangh, the hindu party and the organization. but the above organizations have never demanded to cancel the special status received by some other states. this proves that there is not a muslim minority in other states, but there is a muslim majority in jammu and kashmir. by hating a particular religion, the abolition of the article 370 of jammu & kashmir has been demanded by the bharatiya janata party and the rashtriya swayamsevak sangh for the last 70 years. but this demand was not fullled because congress and other secular party's governments were ruling at the center. but in the election of 2014 and 2019, due to the clear majority of the bharatiya janata party, it abolished article 370 and section 35 (a) of jammu & kashmir in order to gain political advantage in the upcoming elections. bharatiya janata party will surely get its political benets. but the nation will have to face its consequences. jammu & kashmir was an integral part of india and it will be the same, there is no doubt in the heart of any indian. but this decision could justify only after taking into consideration the views of the people of jammu & kashmir. the present government must reassure the people of jammu & kashmir in the future by giving them surety that they have fullled the promise given to them. references: 1. daily lokmat: editorial, august 28, 2019 2. daily loksatta: editorial day, august 6, 2019 3. daily loksatta: editorial day, august 7, 2019 4. domel to kargil: major shashikant giridhar pitre (rajahans publication), pune. 5. jammu & kashmir: swayatta ki swatantrya (freedom or autonomy), yd phadke (akshar prakashan), mumbai. 6. iron man sardar valabbhai patel, b. krishna (indus source books), mumbai. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 32.dr akhil shine ss.cdr introduction ayurveda is known as science of living beings. it concerns the maintenance of health of healthy living beings and restoration of health of the diseased ones. meteorology is the study of weather and climate. climate is the geographical concept representing a summation of whole range of meteorological phenomenon. the weather has found to have a profound effect on human health and well beings. medical disorders such as bronchitis, peptic ulcer, adrenal ulcer, glaucoma, goitre, eczema and harps zoster are related to seasonal variations in temperature. humidity has also a considerable inuence on morbidity in the winter because cold, dry air leads to excessive dehydration of nasal passages and upper respiratory tract and increased chance of viral and 1microbial infection. components of meteorology: atmospheric pressure, air temperature, humidity, rainfall, direction and speed of wind and movements of clouds and character of weather. air pressure is determined by barometer, preferably mercuric barometer is used. temperature is determined by thermometer. humidity: amount of moisture present in the air, determined by hydrometer winds: produced by the disturbance of equilibrium of the low masses of air in a free mobile atmosphere and the cause of disturbance are difference of atmospheric pressure it can changes in temperature. wind speed is measured by anemometer. clouds: masses of vapor condensed into minute h oparticles 2 which oat in the air in the highest regional of atmosphere (1 to 4 miles above the surface of earth). ceilometers are measuring the cloud heights. visibility: transmissometer is measure the total effect of smoke, fog and other restriction to vision in atmosphere. precipitation: indicated by the amount of rain or snow that has 2fallen. measure by rain gauge and snow gauge. various branch of meteorology 1. synoptic meteorology 2. dynamic meteorology 3. physical meteorology 4. agricultural meteorology 5. applied meteorology 6. bio-meteorology seasons and the positions of the earth around the sun with reference to the northern hemisphere summer solstice north pole is directly tilted toward the sun. it occurs every june 21 or 22. longest day and shortest night are experienced. vertical rays of the sun strike the tropic of cancer. autumnal equinox no pole is tilted toward the sun. it occurs every september 22 or 23. equal length of day and night is experienced. vertical rays of the sun strike along the equator. winter solstice south pole is directly tilted toward the sun. it occurs every december 21 or 22. shortest day and longest night are experienced. vertical rays of the sun strike the tropic of capricorn. spring equinox no pole is tilted toward the sun. it occurs every march 21 or 22. equal length of day and night is experienced. vertical rays of 3the sun strike along the equator. meteorological relevance of uttarayana kala and dakshinayana kala original research paper dr. akhil shine ss md (ay) x 31gjra global journal for research analysis ayurveda rithucharya is one of the important concepts explained in ayurveda. it deals with comprehensive management of diet pattern, behavior and lifestyle modication in relation to change in the seasons. in short, ritucharya is the seasonal regimen, rules and regulation to what to do and what not during season and seasonal changes. if one follow the regimens prescribed under each and every rithu such person is never inicted with seasonal diseases or disorders and he always remains as a healthy person. as we know that there are two ayana or solstices are there in one year or we can say that sun changes its position twice every year. these changes are known as uttarayana i.e. summer solstice and dakshinayana i.e. winter solstice. meteorology is the study of weather and climate. the weather has found to have a profound effect on human health and well beings. abstract keywords : meteorology, uttarayana kala, dakshinayana kala volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 32 x gjra global journal for research analysis bases of the division of ritu and ayana: seetha lakshana, ushna lakshana, varsha lakshana, chandra marga gamana, surya marga gamana. seasons in ayurveda and modern view: ayurveda is consider the apparent movement of the sun with respect to the earth assuming that earth always in same position but in moden science consider the movement of earth with respect to sun. samvasara is divided in two ayana, uttarayana and dakshinayana, each ayana has 3 ritu. classication of ritu uttarayana -sisira , vasantha and greshma dakshinayanavarsha, sharad and hemantha susrutha, two rainy seasons are included varsha and pravrit uttarayana (adanakala) sun appears to moving from south to north day by day and this movement continues for 6 months. it is correlated to summer solstice (sun is over tropic of cancer). the period during which rising sun appears on the sky moving from southern end towards north day by day. sun become powerful but wind and moon become weak (agneya predominance) and length of day time will be more. uttarayana: agneyaagni guna paradhana, ruksha gunayukta, tikta, kashaya and katu rasa pradhana, bala gradually decreases. dakshinayana (visargakala) sun appears to be moving from north to south day by day and movement continuous for 6 months. it is correlated to winter solstice (sun is over the tropic of capricorn). the period during which the rising sun appears on the sky moving from northern end towards south day by day and longer night than day. astrological view, sun enter karkidaka rasi. dakshinayana: soumyaseeta guna pradhana, snegdha guna yukta, amla, lavana and madhura rasa pradhana, bala 4gradually increases. vishuvattu day correlated to 2 equinoxes, it is happening twice in each year. sun enter the thulam rasi is correlated to autumnal equinox (september-october) and sun enter the meda rasi is correlated to spring equinox(march-april) in kerala, makara is consider starting of one year and meda is the middle of thuttarayana and celebrated as vishu. 10 day of meda consider as extract middle of uttarayana. indian season-correlation to modern view meteoro log ica l re levance of ut tarayana and dakshinayana sisira ritu: cold get increased more by the clouds, breeze and rain, dryness is seen also will be seen since it starting of adana kala, low temperature with occasional rainfall. vasantha ritu: wind blows from south, sunrays are coppery in colour, temperature will be rising, and trees are full of fresh buds. greshma: sun rays become extremely hot, all animal suffer from the effect of hot wind and sun and constant sweating. varsha: rainy season, wind blows from west, clouds move slowly making the sky appear dirty, rainbows and thunderstorms are also feature of season. sarath rithu: cloud will be white in colours, sunrays will become sharp because of the clear atmosphere, rise of agasthya nakshatra. pravrit rithu: rainy season, sky will be covered with clouds, wind from west will blow, thunder and little rain. hemantha: atmosphere temperature low, smoky covering of mist, cold breeze inuence of rithu on tridosha greshma (vatha chayam): agravated agnyabhva of environment, h o is laghu quality, katu rasa predominant 2 nature and increased of rooksha, laghu, vidaha quality in body, (kapha prasamana) external environment is rooksha and ushna guna are increase varsha (vata prokopa/pitta chaya): rain and cold winter favors the prakopa of vata, amla rasa predominant, amla vipaka in the body usage leads to pitta increase and reaches pitta chaya but cold atmosphere it will not proceed to prokopa. sarath (pitta prakopa ) : sky become clear and sun shine produce more heat hemantha (pitta prasamana): cold atmosphere, manda quality etc sisira (kapha chaya): cold season with increase kapha vasantha (kapha prakopa): ushna guna increase with frozen 5kapha start to melt inuence of rithu on human body bala or strength: uttarayana kala strength of the people will be maximum and poor in dakshinayana kala. agni: cold season agni concentrate interior of the body. so digestive power will become maximum. in vasantha rithu agni is increased heat in external environment course melt kapha and produce kapha prakopa it may cause decrease digestive power. in greshma and vasantha agni will be least (increased vata). in sarath, agni improve and slowly reaches maximum and continuous at hemanta. 6 rithu charya-maintenance of homeostasis: pre designed plan of food and regimen varies for each season thus prevent disease formation. opposite guna of the season will be neutralize tendency of dosha vitiation. evacuation therapy like emesis, purgation etc are stopped in season ending with early winter, summer and rainy season except in the case of emergency. in emergency therapy should administer carefully after modifying the seasonal effects by articial means. seasonal variation and internal chemical environment: cellular and humeral immunity is reduced in rainy season, volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra ritu season solstice position of the sun vasantha spring spring equinox equator(medium amount of sun rays) greshma summer summer solstice tropic of cancer pravit and varsha monsoon sarath autum autum equinox equator(medium amount of sun rays) hemantha ,sisira winter winter solstice tropic of capricorn(less amount of sun rays) dosha sanchaya (accumulation) prakopa (aggravation) prashamana (pacication) vata grishma varsha sharad pitta varsha sharad hemantha kapha sisira vasantha grishma plasma cortisol is elevated in autumn and constriction of sodium space is more in summer season. effect of climate on human health effect of hot climate on the body: diminution of metabolism is result in loss of weight; diminish respiration result in to reduction of o in blood and digestive power decreased.2 effect of cold climate on the body: increase metabolism, oxygenation of blood, elimination of co and excretion of 2 urine increased and increased body and mental activity. effect of humidity on health: impairing normal function of skin, growth and development of micro-organisms and hinder in perspiration. effect of high altitude on climate: mountain sickness (symptoms are deep breathing, quick pulse, mental fatigue, cyanosis, nausea, head ache, intestinal disturbance & fainting, palpitation, bleeding from nose) effect of increased atmospheric pressure on health: increase absorption of o may cause caisson's disease.2 effect of rainfall on climate: reduce atmospheric pressure and washes the impurities and microbes contained air may 7produce infectious diseases. disease prevalence due to avoidance of rithucharya hemanta and sisira (cold environment): myocardial infraction, different type of paralysis, hyper tension, heart burn, acid regurgitation, arthritis, stiff joint, swollen sinus. same effect and much intensity were seen in sisira. vasantha: digestive system affects (agnimandya due to reduction in secretion of digestive enzyme) kaphaja vyadi and digestive problem. eg-tamaka swasa, pneumonia, rhinitis, common cold, cough, anorexia, dyspepsia, allergic manifestation. greshma: excessive heat outside, heat stroke, hemorrhagic disease, dehydration, acidosis, chickenpox, hepatitis, jaundice and conjunctivitis. varsha: vitiation of tridosha ,alimentary problems are more in varsha ritu, impurity of water may cause water born diseases (diarrhea, bacillary dysentery, viral hepatitis, cholera, typhoid, worm infestations etc,) and varsha rithu enhance breeding of mosquito (malaria, lariasis, dengue fever etc ) sarath rithu: kopa kala of pitta, pittaja vyadhi are more seen 8(burning sensation, viral fever, and inuenza will be noted) previous research works regarding this subject: floris ad et. al (2009) examined the effect of birth season on foetal development and longevity and found that signicantly increased birth weight, gestational age and longevity in individual born during the autumn and winter seasons of the year. these individual also established statistically signicant lower prevalence rates for foetal growth restriction and premature birth. also they observed increased temperature at the time of birth linked with adverse effects on foetal development and longevity. heart failure and cerebrovascular accidents have been correlated many times with ambient monthly temperatures. 9seasonal changes in skin disease were reported in nepal. according to research the metabolic and temperature response to mild cold were investigated in summer and winter in a moderate oceanic climate. the average metabolic responses during cold exposure were signicantly higher in winter as compared to summer. fast changes in temperature are probably may produce a number of physiological changes in the body. rapid drops may affect blood ph, blood pressure, urine volume and tissue permeability. also, platelet counts in healthy subjects were signicantly higher in summer than in winter. hormone secretions are periodic variation release that may be inuenced by seasonal variation; same is observed in the case of liver function and serum uric acid and triglycerides levels. some study suggests that systolic and diastolic blood pressure values differed signicantly across the four seasons and in these seasons, due to moderate cold, heat and rain the season having common character are most convenient and not harmful to body and drugs. conclusion in ayurveda is not only mentioned the preventive aspect but also mentioned how treatment should be given considering seasonal effects. this indicates that acharya was aware about the variations in physiological parameters in various seasons. due to change in global warming, there are marked seasonal variations observed in india and abroad. heavy rainfall with extended monsoon seasons or varies short duration of rainy season with scanty rainfall as described by acharya as atiyoga and hinayoga respectively are observed nowadays. thus the seasonal regimens prescribed by acharya if followed cautiously and strictly will surely prevent many diseases known to be produced due to lack of seasonal homologation. this marks the importance of acharya thoughts which are still applicable and useful for the preventive perspective of ayurveda. references 1. dr. mangalagowri v rao, text book of swasthavritta, chaukhambha orientalia ,varanasi 2. k. park, park’s text book of preventive and social medicine, 25th edition 3. mohit kumar sharma, suresh chandra, a text book of astronomy and astrophysics. 4. vagbhata, ashtanga hridaya,varanasi, chaukhamba orientalia, 9th edition,2005, sutra sthana, chapter 3, 5. dr. bargale sushanth sukumar, dr. shashirekha hk, text book of swasthavritta, chaukhambha publication 6. dr. mangalagowri v rao, text book of swasthavritta, chaukhambha orientalia ,varanasi 7. mahajan and gupta, text book of preventive and social medicine, jaypee 4th edition 8. gn prabhakara, short text book of preventive and social medicine, jaypee 2nd edition 9. floris ad et. al (2009), article. x 33gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction after studying several research works in the �eld of reactive power compensation, the demand for controllable reactive power source has gone up mainly for efficient and reliable operation of ac electric power system . var compensators should be controlled to provide rapid and continuous reactive power supports during static and dynamic power system operating conditions . flexible ac transmission systems (facts) controllers are emerging as an effective alternative to increases or enhance power transfer capability and stability of the network by redistributing the line �ow and regulating the bus voltages. static var compensator (svc) andstatcom are some of the commonly used facts controllers . power system stability is the ability of the system to regain its original operating conditions after a disturbance to the system . power system transient stability analysis is considered with large disturbances like sudden change in load, generation or transmission system con�guration due to fault or switching. it is very important to stable the voltage supply, so that the performance is increases and because of the stability the loss is reduces. statcom a static compensator (statcom) is a device that can provide reactive support to a bus. it consists of voltage sourced converters connected to an energy storage device on one side and to the system on the other. the use of facts (�exible ac transmission system) devices in a power system can potentially overcome limitations of the present mechanically controlled transmission systems. by facilitating bulk power transfers, these interconnected networks help minimize the need to enlarge power plants and enable neighboring utilities and regions to exchange. the stature of facts devices within the bulk power system will continually increase as the industry moves toward more competitive posture . fig :gto inverter the use of facts (�exible ac transmission system) devices in a power system can potentially overcome limitations of the present mechanically controlled transmission systems. by facilitating bulk power transfers, these interconnected networks help minimize the need to enlarge power plants and enable neighboring utilities and regions to exchange power. the stature of facts devices within the bulk power system will continually increase as the industry moves toward a more competitive posture in which power is bought and sold as a commodity. as power wheeling becomes increasingly prevalent, power electronic devices will be utilized more frequently to insure system reliability and stability and to increase maximum power transmission along various transmission corridors. static synchronous compensator, or statcom, is a shunt connected facts device. it generates a balanced set of three phase sinusoidal voltages at the fundamental frequency, with rapidly controllable amplitude and phase angle. this type of controller can be implemented using various topologies. how-ever, the voltagesourced inverter, using gto thyristor in appropriate multi-phase circuit con�gurations, is presently considered the most practical for high power utility applications. fuzzy logic fuzzy logic system is the process of formulating the mapping from a given input to an output using fuzzy logic. the mapping then provides a basis from which decisions can be made, or patterns discerned. in recent years, fuzzy system application has received increased attention in various areas such as automatic control, data classi�cation, decision analysis, expert systems, and computer vision. because of its multidisciplinary nature, fuzzy inference systems are associated with a number of names, such as fuzzy-rulebased systems, fuzzy expert systems, fuzzy modeling, fuzzy associative memory, fuzzy logic controllers, and simply (and ambiguously) fuzzy systems. in conventional controller, the system or process to be controlled, where as in a fuzzy logic controller the focus is on human operator's behavior and hand on experience. first, the system is modeled analytically by a set of differential equations from which control parameters are adjusted to satisfy controller speci�cation. membership function the only condition a membership function must really satisfy is that it must vary between 0 and 1. the function itself can be an arbitrary curve whose shape we can de�ne as a function that suits us from the point of view of simplicity, convenience, speed, and efficiency .the toolbox includes 11 built-in membership function types. these 11 functions are, in turn, built from several basic functions: • piece-wise linear functions • the gaussian distribution function • the sigmoid curve • quadratic and cubic polynomial curves for detailed information on any of the membership functions mentioned next, see the corresponding reference page. by convention, all membership functions have the letters mf at the end of their names.the simplest membership functions are formed using straight lines. of these, the simplest is the triangular membership function, and it has the function name trimf. this function is nothing more than a collection of three points forming a triangle. the trapezoidal membership function, trapmf, has a �at top and really is just a truncated triangle curve. these straight line membership functions have the advantage of simplicity. reactive power compensation using fuzzy logic technique original research paper k. veeraragavan ap/eee ifet college of engineering engineering in this paper we proposes an automated solution based on fuzzy controller to statcom in which all the decisions are based on the actual data points such as load, voltage levels and current in the systems. additionally the proposed solutions helps maintain voltage levels, control voltage �uctuations, improve power factor and minimize human intervention resulting in the improved and efficient system. we also provide the result analysis. abstract keywords : fuzzy controller , membership function. p. balapriyan* ap/eee ifet college of engineering *corresponding author 54 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 two membership functions are built on the gaussian distribution curve: a simple gaussian curve and a two-sided composite of two different gaussian curves. the two functions are gaussmf and gauss2mf. the generalized bell membership function is speci�ed by three parameters and has the function name gbellmf. the bell membership function has one more parameter than the gaussian membership function, so it can approach a non-fuzzy set if the free parameter is tuned. because of their smoothness and concise notation, gaussian and bell membership functions are popular methods for specifying fuzzy sets. both of these curves have the advantage of being smooth and nonzero at all points. although the gaussian membership functions and bell membership functions achieve smoothness, they are unable to specify asymmetric membership functions, which are important in certain applications. next, you de�ne the sigmoidal membership function, which is either open left or right. asymmetric and closed (i.e. not open to the left or right) membership functions can be synthesized using two sigmoidal functions, so in addition to the basic sigmf, you also have the difference between two sigmoidal functions, dsigmf, and the product of two sigmoidal functions psigmf. polynomial based curves account for several of the membership functions in the toolbox. three related membership functions are the z, s, andpi curves, all named because of their shape. the function zmf is the asymmetrical polynomial curve open to the left, smf is the mirror-image function that opens to the right, and pimf is zero on both extremes with a rise in the middle. there is a very wide selection to choose from when you're selecting a membership function. you can also create your own membership functions with the toolbox. however, if a list based on expanded membership functions seems too complicated, just remember that you could probably get along very well with just one or two types of membership functions, for example the triangle and trapezoid functions. the selection is wide for those who want to explore the possibilities, but expansive membership functions are not necessary for good fuzzy inference systems. finally, remember that more details are available on all these functions in the reference section. in fuzzy logic controller, these adjustments are handled by a fuzzy rule based expert system developed on the knowledge gained by the human process operator. after choosing proper variable as input and output of the fuzzy controller, it is required to decide on the linguistic variables. these variables transform the numerical value of the input of the fuzzy controller, to fuzzy quantities. the number of this linguistic variable speci�es the quality of the control which can be achieved by using the fuzzy logic controller. as the number of linguistic variable increases computational time increases but the quality of the controller improves. therefore, a compromise between the quality of control and computational time is needed to choose the number of linguistic variable. fuzzy rules human beings make descisions based on rules. although, we may not be aware of it, all the descisions we make are all based on computer like if-then statements. if the weather is �ne, then we may decide to go out. if the forecast says the weather will be bad today, but �ne tommorow, then we make a descision not to go today, and postpone it till tommorow. rules associate ideas and relate one event to another.fuzzy machines, which always tend to mimic the behaviour of man, work the same way. fig :real power references 1. s.y. lee, c.j. wu, w.n. chang: a compact control algorithm for reactive power compensationa statcom under various faults in power system”, international journal of advanced computer research (ijacr), volume-2number-4 issue-6 december-2012. 2. n.karpagam, d.devaraj, “fuzzy logic controlof static var compensator for power system damping”, international journal of electrical and electronics engineering,2009. 3. karuppanan pand kamalakant a mahapatra, “pi, pid and fuzzy logic controller for reactive power and harmonic compensation”, aceeei nt. j. on electrical and power engineering, vol.01, no. 03, dec2010. x 55gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 introduction ultrasonography is essential investigation in obstetric management. apart from assessment of fetal anomalies, it has a key role in assessment of placental anomalies, fetal circulation and fetal growth parameters. it has an important role in detection of intrauterine growth restriction (iugr) pregnancies (1). iugr is a common diagnosis in obstetrics and carries an increased risk of perinatal morbidity and mortality. identication of iugr is crucial because proper evaluation and management can result in a favourable outcome. ultrasound biometry is the gold standard for assessment of fetal growth parameters and identication of iugr. placenta is a fetal organ of pregnancy, which provides oxygen and nutrition to the growing fetus and carries out excretory functions as well. ultrasound is the rst line modality in imaging the placenta. donald introduced placental localization by ultrasound in 1965 (2). apart from site localization, measured placental thickness can be used as a gestational age indicator due to a linear increase in its thickness with advancing gestational age (3,4). with this background, we planned to conduct a study, where we measured placental thickness in pregnant women, who were sure of their last menstrual period (lmp) and assessed the relationship of placental thickness with gestational age by lmp and compared these ndings in normal and iugr pregnancies to nd whether any signicant difference is present between these two groups. material and methods after getting approval from institutional ethical committee of g.s.v.m. medical college, kanpur, uttar pradesh, india; this prospective cross sectional study was conducted in the department of radiodiagnosis in collaboration with the department of obstetrics and gynaecology of same institute between august 2016 to july 2017. all pregnant women who thwere sure of their lmp coming for antenatal usg between 18 thto 40 weeks of gestation were enrolled. usg was performed using a sonoace x8 system with 2-5mhz convex array transducer. placental thickness at cord insertion site was measured keeping the plane of transducer perpendicular to the placental basal and chorionic plates. we excluded women with gestational diabetes mellitus, multiple pregnancies, polyhydromnios, diagnosed cases of fetal hydrops and pregnancies with any morphological variation in placenta or cord insertion. women with poor visualization of cord insertion site were also excluded. variables like maternal age, previous obstetric history, body mass index, placental position, hemoglobin level and blood pressure were also recorded. study participants were categorized into two groups i.e. group a (iugr pregnancy) and group b (normal pregnancy) based on outcome newborn weight of <2500 grams and ≥2500 grams respectively. data were recorded in microsoft excel sheet and was analysed using spss software. mean placental thickness (mpt) with standard deviation (sd) were computed for each gestational age in both groups. the correlation and regression coefcient were calculated to quantify the relationship between the gestational age (weeks) and placental thickness (mm) in both groups. p value <0.05 was considered signicant. unpaired't'-test was applied to compare the difference between the means of the two groups at each gestational age. results total 627 pregnant women, who were sure of their lmp, were enrolled. out of which 445 participants completed this study and 182 were lost to follow-up. among 445 participants, 147 were included in group a and 298 study participants in group b. maximum study participants were observed in age group 21-25 years. (figure 1) placental thickness measurement by ultrasonography and it's correlation with gestational age in normal and intrauterine growth retarded pregnancy original research paper ashok kumar verma md, department of radiodiagnosis; gsvm medical college, kanpur; up, india radiodiagnosis backgroundultrasonography is modality of choice for fetal evaluation, estimation of gestational age and detection of fetal growth restriction in pregnancies. objectivethis study was conducted with the aim of evaluating placental thickness, its role in estimation of gestational age of the fetus and in predicting normal and fetal growth restriction as outcome. methodsth thusing ultrasonography placental thickness was measured at cord insertion site from 18 to 40 weeks of gestation. study participants were categorized as normal and intra uterine growth restriction based on birth weight of newborns. correlation of placental thickness with gestational age was calculated and compared in both groups to nd any signicant difference. resultsa positive correlation was observed between placental thickness and gestational age in both groups. pearson's correlation coefcient (r) was calculated for both groups. it was 0.3221 and 0.7450 in intra uterine growth restriction and normal ndgroup respectively. in normal group placental thickness (mm) corresponds to gestational age (weeks) upto 32 weeks. after th th th ththat mean placental thickness remains nearly stationary upto 40 weeks with average thickness 31 mm. in 18 , 19 and 26 weeks of gestation, placental thickness was more in iugr group (22.5±4.2 ,28.1±5.2 and 31±5.5) as compared to normal group (18.7±1.6, 19.6±1.9 and 26±3.1). conclusionmeasured placental thickness at the umbilical cord insertion site can be used as an early sonographic parameter in detection of intrauterine growth restriction in singleton normal pregnancies. abstract keywords : ultrasonography, placental thickness, gestational age, intrauterine growth restriction. rajlakshmi yadav* md, department of radiodiagnosis; gsvm medical college, kanpur; up, india*corresponding author rahul chavhan md, department of radiodiagnosis; gsvm medical college, kanpur; up, india volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 90 x gjra global journal for research analysis total 445 measurements were taken. minimum number of measurements recorded (at any single gestational week) was 1 and 4 and maximum were 15 and 28 in group a and group b respectively. (figure 2) mpt was calculated for each gestational week in both groups. (table 1) a positive correlation was observed between mpt and gestational age in both groups. pearson's correlation coefcients (r) were 0.3221 and 0.7450 in group a and group b respectively; showing more strength of correlation in group b. mean placental thickness in different gestational age shows linear relation in both groups. (figure 3) thin group a, mpt is higher than gestational age till 29 weeks of st th thgestation excluding 21 , 28 and 34 week, where it thcorresponds to the gestational age. beyond 29 week, mpt is thlower than the gestational age till 40 week. however, in group b, placental thickness corresponds to gestational age up to nd th32 week. after that it remains nearly stationary till 40 week with average thickness of 31 mm. regression analysis yielded a linear equation of relationship between placental thickness in mm (x) and gestational age in weeks (y) for both groups: group a→ y=22.1068+0.2692x group b→ y=6.062+0.7947x minimal placental thickness measured in group a and group thb were 17 mm and 16 mm respectively at 18 weeks of gestation; while maximum thickness measured was 49mm thand 44mm at 36 gestational weeks. th th thmean placental thickness at 18 , 19 and 26 weeks is signicantly more in group a (22.5±4.2 ,28.1±5.2 and 31±5.5) as compared to group b (18.7±1.6, 19.6±1.9 and 26±3.1) with 'p' value <0.05. an increased placental thickness in these gestational weeks can suggest abnormal fetal outcome. in the total 445 study participants range of haemoglobin distribution was 4.3gm% to 12.7gm%. haemoglobin range of 9 10gm%is seen in maximum number of cases (35.9%) and range 12-13gm% in minimum number of cases (1.3%). (table 2) discussion from previous studies it has been seen that placental size increases linearly with advancing gestational age. any abnormaly thin or thick placenta may be an indicator of abnormal fetal outcome or any pathological condition. elsa et alreported that placental thickness less than 25 mm in third trimester is subnormal and may be associated with intrauterine growth retardation and placental thickness more than 40 in third trimester is abnormally thick and may represent pathological condition like maternal diabetes mellitus, fetal hydrops, intra uterine infections (5). our study showed a linear relation between placental thickness and gestational age (by lmp) in both normal and th thiugr cases from 18 week to 40 week. in group b, placental thickness (mm) is almost corresponding with gestational age th nd(weeks) from 18 to 32 week, after that placental thickness slightly decreases and remains nearly constant with average thplacental thickness of 31mm till 40 week. maximum mpt in th normal group was 33mm at 36 week. hoddick et al found average placental thickness was increasing with advancing menstrual age (6). mital p and hooja n also found an increasing mpt with advancing gestational age and between nd th22 to 35 week of gestation, the placental thickness coincide almost exactly with the gestational age (weeks) (2,7). anupama jain et al reported similar correlations between placental thickness and gestational age (8). they found placental thickness (mm) almost matched gestational age th rd (weeks) from 27 to 33 weeks of gestation. grannum et al reported that placental thickness would increase linearly until rd33 weeks of pregnancy, after which there was gradual thinning (9). berkowitz et al reported gradual decrease in placental size after 32 weeks until term (10). in group b, we nd stronger linear relation between placental thickness and gestational age. however in group a, placental stthickness does not coincides with gestational age except in 21 , th th28 and 34 gestational weeks. more diverse value of placental thickness was seen in iugr cases as compared to normal cases indicating that thin or thick both type of placenta are associated with intrauterine growth retardation. statistically signicant difference in the mpt of iugr and normal group was seen only th th thin 18 , 19 and 26 gestational weeks, with mean values more in iugr as compared to normal group (22.5±4.2, 28.1±5.2 and 31±5.5 vs 18.7±1.6, 19.6±1.9 and 26±3) suggesting earliest identication of iugr pregnancy is possible by antenatal usg in these gestational weeks. cross sectional prospective study of correlation between placental thickness and gestational age is done in both normal and iugr group by mathai et alin india (1). they also found positive correlation between placental thickness and ultrasonographic gestational age in both normal and iugr groups. in their study statistically signicant difference in the th thmpt in both groups were seen in 26 and 30 ultrasonographic gestational weeks with mpt lower in iugr group as compared to normal group. conclusion antenatal ultrasonographic measurement of placental thickness at cord insertion site would help in predicting outcome (normal/iugr) of the pegnancy. therefore, abnormal placental thickness in a particular gestational age can be used as an addition tool in early detection of iugr in singleton pregnancy. acknowledgments the authors acknowledge the support of ashok kumar verma for his valuable guidance in designing this study; shyam madheshiya, deepak thangraj, ravindra pandey and nachiket mangaraj in enrolling study participants for this study. we also acknowledge the support of study particpants who came forward to be a part of this study. table 2. distribution of haemoglobin concentration in both groups iugr¶intra uterine growth retarded volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra haemoglobin (gram%) group a (iugr¶) group b (normal) number of cases 4-5 10 0 10 5-6 8 1 9 6-7 14 5 19 7-8 33 39 72 8-9 42 78 120 9-10 29 131 160 10-11 6 30 36 11-12 3 10 13 12-13 2 4 6 total no. of cases 147 298 445 table 1. relationship between gestational age and placental thickness in both groups ga* (weeks) group a (iugr¶) group b (normal) p-value placental thickness (mean±sd) n** placental thickness (mean±sd) n** 18-18.6 22.5±4.2 4 18.7±1.6 28 <0.05 19-19.6 28.1±5.2 6 19.6±1.9 15 <0.05 x 91gjra global journal for research analysis figure-1 maternal age distribution figure-2 number of cases at different gestational age figure-3. mean placental thickness in different gestational age references1. mathai bm, singla sc, nittala pp, chakravarti rj, toppo jn. placental thickness: its correlation with ultrasonographic gestational age in normal and intrauterine growth-retarded pregnancies in the late second and third trimester. j obstet gynaecol india. 2013 aug;63(4):230-3. 2. donald i. on launching a new diagnostic science. am j obstet gynecol 1968;103:609-28. 3. mital p, hooja n, mehndiratta k. placental thickness a sonographic parameter for estimating gestational age of the fetus. ind j radiol imag 2002;12:553-4. 4. jain a, kumar g, agarwal u, kharakwal s. placental thickness a sonographic indicator of gestational age. j obstet gynaecol india 2001;51:48-9. 5. elsa aa, magdoleinsa, carolineea, abdelmoneimsa. prediction of fetal growth by measuring the placental thickness using ultrasonography. journal of gynecology and obstetrics. 2014; 2(2): 26-31. 6. hoddick wk, mahoney bs, callen fw, filly ra. placental thickness. j ultrasound med. 1985; 4: 479-482. 7. mital p, hooja n, mehndiratta. placental thickness – a sonographic parameter for estimating gestational age of the fetus. ind j radiol imag. 2002; 12( 4): 553554. 8. anupama jain, ganesh kumar, agarwal u, kharakwal s. placental thickness – a sonographic indicator of gestational age. journal of obstetrics and gynaecology of india. 2001; 51(3): 48-49. 9. granum pat, hobbins jc. the placenta. radiol clin north am. 1982; 20: 353. 10. granum pat, berkowitz rl, hobbins jc. the ultrasonic changes in the maturing placenta and their relation to fetal pulmonic maturity. am j obstet gynecol. 1979; 133: 915-922. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 20-20.6 23.4±5.2 5 20.6±2.8 19 >0.05 21-21.6 22±1 3 21.6±2.7 12 >0.05 22-22.6 25±0 1 23.1±6.1 11 23-23.6 29±0 1 23.8±2.6 16 24-24.6 27±0 1 25±1.9 13 25-25.6 27±4.8 4 25.5±3 10 >0.05 26-26.6 31±5.5 15 26±3.1 12 <0.05 27-27.6 30.2±5.2 8 27±2.1 11 >0.05 28-28.6 28.5±4 9 28.1±3.3 11 >0.05 29-29.6 31±5.3 10 28.5±2.5 6 >0.05 30-30.6 28.2±3.8 4 29.1±2.7 16 >0.05 31-31.6 27.4±5.4 5 30.7±3.3 16 >0.05 32-32.6 30.4±9.7 9 32±5.4 25 >0.05 33-33.6 28.3±3.9 5 30.9 ±5.8 15 >0.05 34-34.6 34.1±8.5 15 31.8±2.9 16 >0.05 35-35.6 30.6±7.5 9 31.2±4.8 16 >0.05 36-36.6 32.4±7.2 13 33±5.1 14 >0.05 37-37.6 33.6±8.5 11 29.8±5 8 >0.05 38-38.6 33±9.2 4 31.5±3.7 4 >0.05 39-40 28.8±6.7 5 30.5±7 4 >0.05 total 147 298 92 x gjra global journal for research analysis introduction: crs is a rare congenital anomaly characterized by distal vertebral malformations, usually co-existing with spinal cord malformations, neurological decit in lower limb & neurogenic bladder. the incidence is 1 in 40,000-60,000 live births. the syndrome occurs more frequently in offsprings of diabetic than 1 nondiabetic mothers .the incidence is about 1 in 350 infants of diabetic mothers which is about 200fold increase in diabetic 2patients than in general population . crs may range from absent coccyx as an isolated nding without neurological sequelae, to sacral or lumbosacral 2agenesis . it can affect the lower extremities, the lumbar and coccygeal vertebrae and corresponding segment of the spinal cord. the neurological orthopedic, gastrointestinal, genitourinary and cardiac anomalies,imperforate anus malformed genitalia and renal dysplasia/aplasia and 3congenital heart defects are commonly seen . case report: a 5yrs 8months old girl, the only child of non-consanguinous healthy parents. according to the mother's report, she had gestational diabetics and tiffa scan was not done. antenatal usg's were done and were told normal to parents. the child was delivered preterm with 1kg birth weight. postnatal examination showed hypoplastic lower limb with abducted hips with hypoplastic gluteal muscles. fig 1a: showing picture of baby with caudal regression syndrome fig 1b :showing polydactyly x-ray &mri of the lumbosacral region suggests of crs/sacral agenesis. neuro sonogram was normal; also had b/l contractures of knee with right femur fracture. fig 2: showing x-ray of baby with caudal regression syndrome usg abdomen revealed right pelvic kidney with b/l mild hydro uretro nephrosis, tft's normal, and all other routine blood investigations were normal. at the age of 4yrs,due to acute pyelonephritis, the child was taken to higher center and evaluated. usg abdomen suggestive of right pelvic kidney,b/l hydrouretronephrosis, trabeculations & diverticular & post-void residue in urinary bladder indicative of neurogenic bladder.mcug was done suggestive of neurogenic bladder with b/l vur. fig 3: showing micturating cystourethrogram routine blood investigations were done, and renal function tests were slightly above the baseline. caudal regression syndrome-a case report original research paper vineela dantuluri postgraduate resident,department of paediatrics,konaseema institute of medical sciences and research foundation,amalapuram,e.g.dist,ap. x 35gjra global journal for research analysis paediatrics background: caudal regression syndrome(crs) is a spectrum of congenital malformation which consists of anomalies of the rectum ,genitourinary system,lumbosacral spine and the lower limbs. case characteristics: a 5yrs 8months female child with sacral agenesis,hypoplasia of lower limb with neurogenic bladder with chronic kidney disease(ckd). observation: crs usually present with variety of other associated anomalies.therefore thorough examination should be done to rule out other anomalies message: proper diagnosis helps in therapeutic and may improve the outcome. cic helps in prevention or delay in occurrence of ckd. abstract keywords : caudal regression syndrome, chronic kidney disease, continous intermittent catheterization. surya laxmi devi matta* postgraduate resident, department of paediatrics,konaseema institute of medical sciences and research foundation ,amalapuram, e.g.dist,ap. *corresponding author ramesh t.v professor &head of the department, department of paediatrics, konaseema institute of medical sciences and research foundation ,amalapuram, e.g.dist,ap. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 36 x gjra global journal for research analysis antibacterial prophylaxis with cexime was started, and cic was taught to the parents and was advised to do it regularly. but the child had lost to follow up for the next two years and at the age of 5yrs 8months she was referred to our hospital because of deterioration of renal function. usg abdomen and pelvis showed progression of b/l hydronephrosis and dilatation of ureters. treatment: thorough disease history taken from his mother revealed selfdiscontinuation of therapy at least 1 ½ years ago. therefore therapy was restarted and diagnosis of crs with ckd with anemia with neurogenic bladder was made. the child was kept on i.v antibiotics and nephrologist and urologist consultation was taken, and inj ceftriaxone, inj sodium bicarbonate,inj erythropoietin 2000iu s.c every weekly and tab amlodipine and continuous bladder drainage were advised. currently, the girl is under ambulatory nephrological care and her ckd is stable. discussion: crs is a result of neural tube defects that appear at an early embryonic stage. its etiopathogenesis is still unclear. several etiological factors were suggested including genetic predisposition vascular hypoperfusion vitamin a intoxication exposure to organic fat solvents, radiation, use of lithium salts, 4amphetamine or alcohol . the incidence of crs is 1,3,4signicantly higher in children of diabetic mothers . in some patients with crs, specic musculoskeletal manifestations may be observed including shortening of lower limbs due to lack of their growth, exed and abducted hips, exion contractures of hips, knees and pelvic deformity. in those patients, crs may be suspected prenatally during routine usg examination, but it should be emphasized that the nal diagnosis can be made exclusively by performing mri of the lumbosacral spinal cord. in the majority of the patients with crs, different forms of lower urinary tract neurogenic dysfunctions were observed including neurogenic bladder, lack of voluntary sphincter control. some of them cannot be recognized before toilet training. patients who are suffering from crs seem to represent the population at high risk of ckd development so that urological and nephrological examinations, including a urodynamic study are necessary for all children with crs for identifying urinary system disorders. ckd may be prevented or delayed in patients with crs by the adequate treatment that usually includes anticholinergic agents, alpha-adrenergic antagonists, antibacterial 1,5prophylaxis and cic . the course of the disease in our patient showed importance of such therapy. its discontinuation leads to a progression of b/l hydro uretronephrosis and signicant lowering of egfr. in conclusion, there is no doubt that proper diagnosis helps in therapeutic decisions and may improve the outcome. references: 1. zaw w stone dg, caudal regression syndrome in twin pregnancy with type 2 diabetes, j perinatal2002,22:171-174. 2. becerra je, khoury mj, codero jf, erickson jd, diabetes mellitus during pregnancy and risk of specic birth defects, a population-based case-control study,pediatrics 1990 85:1-9 3. singh sk, singh rd, sharma, caudal regression syndrome-case report and review of literature. pediatric surgery. int2005;21:578-581. 4. s.b.bauer ;neurogenic bladder:etiology and assessment paediatric nephrology,23(2008), p.p-541-551. 5. p. gehlot.j.mandliya; caudal regression syndrome. int j basic appl med sci, 1(2011), pp 126-130. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: the national family health survey is a large-scale, multi-round survey conducted in a representative sample of households throughout india. all national family welfare surveys have been conducted under the stewardship of the ministry of health and family welfare, government of india, with the international institute for population sciences, mumbai, serving as the nodal agency. the institute is expected to collaborate with eld organizations to conduct the survey. icf international (formerly macro international), maryland, usa, provides technical assistance for all four surveys conducted as on date. critical appraisal the survey is not an easy job. such large-scale surveys often face challenges in data collection, in terms of several nonsampling errors arising due to shifting of age and year of birth across the reference boundaries, interviewers' characteristics, interviewers' fatigue, length of the survey instruments, time taken to complete interviews, number of sensitive questions, presence of others at the time of interview, involvement of large number of survey organization with varied capacities etc. it is important that a scientic approach is adopted to understand and measure the possible errors and appropriate lessons are learned. so, the critical appraisal of data quality is important to improve the same. this article is based on the experience of nfhs-4. all the information was collected from the eld experience when one of the authors worked as a project ofcer in tamil nadu state. training programme: in 2015 nfhs-4 survey started in tamil nadu. 300 interviewers (male and female) participated in the survey. the training was conducted in dindigul. the interviewers were from different disciplines, like pure science, engineering, different social sciences, but very few candidates came from demography eld. the training place was arranged by the field agency (fa) in a marriage hall. the hall was near bus stand, market street. the interviewers were accommodated in the same marriage hall where space was not sufcient for all. interviewers were absent most of the time during the training period as they were frequently suffering from health problems like fever, diarrhoea because of the unhygienic place. the place was not suitable for training. time to time disturbances occurred in the buildings so the training place (hall) was frequently changed within the building. different type of methods was followed to give training like lecture, lcd projection, participatory, question session, practical session, mock interview, practical session, recollection and conducting the test. ice break session was not conducted. there was no entertainment for trainees. they were not given enough time to take the session. the fa was careful to keep costs low. mismatch of the respondent's name, address and age in the main survey in terms of several non-sampling errors arose due to the shifting of age and year of birth across the reference boundaries in mapping. mapping was poor; some structure was not in the correct segment but in a different segment on mapping. interviewers: most of the interviewers were struggling to understand the terminology of the survey questionnaire. during the survey, the interviewers used english words which the rural people were unable to understand. for example, some of the medical terms (like female sterilization/ contraceptive etc.) used by the field investigators in english was not clear by the respondents hence, they were unable to give a proper answer to them. there was no safety for the female interviewers in the training place. a large number of girls were staying at a very big dormitory and nobody was taking care of them. a brothel lady was mingling with the girls without any restrictions. food quality and quantity were poor. there was no identity cards with them overall eld investigators did not probe well and they missed some important questions because of the language problem. some translation from english to tamil was bad in computer assisted personal interview (capi). the male interviewer was hesitating to probe regarding hiv session and sexual behaviour related questionnaire. some people had poor handling skill in capi. field investigators' (fi) rapport was not good, as they could not understand the local language. fi's understanding was poor as they enquired about unnecessary questions again and again, and the respondents got irritated hence, more time was wasted. fi was hesitant to ask about contraceptive methods and sexual orientation but some of them were more open. on the state's front, people were speaking the mixed language, and fi got confused and could not explain the subject to the respondents. most of the women were hesitant to explain about their sexually transmitted infection (sti)/reproductive tract infections (rti) problems with the unmarried girls. (e.g) vellore, kanyakumari, krishnagiri, mahe. health investigator (hi) did not follow the protocol to measure blood pressure (bp). (e.g) in nfhs-4 hi the measurement instrument should be kept in her/his hand at the heart level when measuring bp, but the device was not placed at heart level. hemoglobinometer (hb) meter closed very fast, microcuvette could not check for bubbles, microcuvette container expiry date was not mentioned. critical appraisal to improve the data quality in the national family health survey original research paper dr. k.tamilselvi srineduncheri (po) kattumannarkoil (tk) cuddalore (dt), tamil nadu-608 7 03 x 35gjra global journal for research analysis management national family health survey is one of the pillars of health planning and policy-making in the country. these surveys primarily serve to provide essential data on health to nation. however, the critical appraisal of data quality is important to improve the same. this article is based on the experience of national family health survey (nfhs)4 that includes assessing eld agency, interviewers, etc. and suggests improving the quality of data. abstract keywords : dr. vani archana* senior research fellow (icssr) iitm, chennai*corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 36 x gjra global journal for research analysis the survey team did not follow proper disposal of biohazards waste as per the protocol. they did not hand over to the health centre (phc/gh) to burn the biohazards. hi could not handle weighing machine properly. the supervisor in monitoring the cab process with lack of supervisor's training and knowledge about the clinical anthropometric biochemical (cab) caused difculties in monitoring the cab process. some supervisors forget to ll the biomarker questionnaire cover page and were not playing their role properly. some supervisors misbehaved with the investigator, particularly female investigators. some of them misused their power without understanding their responsibility. hence, some qualied interviewers had to leave the survey. field agency mapping listing was poor. fa tried to complete the survey in haste. fa staffs were more ignorant regarding national level health survey. they did not understand the value and importance of the data, and their eld experience was also very poor. moreover, they could not understand the local language, this drawback created more problems between fi and fa. they acted inhumanely. (e.g) in nfhs-4 the fi waiting for food with an empty stomach but the coordinator was eating in front of them. field agency (fa) failed to provide the required vehicle to each team separately. cab materials, health card, referrals forms of anemia, blood glucose, blood pressure, and ictc for main survey eld work were not adequately provided to investigators. supervisor provide, iodine test kit, sample of ors powder, ifa/syrup, iron, vitamin a tablet, coulometer battery, list of social service organizations, list giving hindu/muslim months for age calculation etc. were not provided adequately. insufcient space for storage of the cab materials and usb card/data card for internet usage was also inadequate. during the survey the supervisor, met with many problems like accommodation, moving from one place to another. (e.g) the survey was not getting permission from local ofcials, like district, block and rural was not easily provided for the survey'. within the town, the vehicle used for the survey team was stopped by a policeman who asked many questions with the supervisor about the sticker on the van (sticker named “on duty govt”), the supervisor explained the policeman but he was not convinced and told that 'no information came to my station and without proper information you cannot move in the town'. finally, the supervisor personally contacted with their senior and then the problems were solved. fa was not properly recruiting the field investigator, the selection was not based on their educational qualication and eld experience. not even sufcient and good food was provided to investigators. supervisors were not allowed to use their mobiles. team composition (one supervisor, one male investigator, three female investigators and two for cab) was not according to the protocol. fas coordinators were not visiting the primary sampling unit, did not discuss the eld issues, no surprise visits. fa was not rechecking the fi data, did not monitor the cab activity. delayed in it persons' service which further delayed the completion of the primary sampling unit.(e.g) nfhs-4, in any (psu), when there was a failure in fis' capi, the it person came late. fa and other partners never met to discuss eld situation during the main survey. (e.g) international institute for population sciences (iips), icf, ministry of health and family welfare (mohfw). interviewers faced the problems: the language was the main problems for them, the fa coordinators were not domicile of the state and no staff were there who could speak the regional language tamil. after the start of the survey, researchers were either not paid or paid less than mandatory minimum wages and had to work in unsafe conditions. they were not allowed holidays and were issued letters saying that if they leave their work midway, they were not entitled to any payment. most of the interviewers were hungry when the author visited the team because of the delay of da. field agencies often violated labour laws with regard to payment, accommodation, travel and insurance. the agency violated several labour norms. researchers were not paid during their four-week training and were made to wait another month and a half without any emoluments before the survey was initiated. suggestions to improve the quality of data: the biggest shortcoming was an insufcient number of poorly trained and poorly paid eld agents to collect data who received very little logistical support and work under harsh conditions. this adversely affected the quality of the data collected as the design of the survey was made by untrained eld agents. to avoid such problems, the study proposes the followings. to field agency: ÿ involve the government institution as fa like national institute of rural development (nird), state institute of rural development (sird), population research centre, and universities. ÿ the trainer should be demographer, as the demographer role is important during the training period to complete the survey. ÿ should be given honorarium without delay as well as vehicle and other facilities to the demographer. ÿ field agency (fa) should get proper cooperation from the state, district and local authorities, and authenticate the permission through ofcial emails. ÿ prepare the permission letter both in english and local language to get permission easily from the state, district and local bodies to conduct the survey. ÿ recruitment should be done in the proper manner, like give add in newspapers; local channels etc, the interviewer should be a postgraduate. also, preference should be given to the research scholars with the background of population studies and social science students. ÿ should assure the interviewers safety, should give id card, incentives, mobile, diesel, allowance, food accommodation, without delay. ÿ fa should appoint qualied and a sufcient number of the coordinators to help and monitor the survey team. if the coordinator will be research scholars it will improve the survey quality. ÿ should give referral card to the respondents. ÿ field agency should ensure the safety of women investigator. ÿ field agency coordinator when visiting the team should discuss with the survey team about their accommodation, food, ta, da, incentives, health conditions etc. should be given refreshment to the interviewer in the eld. ÿ should monitor during mapping listing to avoid variations of non-sample error. to nodal agency: ÿ should appoint their eld survey team project ofcer (po) and senior project ofcer (spo) with the background of demographic/population studies for the eld candidates. ÿ nodal agency's field survey team (po, spo) should closely monitor the field agency. this may affect the volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra quality of the survey. ÿ the nodal agency referee should re-interview at least once in a week. ÿ the nodal agency po, spo when going for the eld visit, should approach the field investigator carefully and covertly and speak appropriately to avoid abuse of power. they need to act in a fair and reasonable manner, without any possibility of hatred and reprimanding the eld investigators with understanding. (e.g) some po misbehaved with the interviewers and supervisors during the nfhs-4 survey, this caused the qualied supervisor and interviewers to leave the survey. ÿ the po, spo should avoid blaming the colleague, misinterpreting the colleague, as well as the nodal agency should analyze their (po, spo) statement before taking any action against. ÿ the nodal agency should arrange the place for the trainers (po, spo) at the institute. if it is not possible, they should arrange training elsewhere or other institutions. (e.g) staying is a problem in iips during the training period. ÿ on the states frontier level, involve the native district persons as field investigator, it will avoid language problems. others: cab and supervisors' oral and written exam questions were not in the local language. after completion of the training, they conducted the exam. the test question paper was in the english language. but the training was in the tamil language. the interviewer were confused and could not understand the test questions properly. in addition, add some topic in the questionnaire to improve the uses of data. for e.g., in household questionnaire add about the agricultural system, type of fertilizer, plastic usage, disposal of their wastage from home. conclusion: nfhs data .is important to all' with 'the main objective of the nfhs has been to provide essential data on health and family welfare and other related issues in india. nfhs data are useful in research and policy-making particularly in health planning of the country. hence, controlling the quality of data collection is the most important task of the survey. the shortcomings of the survey should be explored without any bias. interest of the interviewer is a must while collecting data. field agency should keep in mind that the survey is not a job but his services to the nation. a huge amount is spent to collect the health information, if the workers are not interested in their work, the time, energy, money all will be wasted. x 37gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction epistaxis , bacteremia, mucosal tears, sinusitis, turbinate avulsion, perforation of pyriform fossa etc are some of the complications following nasotracheal intubation. we report a case of previously undetected nasal spur leading to endotracheal tube cuff tear which adjoined to the difcult airway senario in a patient with temporomandibular joint ankylosis. case report an 18 year old patient with temporo-mandibular joint ankylosis was posted for gap arthroplasty. airway assessment revealed decreased mouth opening of 1 cm measured incisor to incisor and right nostril patency more than the left. successful placement of breoptic guided nasotracheal tube was done via the right nostril but ination of the endotracheal cuff failed. suspecting a defect in the cuff, endotracheal tube was exchanged with another using cook's airway exchange catheter. astonishingly, cuff ination failed yet again. suspecting some pathology along the nasal passage , breoptic nasal intubation was done through left nostril with successful cuff ination. intra operative period was uneventful and nasal endoscopy was done prior to extubation which revealed a sharp spur in the right nostril. discussion the cuff of the endotracheal tube can be damaged due to multiple reasons during its passage through the nasal cavity with deviated nasal septum or any abnormal bony structure . nasal endoscopy/ breoptic bronchoscopy may reveal such pathologies in airway anatomy but our institutional practice of using a split nasal airway led us to miss the nasal spur. the extent of the nasal examination is debatable especially if the bilateral nasal cavities are patent. conclusion endotracheal tube cuff tear by a nasal spur is rare. but an anaesthesiologist should remain abreast of this airway anomaly, impending complications and immediate management during nasotracheal intubation. references 1. coe t. r., human m. the perioperative complications of nasal intubation: a comparison of nostril side. anaesthesia 2001;56:227-84. 2. feng yp, lee cy, luk hn, peng sy. cuff damage caused by a nasal spur during nasotracheal intubation: a case report. fujen journal of medicine 2014;12(2):119-24. endotracheal cuff tear during awake fibreoptic guided nasotracheal intubationan anaesthesiologist's nightmare a case report original research paper dr. garima anant* assistant professor department of anaesthesia, p.g.i.m.s, rohtak *corresponding author x 1gjra global journal for research analysis anaesthesiology various factors may contribute to the endotracheal tube cuff tear during nasotracheal intubation. we report a sharp nasal spur in the right nostril leading to failed cuff ination. an 18 year old male with tm joint ankylosis was posted for gap arthroplasty. twice after successful bre-optic guided nasotracheal intubation but failed cuff ination via the right nostril, a successful attempt was made at nasotracheal intubation with cuff ination via the left nostril. cuff tear caused by a nasal spur is infrequent, but an anaesthesiologist should be abreast of this complication and its subsequent management during nasotracheal intubation. abstract keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. aman kaur saini post graduate md first year student department of anaesthesia, p.g.i.m.s, rohtak introduction: cardiovascular disease (cvd) is the principal cause of death worldwide. according to world health organization (who) cardiovascular diseases contribute to 20% of mortality and is estimated to have caused over 15 million deaths comprising more than one third of all deaths in the year 2001.(1) hypertension is the most common cardiovascular disease affecting 50% of individuals above the age of 50 years. according to survey the prevalence of hypertension is 972 million worldwide and it keeps on increasing so rapidly that in 2025 this number may exceed 1.56 billion with one in three adults worldwide having raised blood pressure.(2) the joint thnational committee (7 jnc2003) on hypertension advocates non pharmacological therapy to be an important component of treatment of all patients with hypertension and prehypertension. in some stage-1 hypertensives lifestyle changes (like dietary restrictions on sodium and alcohol, healthy eating plan, weight reduction in obese and increasing aerobic activity) are sufcient enough to bring down the elevated blood pressure without the need of drug therapy on a daily basis. in others, though lifestyle modication is insufcient and pharmacological treatment becomes necessary, these lifestyle changes need to be continued lifelong, since they facilitate the effects of drugs.(3) whole grain like wheat (tritium aestivum linn.) nds a place in the recommended dash diet and is an important component of human diet, particularly in developing countries. epidemiological studies reveal that consumption of whole grain and its products are protective against chronic diseases such as cardiovascular diseases, diabetes and cancer. wheat when harvested as young green shoots germinated over a period of 6-10 days is generally called 'wheat grass' and it is known as 'functional food' during which vitamins, minerals and phenolic compounds such as avonoids are synthesized in wheat sprouts reaching maximum antioxidant potential.(4) herbal products are highly acceptable and used 70 to 80% of the world population for their primary health care, especially in developing countries, due to their easy access, lesser side effects and low cost. it is also known to possess antioxidant as proven in several studies. (5,6) this property might protect the heart and preventing the most important cardiovascular complication and cause of death due to hypertension i.e. myocardial infarction. this study will denitely help and add knowledge in scientic exploration of antihypertensive & cardioprotective potential of this promising herb in animal models. this study was carried out to nd out the anti-hypertensive potential of triticum aestivum linn. by observing its effect on fructose fed hypertensive rats. subjects and methods: this was a longitudinal study done on thirty healthy albino rats weighing between 100-200gms. prior to the dietary manipulation, all rats were fed standard rat chow, containing 60% vegetable starch, 11% fat and 29% protein, water ad libitum and maintained on 12 hours light/dark cycle. simultaneously rats were acclimatized to the procedure of blood pressure measurement daily for one week. drugs & chemicals: the drugs selected for the study were obtained in pure powder form from the following sources. 1fructose – analytical grade 2triticum aestivum powder –girmes wheat grass, pune 3carvediliol – alkem company, mumbai, maharastra, 400013 hypertension was induced in albino rats by administration of high fructose diet, as per the method described by hwang et al(1987).(7) plan of the study was as follows. thirty albino rats were grouped into ve groups of six rats in each, and housed in separate cages group-wise. the parameters like systolic blood pressure (sbp), diastolic blood pressure (dbp), mean arterial pressure (map) and heart rate (hr) were recorded on ththe 16 day of drug administration. the mean of three observations for each parameter were taken as the nal recorded value of each rat of all groups. study of antihypertensive activities of wheat grass (tritium aestivum linn) in albino rats original research paper dr annapoorna sahoo tutor, pharmacology department, bhima-bhoi medical college and hospital, balangir, odisha pharmacology context: hypertension is the most common cardiovascular disease affecting 50% of individuals above the age of 50 years. whole grain like wheat (tritium aestivum linn.) may have cardioprotective effect. aims: this study was carried out to nd out the anti-hypertensive potential of triticum aestivum linn. by observing its effect on fructose fed hypertensive rats. settings and design: this was a longitudinal study done on thirty healthy albino rats methods and material: thirty albino rats were grouped into ve groups of six rats in each, and housed in separate cages groupwise. the parameters like systolic blood pressure (sbp), diastolic blood pressure (dbp), mean arterial pressure (map) and thheart rate (hr) were recorded on the 16 day of drug administration. statistical analysis used: anova test and post hoc dunnett test using spss version 16, unpaired t test results: signicant reduction in blood pressure and heart rate was seen. conclusions: we found signicant favourable effect of tritium aestivum linn on hypertension, however multiple clinical studies are recommended. abstract keywords : tritium aestivum linn, hypertension dr pravin dhone* professor and head, bhima-bhoi medical college and hospital, balangir, odisha *corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra group diet drug dose duration control standard diet distilled water 0.5 ml for 15 days orally 2 high fructose diet distilled water 0.5 ml 3 high fructose diet triticum aestivum extract 200mg/ kg 46 x gjra global journal for research analysis blood pressure measurement: thon 16 day fructose diet was withdrawn. rats were removed from the cages and taken to the laboratory at 09.00hr, they were allowed free access to normal chow diet & water, kept calm and quiet (noise free) area before the blood pressure measurement. the body weight of all the rats was measured. the blood pressure of each rat was measured at 13.00hr. the tail cuff method without external pre heating was used using nibp system by standard method. statistical analysis--the comparison were done using anova test and post hoc dunnett test using spss version 16, unpaired t test and p<0.05 was considered as statistically signicant. results: the effect of triticum aestivum on fructose induced hypertension in rats is evident in table 1. effect of triticum aestivum linn. on blood pressure and heart rate of fructose induced hypertensive rats 15 days is shown in table 2. signicant reduction in blood pressure and heart rate is shown in the table. table no 1: body weight and pattern of hypertension induced by fructose (10%) diet in albino rats *p <0.05 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 4 high fructose diet triticum aestivum extract 250mg/ kg 5 high fructose diet carvedilol 5mg/kg group diet consumed body weight (gms) sbp dbp map hr (beats/ min) mmhg 1 normal chow diet 200.16 6.5 118.1 2.2 96.0 2.52 103.15 2.25 372.42 13.05 2 fructose (10%) diet 2042.4 *132.64 0.57 *109.1 0.71 *116.66 0.515 *467.44 4.24 parameters (mmhg) group1 control (distilled water) group 2 (fructose solution 10%) group 3 (triticum aestivum 200mg/kg +fructose solution 10%) group 4 (triticum aestivum 250mg/kg +fructose solution 10%) group 5 (carvedilol 5mg/kg +fructose solution 10%) sbp ± se 118.16 ±0.723 132.33 ±1.52 125.83 ±0.456 ***119.50 ±0.67 ***104.34 ±2.16 dbp ± se 96.00 ±0.81 111.167 ±3.07 *103.167 ±1.74 ***98.833 ±1.13 ***84.167 ±1.35 map ± se 103.5 ±0.61 ***118.16 ±1.7 *110.67 ±1.2 ***105.83 ±0.60 ***91.00 ±1.06 hr± se 372.16 ±7.67 ***467 ±5.91 *418.34 ±4.94 ***404.00 ±4.67 ***333.00 ±5.38 table no 2: effect of triticum aestivum linn. on systolic blood pressure (sbp), diastolic blood pressure (dbp), mean arterial blood pressure (map) of fructose induced hypertensive rats 15 days after continuous administration (dose in mg/kg) discussion: this study was carried out to nd out the anti-hypertensive potential of triticum aestivum linn. by observing its effect on fructose fed hypertensive rats. wheat grass refers to the young grass of wheat (triticum aestivum) germinated for a period of 6 to 10 days. it contains vitamin c and e, ß carotene, ferulic acid, vanilic acid and phenols, especially avonoids. wheat grass juice is found to have healing properties in various degenerative diseases and is known to benet blood cells, bones, glands, kidney and other parts of the body. (8,9,10) since little or no work has been done on the antihyper lipidemic, antihypertensive effects of wheat grass, the present study was designed to analyse its role on isoproteronol induced myocardial insufciency and hyper tension. a signicant rise in systolic, diastolic and mean artrerial pressure along with an increased heart rate was noticed, when on fructose diet. the mechanism of hypertensive effect is postulated to be due to hyperinsulinemia and insulin resistance leading to a rise in blood pressure. there was signicant rise in all blood pressure parameters of rats maintained on high fructose diet as compared to control rats on normal chow diet. triticum aestivum was found to exhibit signicant antihypertensive effect in the form of systolic blood pressure, diastolic blood pressure, mean arterial pressure and the heart rate. with the increase of the dose of the test drug, antihypertensive effect was signicantly increased. with the increasing duration of treatment, the effect was increased & comparable to that of standard drug, carvedilol. (9,10) to conclude, we have evaluated the therapeutic potential of wheat grass in hypertension. we found signicant favourable effect on reducing hypertension. however multiple clinical studies involving human volunteers are recommended to evaluate their favorable effect. references: 1. world health organisation. world health organisation epidemiology and burden of disease unit.geneva, 2003. 2. beevers g, lip gy ,o’brien e.abc of hypertension ;the pathophysiology of hypertension .bmj.2001:322:912-6[pmcid: pmc1120075][pubmed: 11302910] 3. chobanianav, bakris gl, black hr ,cushman wc, greeen la,izzo jl,jr,et al. seventh report of the joint national committee on prevention ,detection, evaluation, and treatment of high blood pressure.hypertension, 2003;42:1206-52.[pubmed :14656957] 4. pickering tg. pathology of exercise hypertension.herz .1987;12:11924.[pubmed :2953661] 5. kyrou i, chrousos gp, tsigos c. stress, visceral obesity, and metabolic complications. ann n y acad sci.2006;1083:77-110.[pubmed :17148735] 6. wofford mr, hall je. pathophysiology and treatmengt of obesity hypertension. curr pharma design . 7. hwang is ho h,horffman bb ,reaven gm.fructose –induced insulin resistance and hypertension in rats. hypertension.1987;10:512-6. 8. kulkarni sd, tilak jc, acharya r, rajurkar ns, devasagayam tpa, reddy avr. evaluation of the antioxidant activity of wheatgrass (triticum aestivum l.) as a function of growth under different conditions. phytother res 2006; 20: 218–227. 9. padalia s, drabu s, raheja i, gupta a, dhamija m. multiple potential of wheatgrass juice (green blood): an overview. chron young scientist 2010; 1: 23-28. 10. sri jaya m, gayathri s. antioxidant activity of wheatgrass & impact of supplementing grass extract anaemics. biomed 2009; 4: 262-268. * p<0.05,** p<0.01,*** p<0.001 x 47gjra global journal for research analysis background the prevalence of type 2 diabetes (t2d), also known as diabetes mellitus, has been on the increase around the world. governments are investing heavily in providing the muchneeded healthcare to assist diabetic persons to manage their conditions and live long quality life. however, there have been concerns regarding the unwillingness of person with diabetes to seek medical attention regularly (lee, tong, & wah, 2016; bajaj, 2018). according to bajaj (2018), this is a serious issue due to the nature of diabetes treatment, where patients have to comply with regular treatment. in india, studies conducted in different states revealed unsatisfactory healthcare seeking behaviors (sawant & kokiwar, 2017; bhosale et al., 2017; kishore et al., 2015). there is a need for a regular physiotherapy to assist diabetes patient manage their blood sugar levels. the compliance with medical treatment is a critical step for ensuring that persons with diabetes mellitus are not only healthy but also productive in the society. failure to seek health care on a regular basis may lead to serious medical complications associated with the inability to control blood sugar levels. this paper explores the healthcare seeking behaviors among persons with diabetes in dakshina kannada district in karnataka, india. figure 1: the map of dakshina kannada district in karnataka state, india, retrieved from: https: // tools. wmabs.org/ geohack/ geohack. php? pagename = dakshina_ kannada&params =12.8 7_n _ 74.88 _ e _ type : city_region:in-ka india is one of the many countries that are keen on availing regular medical services for persons living with diabetes (rao et al., 2018; sirari, patro, datta, & lakshmi, 2018). however, it remains unclear whether diabetic persons are seeking medical attention as required. for example, a recent study by eshwari, kamath, rao, and kamath (2018) revealed how families in karnataka state in india are using 3% to 21% of their income on inpatient and outpatient services. studies revealed that the healthcare seeking behaviors among patients from iran (basity & iravani, 2014), uganda (hjelm & atwine, 2011), and philippines (perry & espinosa, 2017) were inuenced by their economic status and social factors. in contrast, the studies on malaysia (low et al., 2016), and nepal (thapa et al., 2018) showed satisfactory healthcare seeking behaviors. this shows the commitment at the government level to facilitate and encourage healthcare seeking behavior. for example, inche zainal et al. (2014) noted how distance from the healthcare facility, support from family members, and the duration of the disease inuenced the healthcare seeking behavior among nepali patients. these ndings show the specic areas that can be manipulated to inuence healthcare seeking behaviors. methods design this study employed a qualitative method by focusing on diabetic persons in dakshina kannada district in karnataka. specically, a qualitative descriptive study facilitated the collection and analysis of data on health care seeking behaviors among diabetic individuals. the used of interview approach helped in gaining deep insights regarding the reasons that for health care seeking behaviors. participants as part of the study, 14 persons with diabetes were in interviewed. these participants were identied using the snowball sampling method. the idea was to use the social connections of the locals and ask around about individuals known to have diabetes mellitus. health-care seeking behavior among persons with diabetes in dakshina kannada: an interview study original research paper sandesh k. s research scholar, institute of development studies, university of mysore. x 7gjra global journal for research analysis epidemiology background: seeking health care is crucial for assisting persons with diabetes mellitus to manage their blood sugar levels. the aim of this study was to explore health care seeking behavior among persons with diabetes mellitus in dakshina kannada district and the factors inuencing such behaviors. methods: a qualitative research method was applied to explore the health care seeking behaviors among 14 individuals (8 females and 6 females) with diabetes mellitus in dakshina kannada. a snowball sampling technique helped in identifying willing participants aged 18 years and above. results: the ndings showed that diabetic persons in the district seek medical attention in public hospitals. however, the ndings revealed unsatisfactory health care seeking behaviors among the majority of the patients. the majority of the interviewees admitted not seeking regular medical attention to various reasons. the main reason for poor health care seeking behaviors is nancial constraints, where the interviewees expressed their unwillingness to use the limited family resources. other reasons include lack of family support and distance to health care facilities. conclusion: in brief, the health seeking behaviors among persons with diabetes mellitus in dakshina kannada is similar to the rest of india and other developing nations. the unsatisfactory health care seeking behaviors is linked to the socio-economic situation such as income, level of poverty, and family support. therefore, addressing these factors will signicantly improve the health care seeking behaviors among diabetic persons in future. abstract keywords : diabetes mellitus, health care seeking behaviors, compliance, financial constraints dr. mangala s. m* institute of development studies, university of mysore. *corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 8 x gjra global journal for research analysis the inclusion criteria as part of the selection process, three inclusion criteria were used. first, only individuals with diabetes were selected. second, only individuals who have lived in dakshina kannada district for more than year were included. the aim of this criterion was to exclude non-local persons. third, the age limit was 18 years and above with the aim of excluding minors. lastly, persons with any form of psychiatric disorders were excluded. since such individuals' ability to make the right or informed decisions may be compromised, it was necessary to exclude them. doing so helped in ensuring the credibility of the study. ethical considerations the researcher strictly observed the ethical code of conduct when handling interviewees as well as their information. for example, this study is based on voluntary participation. therefore, participants agreed in writing or orally to participate before proceeding. also, the protection of participants' information was achieved by using anonymous identication rather than real names. data collection the data collection took place within a one-month period. semi-structured interview questions were used to collect the data from using the local kannada language. as part of the interview, open-ended questions were used. this gave the interviewees the much-needed freedom to express themselves and give their reasons. once collected, the data, which was audio-recorded, was transcribed to facilitate the qualitative analysis. findings the ndings show that respondents were seeking health care in both private and public hospitals. however, the health care seeking behaviors was unsatisfactory for most of the respondents. the ndings show that the majority of the interviewees have unsatisfactory health care seeking behaviors. specically, only two out of 14 admitted seeking regular medical checkups. most of the interviewees also admitted not checking their blood sugar levels on a regular basis. as table 1 shows, nancial constraints are the main challenge facing persons with t2d in the district. according to them, they have more pressing issues in their families that need to be addressed. this explains why their health is not a priority. apart from nancial constraints, distance to healthcare facilities was also a challenge. family support is also an important factor since those with satisfactory health care seeking behaviors admitted having supportive families. the support is either nancial or moral support. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra table 1: the summary ndings interviewee finding 1 finding 2 summary 1 financial constraints i try my best moderately satisfactory 2 financial constraints health not a priority, my family rst unsatisfactory 3 financial constraints, other family needs come rst the facilities is far unsatisfactory 4 financial constraints the medical center is far unsatisfactory 5 supporting relatives availability of funds moderately satisfactory 6 financial constraints relatives are not supportive unsatisfactory 7 the facilities are far financial constraints inuence healthcare seeking behaviors negatively unsatisfactory 8 financial support is there the hospital is close satisfactorily 9 supportive relatives i can afford regular healthcare satisfactory 10 financial constraints other family needs come rst health not a priority unsatisfactory 11 the hospital is far health is not a priority unsatisfactory 12 financial constraints other family needs come rst distance unsatisfactory 13 financial constraints distance unsatisfactory 14 supportive relatives i understand the importance of seeking health care satisfactory discussion the ndings provide crucial district-specic insights regarding health care seeking behaviors in dakshina kannada district. the unsatisfactory health care seeking behaviors reported in this study is similar to the ndings in other parts of india that show unsatisfactory healthcare seeking behaviors (sawant & kokiwar, 2017; bhosale et al., 2017; kishore et al., 2015). although the patients were eager to seek medical attention, they admitted that their socioeconomic factors hindered them from seeking regular medical attention. for example, an interviewee lamented that he was not willing to spend the limited family resources to get medical care since it will push his family to poverty. this reects the ndings by sawant and kokiwar (2017) and bhosale et al. (2017) and kishore et al. (2015) on how diabetic persons react to socioeconomic factors. instead of diminishing the limited family nances, they are more than willing to sacrice their health by not taking medicine, or conducting the much-needed checkups. conclusion in summary, the current study provides crucial insights regarding healthcare seeking behaviors among patients living with t2d. first, it is evident that the health care seeking behaviors in dakshina kannada district is unsatisfactory. this outcome shows the urgency in which the problem should be addressed to help persons with t2d in the district. second, the ndings provide the much-needed evidence regarding the specic factors inuencing the health care seeking behaviors. just like in other parts of the world, socio-economic factors are the main reasons. evidently, issues to do with poverty, accessibility to health care services, and social networks are common variables that inuence such behaviors. references 1. bajaj, s. (2018). rssdi clinical practice recommendations for the management of type 2 diabetes mellitus 2017. international journal of diabetes in developing countries,, 1-115. 2. basity, s., & iravani, m. r. (2014). health seeking behavior of diabetic patients in koohzar village in damghan city. medical archives, 68(6), 384-388. 3. bhosale, s., pawar, a. t., & durgesh, k. k. (2017). healthcare-seeking behavior among diabetic patients in kozhikode, kerala. international journal of medical science and public health, 6(10), 1524-1528. 4. eshwari, k., kamath, v. g., rao, c. r., & kamath, a. (2018). annual cost incurred for the management of type 2 diabetes mellitus—a communitybased study from coastal karnataka. international journal of diabetes in developing countries, , 1-6. 5. hjelm, k., & atwine, f. (2011). health-care seeking behavior among persons with diabetes in uganda: an interview study. bmc international health and human rights, 11(1), 11. 6. inche zainal abidin, s., sutan, r., & shamsuddin, k. (2014). prevalence and determinants of appropriate health seeking behaviour among known diabetics: results from a community-based survey. advances in epidemiology, 2014. 7. kishore, j., kohli, c., gupta, n., kumar, n., & sharma, p. k. (2015). awareness, practices and treatment seeking behavior of type 2 diabetes mellitus patients in delhi. annals of medical and health sciences research, 5(4), 266-273. 8. lee, l. l., tong, s. f., & wah, y. l. (2016). selection of treatment strategies among patients with type 2 diabetes mellitus in malaysia: a grounded theory approach. plos one, 11(1) doi:http: // dx. doi. org/ 10.1371 /journal .pone. 0147127 9. low, l. l., tong, s. f., & low, w. y. (2016). social inuences of help-seeking behavior among patients with type 2 diabetes mellitus in malaysia. asia pacic journal of public health, 28(1_suppl), 17s-25s. 10. perry, p.j.e. & espinosa, m.j.p. (2017). health-seeking behavior and quality of life of patients with diabetes mellitus in iloilo, philippines. international journal of bio-science and bio-technology, 9(1), 103-112. 11. rao, p. v., makkar, b. m., kumar, a., das, a. k., singh, a. k., mithal, a., . . . viswanathan, v. (2018). rssdi consensus on self-monitoring of blood glucose in types 1 and 2 diabetes mellitus in india. international journal of diabetes in developing countries, , 1-20. 12. sawant, g. v., & kokiwar, p. r. (2017). a study of knowledge, practices and treatment seeking behaviour among diabetic patients. international journal of community medicine and public health, 3(3), 741-745. 13. sirari, t., patro, b., datta, p., & lakshmi, p. v. m. (2018). levels of compliance of self-care practices of diabetes mellitus type 2 patients: a study from a tertiary care hospital of north india. international journal of diabetes in developing countries,, 1-8. 14. thapa, s., jha, n., & pyakurel, p. (2018). health care seeking behavior among people living with type-2 diabetes in rural area of eastern, nepal, international journal of public health & safety, 3(3), 166. x 9gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 24.dr mayank shukla.cdr background cerebrovascular disease is one of the most frequently occurring and signicant neurological disorders among the [1,2]adult population . who denes stroke as "the rapidly developing clinical symptoms &/or signs of focal (at times global) disturbance of cerebral function, with symptoms lasting more than 24 hrs or leading to death with no apparent [3]cause other than that of vascular origin" . majority of patients aged ≥65 years with stroke develop dementia and disability worldwide: about 25% of stroke patients develop dementia (4).prolactin is a polypeptide hormone (molecular mass 21500 kd) that is synthesized in and secreted from specialized cells [5]of the anterior pituitary gland, the lactotrophs . normal serum prolactin levels vary between 5 and 25 ng/ml for females while in males the normal prolactin levels range from 2 to 18 ng/ml. [6] inammation and hypercoagulability are linked to the pathogenesis of atherosclerosis and i ts c l in ical manifestations such as coronary or peripheral artery disease and stroke [7]. platelet activation and aggregation have been shown to play an important role in the pathophysiology of atherosclerosis and thrombosis in acute and chronic arterial [1,8] disease. prolactin induces expression of p-selectin in the platelet and augment of adenosine diphosphate-induced platelet aggregation leading to thrombosis in acute coronary syndromes mainly in acute mi, also there was an association [9]between high prolactin level and stroke. aim and objectives : 1) to evaluate correlation between serum prolactin and acute ischemic stroke. 2) to nd out correlation between clinical severity of acute ischemic stroke and level of serum prolactin. materials and method : this is an observational, case control study which was conducted on 50 patients diagnosed with acute ischemic stroke admitted in icu, neurology and medicine ward in geetanjali medical college and hospital, udaipur. 50 controls were also included in the study with unrelated ailments. the study was conducted from june 2018 to december 2018.data of patients were collected by detailed history, clinical examination, investigations and diagnosis conrmed by mri or ct brain. apart from routine investigations, serum prolactin estimation was done. the severity of stroke was assessed as per glasgow coma scale (gcs). selection of cases: inclusion criteria: patients with acute ischemic stroke >18 years of age. exclusion criteria: patients with the history of coronary artery disease, peripheral arterial disease, venous infarcts ,epilepsy, metabolic and endocrine diseases, chronic renal failure, hepatic failure, malignancies, autoimmune and collagen tissue diseases, pregnant females and lactating women, history head trauma, previous intracranial surgical procedures and hemorrhagic stroke, platelet dysfunction and/or abnormal platelet counts, bone marrow diseases and hematological conditions that may lead to suppression of bone marrow, use of various drugs that have effects on bone marrow or prolactin metabolism such as antipsychotics, hormone treatments, prolactin metabolism disorders like pituitary adenoma and prolactinoma and hivaids patients. selection of controls:patients with unrelated illess >18 years of age were selected and exclusion criteria included acute ischemic stroke patients and rest same as for cases. results : with equal number of cases and controls, i.e. 50 in each group. mean age of 100 patients was 59.06±13.32 years.the mean age group in cases was 60.56±13.53 years and in control was 57.56±13.06 years.mean blood uric acid level in cases was 4.98±1.45 and in control was 4.36±1.45 mg/dl, this difference was statistically signicant at p value of <0.05.the correlation between serum uric acid levels and severity of stroke was not statistically signicant. the serum prolactin level in mild and moderate gcs score is 42.28 and 42.72 ng/ml respectively. however, the serum prolactin level of patients with severe gsc score is lower i.e. 33.27 ng/ml as compared to others. for cases pearson's correlation between serum uric acid level and age was 0.348 which is statistically signicant. (p<0.05) table 1. age and serum prolactin level correlation between serum prolactin level and acute ischemic stroke original research paper dr. mayank shukla resident, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india x 11gjra global journal for research analysis general medicine backgroundin this study, we determined serum prolactin level in patients with acute stroke and assessed its relationship with disease severity. methodthis is an observational, case control study on patients diagnosed with acute ischemic stroke in geetanjali medical college and hospital, udaipur.50 cases and 50 controls were included in the study.serum prolactin level along with other blood routine tests were done. resultsthe mean age group in cases was 60.04±2.04 years and in control was 48.76±2.399 years. male preponderance was seen in both cases and control.mean serum prolactin level in cases was 39.678±5.488 and in control was 9.998±0.942 ng/ml, this difference was statistically signicant at p value of <0.05. the correlation between serum uric acid levels and severity of stroke on basis of gcs score was not signicant. conclusionthis study concludes that serum prolactin level can be used as pathological biomarker in patients of acute ischemic stroke but of severity of disease cannot be predicted by its levels. abstract keywords : prolactin, stroke volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. syed javed* associate professor, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india *corresponding author age group case mean serum prolactin control mean serum prolactin <20 0 6.88 21-30 27.7 8.245 31-40 26.38 13.445 41-50 21.398 10.773 12 x gjra global journal for research analysis table 2. gcs and serum prolactin in cases the relationship between the gcs score and outcome is the basis for a common classication of acute traumatic brain injury: severe gcs 3 to 8, moderate gcs 9 to 12 and mild [12]gcs 13 to 15. table 3. difference between cases and controls discussion : a stroke can be dened as a sudden onset of a neurological decit that is due to a focal vascular cause. stroke is an important cause of mortality and long term morbidity. serum prolactin has been described as cause of increased in vivo and in vitro platelet aggregation and these processes are [10]thought to contribute to the pathophysiology of stroke. in our study, mean serum prolactin level in cases was 39.678±5.488 and in control was 9.998±0.942 ng/ml, this difference was statistically signicant at p value <0.05. in the study of tam et al., (2016) the mean serum prolactin for the case group with standard deviation was 117.26±83.52 whereas, the mean serum prolactin with standard deviation for the control group [11]was 11.99±5.25 which was higher than the current study . tripathi et al. (2016) found that the patients of ischemic stroke were having higher serum prolactin level as compared to the controls. mean prolactin level in ischemic stroke patients was [13]11.8 ng/ml and control group was 6.6 ng/ml (p value < 0.01) . the correlation between severity of stroke based on gcs score and uric acid levels was not statistically signicant in our study (p value >0.05). conclusion : serum prolactin can be used as pathological biomarker in patients of acute ischemic stroke. however the levels do not correlate with severity of the disease. references : 1. gawaz m, langer h, may ae. platelets in inammation and atherogenesis. journal of clinical investigation. 2005; 115:3378–84. 2. fateh-moghadam s, htun p, tomandl b, sander d, stellos k, geisler t, langer h, walton k, handschu r, garlichs c, daniel wg. hyperresponsiveness of platelets in ischemic stroke. thrombosis and haemostasis. 2007;97(06):974-8. 3. hatano s. experience from a multicentre stroke register: a preliminary report. bulletin of the world health organization. 1976;54(5):541. 4. llibre j, valhuerdi a, fernandez o. prevalence of stroke and associated risk factors in older adults in havana city and matanzas provinus, cuba (10/66 population-based study) medicc review. 2010;12:20–24. 5. bern ha. the comparative endocrinology of prolactin. recent prog horm res. 1968;24:681-720. 6. majumdar a. mangal ns. hyperprolactinemia. j hum reprod sci. 2013 julsep; 6(3): 168–175. 7. tohgi h, suzuki h, tamura k, kimura b. platelet volume, aggregation, and adenosine triphosphate release in cerebral thrombosis. stroke. 1991 jan;22(1):17-21. 8. nieswandt b. ruggeri zm. platelets in atherothrombosis. nature medicine. 2002 nov;8(11):1227-34. 9. ben-jonathan n, hugo er, brandebourg td, lapensee cr. focus on prolactin as a metabolic hormone. trends in endocrinology & metabolism. 2006 apr 1;17(3):110-6. 10. wallaschofski h, kobsar a, sokolova o, eigenthaler m, lohmann t. coactivation of platelets by prolactin or leptin-pathophysiological ndings and clinical implications. hormone and metabolic research. 2004 jan;36(01):1-6. 11. tam aa. kaya c. baser h. ersoy r. cakr b. mean platelet volume in patients with prolactinoma. arch. endocrinol. metab. 2016;60(4). 12. ghelichkhani p, esmaeili m, hosseini m, seylani k. glasgow coma scale and four score in predicting the mortality of trauma patients; a diagnostic accuracy study. emergency. 2018;6(1). 13. tripathi sk, kamble p and muddeshwar mg. serum prolactin level in patients of ischemic stroke. international journal of contemporary medical research. 2016. 3(12). volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 51-60 50.814 10.286 61-70 29.454 7.207 >70 45.419 10.685 no. of patients percent mean serum prolactin mild 24 48 42.28 moderate 11 22 42.72 severe 15 30 33.27 cases(n=50) controls(n=50) p value age 60.04±2.04 48.76±2.399 <0.05 sex male 30 29 0.8388 female 20 23 prolactin level 39.678±5.488 9.998±0.942 <0.05 introduction: bartter's syndrome ,originally described by bartter's and colleagues in 1962,represents a set of closely related autosomal recessive renal tubular disorder characterised by hypokalemia,metabolic alkalosis,nephrocalcinosis,low or normal blood pressure and vascular resistence to angiotensin ii.histologically,there is hyperplasia of juxtaglomerular cells. prevalence : 1 in 10,00,000. classication: (on the basis of underlying genetics) ÿ type 1-antenatal bartter's syndrome:results from mutation in slc12a1( sodium-chloride-potassium cotrnsporter gene) ÿ typr 2-antenatal/neonatal bartter's syndrome:results from mutations in romk(renal outer medullary potassium channel) gene ÿ type 3-classic bartter's syndrome:late childhood or adolescent onset,caused by mutations of clcnkb (chloride voltage gated channel kb gene) ÿ type 4-bar t ter ' s syndrome wi th sensor ineural deafness:results from loss of function mutations in bsnd(beta subunit of chloride channels) ÿ type 5-gitelman syndrome:results from mutations in slc12a3( sodium-chloride cotransporter) case report: a 19 year old female patient was admitted to civil hospital, ahmedabad with complaints of generalised weakness,easy fatigability,nausea and lower abdominal pain for last 1 month.patient had multiple admissions in last 7-8 months with similar complaints of generalised weakness and bodyache,lower abdominal pain,constipation and easy fatigability.old reports(table-1) were suggestive of hypokalemia , bilateral multiple renal stones with other normal renal and liver function test and haematological parameters.for that patient was treated symptomatically with medications and d-j stenting for renal stones(removed after 2 months) and then referred to civil hospital ,ahmedabad for further evalution of her generalised weakness and fatigability. table-1. after admission to civil hospital ,routine investigations done which were suggestive of hypokalemia with normal renal function test,liver function test,complete blood counts and usg abdomen-pelvis was suggestive of bilateral multiple small stones in calyx of both kidney and ureters. abga was done for further evaluation of persistent hypokalemia and recurrent renal stones which was showing metabolic alkalosis with compensatory respiratory acidosis(ph-7.72, po 92 2 mmhg,pco -52mmhg, s.hco 42 mmol/l,o sat-98%).2 32 so for further evaluation of metabolic alkalosis,hypokalemia and renal stones,urinary potassium was done to rule out extra renal causes of hypokalemia like vomiting,diarrhea, diuretics,steroids use.other causes of hypokalemia like thyroid disorders,starvation,hypomagnesemia were ruled out. 24 hour urinary potassium was 68.7 mmol/day,spot urinary chloride was 34.2meq/l with ttkg >4 conrming the renal source of potassium loss.s.aldosteron and s.cortisol were normal which ruled out possibility of liddle's syndrome, cushing's syndrome,syndrome of apperent mineralocorticoid excess.with above workup salt-losing tubulopathy and channelopathy like bartter's syndrome or gitelman's syndrome was suspected.so to differentiate between bartter's a rare case of adolescent onset bartter's syndrome original research paper dr. nilima k. shah additional professor, department of medicine, b.j.medical college, ahmedabad. x 35gjra global journal for research analysis medicine bartter's syndrome is a group of renal tubular disease characterized by impaired salt reabsorption in thick ascending limb of henle's loop and clinically by the association of hypokalemia,metabolic alkalosis,hypercalciuria/nephrocalcinosis,low/normal blood pressure,vascular resistance to angiotensin ii.most of the cases have been noted in pediatric age group and adult onset cases are rare.here we report a case of 19 year old female patient with adolescent onset of bartter's syndrome who presented with persistent hypokalemia,metabolic alkalosis, normotension, nephrocalcinosis. abstract keywords : bartter's syndrome,salt wasting renal tubulopathy,metabolic alkalosis,hypokalemia,normotension,nephrocalcinosis dr. kartikeya parmar assistant professor, department of medicine, b.j.medical college, ahmedabad. dr. suvika patel* third year resident, department of medicine, b.j.medical college, ahmedabad. *corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. harsh kachhela third year resident, department of medicine, b.j.medical college, ahmedabad. dr. shailesh chauhan third year resident, department of medicine, b.j.medical college, ahmedabad. hb 9.9 g/dl ana(if) negative wbc 10,456 /cmm ana profile negative platelets 278000/cmm anti-ccp 27 u/ml(-ve) esr 69 mm/hour ra factor <10 iu/ml(-ve) crp 98 mg/l total protien 6.37 g/dl sgpt 14 u/l s.albumin 3.57 g/dl s.creatine 0.89 mg/dl urine r/m nad s.potassium 2.9 meq/l s.sodium 144 meq/l usg abdokub left kidney shows stone in middle(5mm) and lower(3 mm) calyx with right kidney shows presence of stone in middle (4mm)and lower(3mm)calyx and mild hydronephrosis with stone (7mm)in right ureter just below puj. 36 x gjra global journal for research analysis syndrome (which is associated with hypercalciuria) and gitelman's syndrome urinary calcium creatinine ratio and serum calcium were done which was 0.32 and 6.9 mg/dl respectively.so clinical diagnosis of bartter's syndrome was made as she was presented with laboratory investigations suggest ive o f pers is tent hypokalemia,metabol ic alkalosis,recurrent renal stones,hypercalciuria and low serum calcium level.for conrmation of diagnosis genetic s t u d y w a s p l a n n e d t o  n d o u t m u t a t i o n s l i k e bsnd,clcnka,kcnj1,slc12a1,slc12a3,clcnkb but could not be done due to economical issues. patient was treated with potassium chloride 20 meq 4 times a day ,spironolactone -50 mg twice a day and symptomatic treatment was given .the administration of medication led to increase in serum potassium to 3.7 to 4.3 meq/l.this improvement in serum potassium concentration also led to reversal of ecg changes,improvement in patient's muscle strength with generalised well-being. discussion: hypokalemia is a common clinical problem,the cause of which can usually be determined from the history(as with diuretic use,vomiting or diarrhea.)but in some cases,however, the diagnois is not readily apparent.the diagnostic workup of patients with hypokalemia is reviewd here.there are two major components to diagnostic evaluation:assessment of urinary potassium losses from other causes of hypokalemia and assessment of acid-base status,since some causes of hypokalemia are associated with metabolic alkalosis or metabolic acidosis. the clinical symptoms of bartter's syndrome are dominated by hypokalemia causing generalised weakness,fatigue, nausea,constipation,anorexia and proxima muscle weakness with cardiac arrythamias in sever cases. clinically bartter's syndrome can be divided in at least two groups:one with early(infancy)and other with late onset of symptoms.neonatal bartter's syndrome characterised by intrauterine onset of polyuria,leading to polyhydroamnios n d t hbetween 22 and 24 weeks of gestation.in adults ,fatigue,nausea,proximal weakness,tetany,renal stones are most common presenting features. the primary defect in bartter's syndrome is an impairment in one of the transporters involved in sodium chloride reabsorption in the loop of henle.the combination of secondary hyoeraldosteronism due to impaired sodium chloride reabsorption and volume depletion leads to increased distal ow and sodium delivery enhances potassium and hydrogen secretion at the secretory sites in the connecting tubules and collecting tubules leading to metabolic alkalosis and hypokalemia. the tubular defects in bartter's syndrome cannot be corrected thus treatment must be lifelong and is aimed at minimizing the effects of extracellular volume depletion as well as correcting the electrolytes abnormalities.potassium supplementation, hypomagnesemia correction,nsaids, drugs blocking distal sodium-potassium ehchange(spironolactone, eplerenone, amiloride),angiotensin inhibitors(acei) are cornerstone of the treatment.kidney transplantation has been performed in rare patients who developed end-stange renal disease due to coexisting renal disease or the effects of chronic volume depletion,electrolyte abnormalities,drug related side effects and/or nephrocalcinosis. conclusion: bartter's syndrome is rare autosomal recessive genetic disorder whose primary pathogenic mechanism is defective transepithelial chloride reabsorption in thick ascending limb of loop of henle due to defective function of proteins responsible for transporting ions to renal cells. as it is rare disorder it requires extensive workup for diagnosis including genetic study for nonspecic clinical presentation of syndrome. the tubular defects of bartter's syndrome cannot be corrected, symptomatic treatment with correction of underlying acid-base and electrolyte abnormalities is the rule. references 1. bartter fc, pronove p, gill jr, maccardle rc (1962). "hyperplasia of the juxtaglomerular complex with hyperaldosteronism and hypokalemic alkalosis. a new syndrome". am j med. 33 (6): 811–28. doi:10.1016/00029343(62)90214-0. pmid 13969763. reproduced in bartter 2.fc, pronove p, gill jr, maccardle rc (1998). "hyperplasia of the juxtaglomerular complex with hyperaldosteronism and hypokalemic alkalosis. a new syndrome. 1962". j. am. soc. nephrol. 9 (3): 516–28. 3. gitelman hj, graham jb, welt lg (1966). "a new familial disorder characterized by hypokalemia and hypomagnesemia". trans assoc am physicians. 79: 221–35. 4. fremont ot, chan jc. understanding bartter syndrome and gitelman syndrome. world j pediatr. (2012) 8:25–30. 10.1007/s12519-012-0333-9 5. ji w, foo jn, o‘roak bj, zhao h, larson mg, simon db, et al. rare independent mutations in renal salt handling genes contribute to blood pressure variation. nat genet. (2008) 40:592–9. 10.1038/ng.118 6. jentsch tj, stein v, weinreich f, zdebik aa. molecular structure and physiological function of chloride channels. physiol rev. (2002) 82:503–68. 10.1152/physrev.00029.2001 7. simon db, bindra rs, manseld ta, nelson-williams c, mendonca e, stone r, et al. mutations in the chloride channel gene, clcknb, cause bartter‘s syndrome type iii. nat genet. (1997) 17:171–8. 10.1038/ng1097-171 8. longo dl, fauci as, kasper dl, hauser sl, jameson jl, loscalzo s. harrison’s principles of internal medicine, vol. 2. 18th ed. usa: the mcgraw hill companies; 2012. p. 2360–1. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction data mining is dened as the process in which useful information is extracted from the raw data. in order to acquire essential knowledge it is essential to extract large amount of data. this process of extraction is also known as misnomer. currently in every eld, there is large amount of data is present and analyzing whole data is very difcult as well as it consumes a lot of time. this present data is in raw form that is of no use hence a proper data mining process is necessary to extract knowledge. the process of extracting raw material is characterized as mining [1]. for the analysis of the simple data there are various cheaper, simpler and more effective solutions are present. the main objective of using data mining is to discover important information that is available in distorted manner. with the help of databases, data mining tools can sweep and can identify previously hidden patterns. data entry key errors are represented by the patterns discovery problems such as network system and fraudulent credit card transactions detection. therefore the result must be presented in the way human can understand possible with the help of network supervisor and marketing manager domain expert. the predictive information can be extracted from various applications with the help of efcient data mining tools [2]. nowadays satellite pictures, business transactions, text-reports, military intelligence and scientic data are the major source of information that needs to be handled. for decision-making no appropriate results are provided by the information retrieval. it is required to invent new methods in order to handle large amount of data that helps in making good decisions. in the raw data it is required to discover new patterns and important information is extracted in order to summarize all the data. in many applications a great success is provided by the data mining and various companies such as communication, nancial, retail and marketing organizations are utilizing this technique in order to minimize their work pressure [3]. for the development of product and its promotion, retailers used data mining approach as by which they can build a record of every customer such as its purchase and reviews. an essential role is played by data mining process when it is impossible to enumerate all application. in the cluster analysis, image processing, market research, data analysis and pattern recognition are some major application of this technique. in the clustering technique, customer categorized group and purchasing patterns has been done in order to discover their customer's interest by the marketers [4]. it is also utilized in biology as it derives the plant and animal taxonomies and also categorizes genes with similar functionality. in geology this technique is used to identify the similar houses and lands areas. supervised and unsupervised learning are the two methodologies utilized by the data mining in order to predict the heart diseases [5]. for learning the parameters of the model, a training set is utilized in supervised learning while in case of unsupervised learning no training set is utilized, for example k-means clustering. classication and prediction are the main objective of the data mining. data process rate and unordered values or data are classied by the classication models while continuous value is predicted by the prediction models. the examples of classication models are the decision trees and neural networks and example of prediction algorithm is regression, association rules and clustering. classication models that can be used in the data mining for the prediction of heart disease are given decision trees, neural networks, and naive bayes classier. in the classication of data mining, the decision tree approach is considered as the most powerful technique [6]. in this method all the models build in the form of tree structure. datasets are breaks into small sets and help in the formulation of an associated decision tree. in the neural network large number of elements is organized in different number of layers that are interconnected to each other. through this approach, the adaptive non-linear data processing algorithms are applied that help in integrating all the multi-processing units. on the basis of the naturally adapting, self -organizing, characterization of these networks is done [7]. the simple probabilistic classier that depends on bayes theorem is known as naive bayes classier which strong independence naïve assumption. this algorithm is also known as the independent feature model. naive bayes classier based on the assumption that features of a particular class present is unrelated to the present feature of any other class. naive bayes classiers are trained to work in supervised learning literature review bayuadhi tama, et.al (2016) presented in this paper a chronic disease that causes major causalities in the worldwide that is diabetes. as per international diabetes federation (idf) around the world estimated 285 million people are suffering from diabetes [8]. this range and data will increase in nearby future as there is no appropriate method till date that minimize the effects and prevent it completely. type 2 diabetes (ttd) is the most common type of diabetes. the major issue was the back propagation with svm classifier for the heart disease prediction original research paper himani rani research scholar punjabi university, patiala, punjab, india x 113gjra global journal for research analysis computer engineering the data mining is the technique to analyze the complex data. the prediction analysis is the technique which is applied to predict the data according to the input dataset. in the recent times, various techniques have been applied for the prediction analysis. in this work, the k-means clustering algorithm and svm (support vector machine) classier based prediction analysis technique is used for clustering and classication of the input data. in order to increase the accuracy of prediction analysis, the back propagation algorithm is proposed to be applied with the k-means clustering algorithm to cluster the data. the proposed algorithm performance is tested in the heart disease dataset which is taken from uci repository. there are 76 attributes present within a database. however, a subset of 14 amongst them is required within all the published experiments. specically, machine learning researchers have used cleveland database particularly at all times. the proposed work will also be compared with the existing scheme (using arithmetic mean) in terms of accuracy, fault detection rate and execution time. abstract keywords : svm, back propagation, prediction dr. gaurav gupta assistant professor punjabi university, patiala, punjab, india volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 114 x gjra global journal for research analysis detection of ttd as it was not easy to predict all the effects. therefore, data mining was used as it provides the optimal results and help in knowledge discovery from data. in the data mining process, support vector machine (svm) was utilized that acquire all the information extract all the data of patients from previous records. the early detection of ttd provides the support to take effective decision. yu-xuan wang, et.al, (2017) analyzed various applications that provide signicance of the data mining and machine learning in different elds [9]. research on the management de-signs of different components of the system is proposed as most of the work is done on the characteristics of the system that varies from time to time. the performance of the system with static or statically adaptive is optimized with the help of proposed method in order to design system. author in this paper proposed a method to design operating system that use the support of data mining and machine learning. all the collected data from the system was analyzed when reply is obtained from a data miner. as per performed experiments, it is concluded that proposed method provides effective results. zhiqiangge, et.al, (2017) presented a review on existing data mining and analytics applications by the author which is used in industry for various applications. for the data mining and analytics eight unsupervised and ten supervised learning algorithms were considered for the investigation purpose [10]. to the semi-supervised learning algorithms an application status was given in this paper. in the process of industry both the methods unsupervised and supervised machine learning is widely used for approximately 90%-95% of all applications. in the recent years, the semi-supervised machine learning has been introduced. therefore, it is demonstrated that an essential role is played by the data mining and analytics in the process of industry as it leads to develop new machine learning technique. p. suresh kumar, et.al (2017) proposed a model that overcome all the problems such as clustering and classications from the existing system by applying data mining technique. this method is used to diagnose the type of diabetes and from the collected data a security level for every patient. there are various affects of this disease due to which most of the research is done in this area [11]. all the collected data of the 650 patient's was used in this paper for the investigation purpose and its affects are identied. in the classication model, this clustered dataset was used as input that is used for the classication process such as patient's risk levels of diabetes as mild, moderate and severe. in order to diagnose diabetes, performance analysis of different algorithms was done. on the basis of obtained result the performance of each classication algorithm is measured. han wu, et.al (2018) proposed a novel model based on data mining techniques for predicting type 2 diabetes mellitus (t2dm). the main objective of this paper is to improve the accuracy of the prediction model and to more than one dataset model is made adaptive in nature. proposed model comprised of two parts based on a series of preprocessing procedures [12]. these two parts are improved k-means algorithm and the logistic regression algorithm. in order to compare the results with other methods the pima indians diabetes dataset and the waikato environment was utilized for knowledge analysis toolkit. as per performed experiments, it is concluded that proposed model show netter accuracy as compared to other methods and also provide the sufcient dataset quality. in order to evaluate the performance of the model it is applied to other diabetes dataset, in which good performance is shown by both the methods. jahinmajumdar, et.al, (2016) presented the most popular research areas in computer science that is data mining and machine learning is utilized in order to provide essential data or information [13]. the sfs and sbs approaches are the optimal approaches and preferred as it use with forward selection. svm techniques are used by the proposed heuristic model as it provides the accuracy and heavy in the computational functions. the accuracy level of svm is measured with the help of dataset. in order to improve the data classication and pattern recognition in data mining mainly feature selection various existing approaches were focused and experimented. as per performed experiments, it is concluded that comparison between the existing techniques was done in order to nd out the best method. the theoretical limitations of existing algorithms were overcome by proposed method. research methodology this research work is based on the prediction analysis of heart diseases. the prediction analysis is the technique in which future possibilities can predicted based on the current dataset. in this research work, technique of svm is applied previously for the prediction analysis. one of the simplest algorithms amongst all the learning machine algorithms is the svm algorithm. since there are no assumptions made on the underlying data distribution, decision tree is known to be a non-parametric supervised learning algorithm. here, on the basis of nearest training samples present within the feature space, the samples are classied. the feature vectors are stored along with the labels of training pictures within the training process. towards the label of its k-nearest neighbors, the unlabelled question point is doled out during the classication process. through majority share cote, on the basis of labels of its neighbors, the object is characterized. the object is classied essentially as the class of the object that is nearest to it in the event when k=1. k is known to be an odd integer in case when there are only two classes present. during the performance of multiclass categorization, there can be tie in case when k is an odd whole number. fig 1: proposed methodology volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra experimental results the proposed approach is implemented in python and the results are analyzed by showing comparisons amongst proposed and existing approaches in terms of accuracy and execution time. 1. accuracy: accuracy is dened as the number of points correctly classied divided by total number of points multiplied by 100, as shown in eqn. 1. accuracy = fig 2: accuracy comparison as shown in gure 2, the accuracy comparison of existing and proposed algorithm is shown. the accuracy of proposed algorithm is high as compared to existing algorithm. 2. execution time: execution time is dened as difference of end time when algorithm stops performing and starts time when algorithm starts performing as shown in eqn. 2. execution time = end time of algorithmstart of the algorithm --2 fig 3: execution time as shown in gure 3, the execution time of proposed and existing algorithm is shown. the execution time of proposed algorithm is less as compared to existing algorithm. 3. cap analysis: -a canonical analysis on the principal coordinates for any resemblance matrix, including a permutation test. cap takes into consideration the structure of the data. so, it is more likely to separate your different levels if there is no strong difference and is good to show the interaction between factors. fig 3: cap analysis as shown in gure 3, the cap analysis is shown in this gure. on the axis of this cure the training dataset is given as input and on the y-axis the test data is given as input. the blue line shows that cap curve which represents accuracy of the classier. conclusion the relevant information is fetched from rough dataset using data mining technique. the similar and dissimilar data is clustered after calculating a similarity between input dataset. the svm used to classify both similar and dissimilar data type in which central point is calculated by calculating an arithmetic mean of the dataset. the central point calculated euclidian distance is used to calculate a similarity between different data points. according to the type of input dataset a clustered data is classied using svm classier scheme. in this research work back propagation algorithm is applied with svm classier to increase accuracy of prediction. the proposed algorithm performs well in terms of accuracy and execution time. in future proposed technique will be further improved to design hybrid classier for the heart disease prediction. references [1] yanhui sun, liying fang and pu wang, improved k-means clustering based on efros distance for longitudinal data, 2016 chinese control and decision conference (ccdc), vol. 11, issue 3, pp. 12-23, 2016. [2] shunye wang, improved k-means clustering algorithm based on the optimized initial centroids, 2013 3rd international conference on computer science and network technology (iccsnt), vol. 11, issue 3, pp. 12-23, 2013. [3] phattharatsongthung and kunwadeesripanidkulchai, improving type 2 diabetes mellitus risk prediction using classication, 2016 13th international joint conference on computer science and software engineering (jcsse), vol. 11, issue 3, pp. 12-23, 2016. [4] jiawei han, michelinekamber, “data mining: concepts and techniques”, vol. 3, pp. 1-31, 2000. [5] ms. tejaswini u. mane, “smart heart disease prediction system using improved k-means and id3 on big data”, 2017 international conference on data management, analytics and innovation (icdmai), vol. 8, issue 11, pp. 123-148, 2017. [6] sellappanpalaniappan, raahawang, “intelligent heart disease prediction system using data mining techniques”, vol. 5, issue 1, pp. 1328, 2008. [7] kanikapahwa, ravinder kumar, “prediction of heart disease using hybrid technique for selecting features”, 2017 4th ieee uttar pradesh section international conference on electrical, computer and electronics (upcon), vol. 4, issue 5, pp. 23-48, 2017. [8] bayuadhi tama,1 afriyan firdaus,2 rodiyatul fs, “detection of type 2 diabetes mellitus with data mining approach using support vector machine”, vol. 11, issue 3, pp. 12-23, 2008. [9] yu-xuan wang, qihui sun, ting-ying chien, po-chun huang, “using data mining and machine learning techniques for system design space exploration and automatized optimization”, proceedings of the 2017 ieee international conference on applied system innovation, vol. 15, pp. 1079 x 115gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 1082, 2017. [10] zhiqiangge, zhihuan song, steven x. ding, biao huang, “data mining and analytics in the process industry: the role of machine learning”, 2017 ieee. translations and content mining are permitted for academic research only, vol. 5, pp. 20590-20616, 2017. [11] p. suresh kumar and v. umatejaswi, “ diagnosing diabetes using data mining techniques”, international journal of scientic and research publications, volume 7, issue 6, june 2017. [12] han wu, shengqi yang, zhangqin huang, jian he, xiaoyi wang, “type 2 diabetes mellitus prediction model based on data mining”, sciencedirect, vol. 11, issue 3, pp. 12-23, 2018. [13] jahinmajumdar, anwesha mal, shruti gupta, “heuristic model to improve feature selection based on machine learning in data mining”, 2016 6th international conference cloud system and big data engineering (conuence), vol. 3, pp. 73-77, 2016. 116 x gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction desmoid tumors are rare soft tissue tumors arising from connective tissue that provides strength to muscle, ligaments and bones. desmoid tumors are rare accounting for about 0.03% of all tumors. the incidence of desmoid tumor is 2-4 per million per year. they are common in 10-40 years of age group and common in females after childbirth with female to male ratio of 2:1.they can be solitary or multiple.desmoid tumor can be abdominal desmoid tumor(arising from abdominal wall),intra-abdominal desmoid tumor(arising from structures connecting abdominal organs) and extra-abdominal desmoid tumor(occurring in shoulder,upper arms and upper legs).desmoid tumors are brous much like scar tissue.they are not considered malignant but they have tendency to invade the surrounding tissue aggressively hence they are difcult to remove surgically. etiology desmoid tumors frequently occur in people with an inherited form of colon cancer called familial adenomatous polyposis. desmoid tumors that are not part of an inherited form are called sporadic desmoid tumors. mutation in ctn nb1 gene or apc gene causes desmoid tumors. mutation of ctn nb1 gene accounts for about 85% of all sporadic desmoid tumor. both these genes are involved in important cell signaling pathways that controls proliferation and differentiation of cells. the ctnnb1 gene codes for beta-catenin protein that interacts with other protein to regulate expression of genes involved in proliferation and differentiation of cells. mutation in ctnnb1 gene leads to abnormally stable beta-catenin that accumulate in cells and acts in an uncontrolled way. the protein produced from apc gene binds with beta-catenin and signals for it to be broken down. mutation in apc gene causes abnormally short protein that is unable to interact with betacatenin which is not broken down and results in accumulation and uncontrolled cellular proliferation and differentiation leading to formation of desmoid tumors. h and e staining of desmoid tumors pathology grossly,desmoid tumors are rm and display white and w h o r l e d c u t s u r f a c e w h i c h m a y b e p o o r l y circumscribed.microscopically,the lesion is proliferation of bland appearing spindle-shaped broblast in a collagenous stroma with inltrative border.mitosis are rare and no atypia is seen.keloid like collagen or extensive hyalinization may be present.desmoid tumors stain positive for vimentin and variably positive for smooth muscle actin or other muscle specic markers by immunohistochemistry.nuclear staining for beta-catenin is positive in approx 80% of sporadic desmoid tumors.therefore,beta-catenin may be extremely helpful in distinguishing desmoid tumors from other spindle cell tumor. case reort a 29-year-old hindu female presented to the opd with complaints of pain in upper abdomen since 2 months which was dull aching in nature aggravated on taking meals associated with early satiety and complaints of nausea and fever since 2 months intermittent relieved on taking medication associated with myalgia and weight loss 4 kgs in 2 months. no complaints of vomiting, diarrhea, constipation, blood in vomit, blood in stool, melaena. no history of dm, hypertension, tuberculosis, blood transfusion, jaundice or any surgery. sleep pattern, bowel and bladder habits are regular and undisturbed. no signicant family history. examination general examination, pulse: 78 beats/minute, blood pressure: 130/80 mmhg, respiratory rate: 18/minute, temperature: normal, systemic examination: per abdominal examination; soft and non tender with a palpable lump of approx. 20x15cm size with well dened margins in the umbilical, epigastric and hypogastric region with rm consistency and mild tenderness upon palpating the lump. investigations routine lab investigations including cbc, coagulation prole, liver function tests and renal function tests and blood grouping and typing. chest and abdominal x-rays. ultrasonography s/o 15x20 cm sized mass in abdomen possibility of gist more likely. usg guided fnac was suggestive of “benign spindle cell a case report: a rare case of desmoid tumor. original research paper dr p. n. kantharia ms professor, department of general surgery, b .j medical college, ahmedabad. general surgery keywords : dr a. b. amin ms assistant professor, department of general surgery, b .j medical college, ahmedabad. dr rajesh d patel ms assistant professor, department of general surgery, b .j medical college, ahmedabad. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr fagun gajjar* mbbs 3rd year resident, department of general surgery, b .j medical college, ahmedabad. *corresponding author 58 x gjra global journal for research analysis tumor”. cect abdomen with pelvis was done which was suggestive of a 19x15x14cm sized well dened heterogeneously enhancing soft tissue density lesion with a possibility of large neoplastic lesion arising from proximal small bowel probably gist. cect images management the main aim of management in this patient was the excision of the tumor with negative surgical margins. the procedure opted was, exploratory laparotomy with excision of the tumor. bowel preparation was done prior to the operation and patient was on liquid diet for two days before the date of surgery. preoperative anesthetic assessment was done and patient was declared t for the procedure. operative note intra operatively, approx.. 20*15*15 cm sized tumor was found arising from mesentery of proximal small bowel at duodenojejunal junction with approx.. 60 cm length of jejunum adherent to tumor. approx. 10 cm distal to jejunal loop(which was adherent to tumor)bowel was transected and mesentery sequentially ligated to mobilize the tumor. tumor pedicle identied and clamps were applied. tumor resected along with jejunum at duodenojejunal junction and pedicle of the tumor transxed using vicryl no.1 and doubly ligated using vicryl no.1. duodenum mobilised by kocherisation and distal end of duodenum was closed by silk 2-0 in two layers.similarly jejunum was closed by silk 2-0 in two layers. closed end of jejunum was brought through a window in transverse mesocolon and side to side duodenojejunal anastomoses was done by silk 2-0 in double layer. intra operative images gure 1; tumor in situ gure 2; tumor mobilised figure 3; tumor specimen biopsy biopsy report was suggestive of spindle cell tumor arising from serosa and subserosal fatty tissue which was abutting muscularis propria of small intestine having moderate cellularity and fascicular growth pattern. no evidence of necrosis or increased mitotic activity was there. sections from surgical margins were free from tumor. section from the specimen of jejunum does not show evidence of tumor inltration. differentials given in biopsy report were:(i)gist ( i i )ben ign ner ve sheath tumor ( i i i ) inammator y myobroblastic tumor (iv)mesenteric bromatosis. immunohistochemistry was advised for conrmation of the diagnosis. slide review at gcri(the gujarat cancer research institute) was suggestive of spindle cell tumor of small bowel likely gastrointestinal stromal tumor without evidence of necrosis or mitosis. immunohistochemistry done at gcri was suggestive of desmoid tumor. discussion desmoid tumors are slowly growing benign tumors having tendency to invade surrounding tissue aggressively. the differential diagnosis of desmoid tumor is broad with broblastic sarcoma on one extreme and reactive broblastic and myobroblastic processes such as nodular fasciitis and hypertrophic scars and keloid on the other.differential diagnosis of intra-abdominal desmoid tumor includes gastrointestinal stromal tumor,inammatory myobroblastic tumor, sclerosing mesenteritis and retroperitoneal brosis.to differentiate desmoid tumor from these entities requires immunohistochemistry in which nucleus of spindle cells stain positive for beta-catenin in cases of desmoid tumor.treatment options include adequate surgical resection with negative surgical margins except when surgery is mutilating and associated with considerable function loss or major morbidity.in cases of positive surgical margins,postoperative radiotherapy alone or in conjunction with systemic therapy in the form of anti-hormonal therapy/nsaids can also be considered to prevent the recurrence. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 59gjra global journal for research analysis introduction after the second world war, there was a great need for the expansion of industries in india. again with the introduction of planned industrial development, the industrial �nance became inadequate to meet the requirements of industrial development of the country. thus in july 1, 1948 the industrial finance corporation of india (ifci) was established by the government under a special act. the prime object of ifci is to provide medium term and long-term �nance to public l imited companies and cooperative organisations. the authorised share capital of the ifci is now raised to rs 20 crore. the idbi, scheduled banks, insurance companies, investment trusts and co-operative banks are the shareholders of the ifci. later, by an amendment to the ifci act, private limited companies have become eligible to get �nancial assistance from ifci. after the establishment of industrial development bank of india (idbi) in 1964, the ifci became a subsidiary to the idbi. again on 24th march, 1993 the industrial finance corporation (transfer of undertaking and repeal) bill 1993 was passed in the parliament in order to privatize the i.f.c.i. now i.f.c.i. would be free to raise resources from the open market and face competition. moreover, with effect from 1st july, 1993, the ifci has been converted into a public limited company and it is renamed as industrial finance corporation of india ltd.india is a developing economy. but the progress of industry is very slow. this is mainly due to the non-availability of �nance. hence, the supply of adequate �nance is required for the development of industries in india. our national government is fully aware of the said problem. accordingly, various agencies have been set up for the supply of industrial �nance to the public and private limited companies. one such agency is the industrial finance corporation. establishment of industrial finance corporation of india in 1948, the government of india set up industrial finance corporation of india (i.f.c.i) with a view of providing medium and long term �nance to industries. the industrial finance corporation started with the authorized share capital of rs. 10 crores divided into 20,000 share of rs. 5,000 each. it can also issue bonds up to �ve times of its paid up capital. the corporation is authorized to borrow from the reserve bank of india, the central government and the world bank, in order to increase its resources. functions the industrial financial corporation of india is authorized to grant loans to industrial companies repayable with twenty �ve years grants, loans in foreign currency to certain industries, under write bonds, shares and debentures etc. provided they are disposed of by the i.f.c.i. within seven years, guarantee deferred payments by importers of capital goods of foreign manufacturers, accept deposit from the local institution, guarantee loans from any bank of a foreign country, subscribe shares of industrial companies. the corporation's role now extends to the entire industrial spectrum in the country. the facilities and services being provided by ifci can be deemed to fall broadly under (a) project �nance, (b) �nancial services and (c) promotional services. the industrial finance corporation has played a vital role in our industrial economy. since its inception, the corporation has provided �nancial assistance to the underdeveloped industrial concerns. the corporation has the power to examine the �nancial aspects of the industrial companies and give valuable advice to the management for improving their schemes. capital of the state corporations each corporation can have a maximum authorized capital of rs. 5 crores. the shares of the corporation can be purchased by the general public as well. the state government concerned guarantees a minimum dividend of 3 1/2 per cent on the share capital. the dividend however, cannot exceed 5 per cent on the share capital. the corporations can augment their resources by �oating bonds and debentures. by the end of march 1974, the corporations had issued bonds amounting to rs. 116 crores. the corporations can borrow from the reserve bank of india as well as from the state governments. functions of the state corporations state finance corporations provide �nancial assistance either by way of granting loans or advances or subscribing to debentures of industrial concerns, or by guaranteeing loans raised by industrial concerns or by underwriting the stocks, shares, bonds and debentures. the corporation can assist private limited concerns and partnership �rms as well. the loans are granted against mortgaged assets and technical soundness of the project is given foremost consideration while granting loans. working of industrial finance corporation of india (ifci) since its inception in 1948, the ifci has sanctioned net �nancial assistance up to march 1993 to the extent of rs 15,430 crore against which the total disbursement was rs 10,380 crore. the industries of high national priority which have been receiving �nancial assistance from ifci include fertilizers, cement, power generation, paper, industrial machinery etc. again, the ifci has registered an impressive performance by earning a net pro�t of 18.81 per cent, i.e.. to the tune of rs 217.59 crore during the period of half year ending on september 30, 1997 as against rs 183.14 crore during the same period of the previous year. in recent years about 50 per cent of the assistance has been advanced to industrial projects located in backward districts of country. however, in recent years, the performance of ifci is not at all satisfactory. total amount of loan sanctioned by ifci initially increased from rs 3,746 crore in 1993-94 to rs 6,580 crore in 1995-96 and then it gradually declined to rs 1,050.4 crore in 2006-07 and then increased to rs 4,015 crore in 2008-09. but the total amount of loan disturbed by the ifci which initially increased from rs 2.163 crore in 1993-94 to rs 4,586.5 crore in 1995role of industrial financial corporation of india (ifci) original research paper dr.s.thirumaran m.a., m.phil., b.ed., ph.d., associate professor & research advisor, pg & research department of economics, national college (autonomous) economics keywords : finance institutions – industrial finance – ifc – idbi. 6 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 96 and then drastically fell to rs 2,164.7 crore in 2000-01 and then to rs 278 crore in 2003-04 and then �nally to only rs 3,311 crore in 2008-09. in 2012-13, total amount of �nancial resources sanctioned and disbursed by the ifci stood at rs 2,219 crore and rs 1,504 crore respectively. unfortunately, ifci has been worse affected due to its huge non-paying assets, willful defaults etc. the government of india have also made an attempt to rehabilitate ifci by subscribing rs 400 crore through long term convertible bonds and also advised idbi, sbi and lic for extending assistance worth rs 200 crore each. in order to meet its outstanding liabilities the government of india has provided rs 2,096 crore as loan during 2002-03 and 2003-04. again the share of non-performing assets (npas) in net loans advanced by ifci stood at 28.0 per cent as at the end of march, 2005. even then the ifci is gradually becoming sick. the government of india is now seriously considering merging ifci with a large psu bank such as punjab national bank. problems of the state corporations 1) the default in repayment of loans is very high with the result that the ability to roll over the funds is considerably restricted. 2) most of the small business units which get loan from the corporations do not follow accepted principles and practices of accountancy. thus it becomes difficult to keep watch over the expenditure. 3) while granting loans to small scale industries, peculiar problem faced is that in these industries individuals very much count. an industry which might be running quite efficiently under one man might become inefficient after the death of the same man. thus continuity of efficient management can hardly be assured. this enhances the difficulties of the corporations. 4) while granting loans proper securities should be available, but in many cases there are not with the result that corporations �nd it difficult to safely advance loans. 5) in order to ensure the return of loan, the corporation is required to observe certain rules and regulations, but the difficulty is that the industries which approach for getting loans do not appreciate these difficulties and create many problems for the management. 6) the corporations have no adequately trained staff to provide advisory service to the industry, when a request for �nancial assistance is received. in case permanent staff is maintained for processing each type of request that will be too costly for the corporation and ad hoc staff cannot be depended upon. 7) the corporation lack self-sufficient organizational set up and also specialized trained staff, thus there is no continuity in policy formulation and execution. 8) the corporations have very limited �nancial resources, keeping in view the fact that new industries are coming up and more and more requests are being received from these industries for �nancial assistance. 9) the corporation has no adequate provision, resources and arrangements to survey backward areas, which have potentialities for growth with the result that their growth suffers. 10) there is overlapping in the activities of state �nancial corporations and commercial banks resulting in competition rather than cooperation. the competition creates many complex problems. suggestions for the improvement of working 1) due place and consideration should be given to the integrity and honesty of the persons applying for the loan, instead of rigid observance of the rules. 2) conferences of representatives of the corporations should be periodically convened to exchange ideas on points of common interest and also to enable each corporation to get bene�t of the experience of the others. 3) state governments should provide interest free loans to the corporations to augment their �nancial resources. 4) wastages of money and resources should be located and avoided. 5) repayment schedule should be so arranged that at the time of repayment small scale and medium industries do not get burdened. 6) more concessions should be given to small scale industries, while granting loans. 7) dividend requirements should be waived for some time, till corporations �nancial resources get augmented. reserve bank of india working gro recommendations it appears that the state governments are quite conscious of the difficulties of small scale and cottage industries. the problems have been discussed at the conference of the representatives of the state financial corporations. international development financial association has promised a $25 million credit in foreign exchange to these corporations. the reserve bank of india also set up in 1970 a working group to review the working of these corporations and report of group was made available to the bank in 1972. the working group recommended augmentation of �nancial resources of the corporation and also suggested that scope of assistance of these corporations should be enlarged. in the opinion of the group management of the corporation should be strengthened, cost of resources lowered and recovery of loans quickened. the working group came out with the recommendation that at least 2/3 of the assistance disbursed by the corporations should go to small units and that dividend obligations should be waived for some time. in 1972 state financial corporations act was amended to enable the corporations to widen their functional role and to extend geographical coverage. conclusion thus it has been suggested that steps should be taken to improve the administrative machinery of the corporation and also to increase its �nancial resources. the industrial finance corporation has to see that all states in india receive �nancial aid from it on a sound economic basis. references 1. agarwala n., indian economics (2002), wiley eastern limited, new delhi. 2. nurkse ragnar: problem of capital formation in underdeveloped countries, oup., london, 1962 3. operational statistics, idbi, publications mumbai, various issues. 4. rbi bulletin, rbi publications mumbai, various issues. 5. report on development banking, idbi publications mumbai, various issues. x 7gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 introduction: the diagnosis of anemia is simple and objective: the world health organization (who) denes anemia as the decline in blood hemoglobin to a concentration below 13 g/dl in men and 12 g/dl in women. however, to conrm that iron deciency (id) is the origin of the anemia is not always easy (1,2). usually, the simple complete blood count (cbc) strongly suggests this origin with typical pattern of microcytic hypochromic and elevation of red cells distribution width (rdw). however, microcytic hypochromic picture may be found in other anemias, like thalassemia, sideroblastic anemia and also in anemia of chronic inammation. few pure and many dimorphic ida cases are normocytic. therefore, a normal mean corpuscular volume (mcv) does not exclude id from being the cause of the anemia. moreover, the presence of microcytosis does not necessarily imply id and can be produced by other anemias (chronic process, sideroblastic anemia) and diseases (e.g. thalassemia). rdw measures the degree of anisocitosis (size difference) of the population of red cells and its elevation is neither sensitive nor specic for id (3, 4, 5). the next step is to determine the so-called iron metabolism (in addition to all other necessary determinations, including levels of vitamin b12 and folic acid) and in many cases the level of c-reactive protein. a typical pattern is a decrease in decreased serum iron (sideremia) serum ferritin, and transferrin saturation. however, this is not the usual case. serum ferritin, in the absence of inammation (usually dened as a normal c-reactive protein level), reects total body iron deposits. thus, a low serum ferritin (< 30 ng/ml) unequivocally means id, whether accompanied by anemia or not. however, as serum ferritin is an acute phase reactant, a normal or even elevated ferritinemia does not exclude the presence of id (6, 7,8). thus, in the presence of an inammatory process (usually dened by an elevated creactive protein level), id could exist even with levels of ferritin up to 100 ng/ml. another parameter of the normal “iron metabolism”, especially useful when the determination of ferritin is equivocal, is the transferrin saturation index. this shows the percentage of transferrin that transports iron and thus a decrease (< 20%) implies id, either absolute or functional. in some cases, even taking into account all these determinations, id can be difcult to diagnose. it generally occurs in situations where the anemia has a multifactorial origin. this is typical in cases of anemia of mixed origin, a chronic process that coexists with id, which is a frequent scenario in gastrointestinal inammatory disease or cancer (9,10,11). these other factors include the determination of soluble transferrin receptor, reticulocyte hemoglobin concentration, the percentage of hypochromic red cells, the concentration of erythropoietin and even the determination of hepcidin(12,13,14). the soluble transferrin receptor is one of the most useful as it is the least inuenced by the presence of inammation and it correlates well with concentration of transferrin receptor in the cell plasma membrane. if the levels are high, id is likely to be a major component of anemia, while in those cases with normal or low levels; anemia is probably not associated with id (15, 16). patients with inammatory conditions such as inammatory bowel disease (ibd), chronic heart failure (chf), and chronic kidney disease (ckd) have high rates of iron deciency with adverse clinical consequences. under normal circumstances, serum ferritin levels are a sensitive marker for iron status but ferritin is an acute-phase reactant that becomes elevated in response to inammation, complicating the diagnosis. proinammatory cytokines also trigger an increase in hepcidin, which restricts iron absorption and promotes sequestration of iron by ferritin within storage sites. patients with inammatory conditions may thus have restricted availability of iron for erythropoiesis and other cell functions due to increased hepcidin expression, despite normal or high levels of serum ferritin. the standard threshold for iron deciency (<30� �g/l) , therefore does not apply and transferrin saturation (tsat), a marker of iron availability, should also be assessed. a serum ferritin threshold of <100��g/l or tsat < 20% can be considered diagnostic for iron deciency in chf, ckd, and ibd. if serum ferritin is 100–300� �g/l, tsat < 20% is required to conrm iron deciency. routine surveillance of serum ferritin and tsat in these at-risk groups is advisable so that iron deciency can be detected. interpretation of serum iron profile and cbc findings in iron deficiency anemia original research paper dilip kumar pandey assistant professor, department of pathology, anugrah narain magadh medical college, gaya, bihar pathology background: iron deciency anaemia is most common anemia worldwide. it is most common in female. in male ida occurs most commonly due to gastrointestinal disease. diagnosis of ida on clinical suspicion is easy with cbc report and iron prole .few dimorphic anemias and anemias in complex clinical settings pose difculty in diagnosis, thus other investigations are also needed. materials and methods: we prospectively collected clinical data, cbc ndings and iron prole results of patients of ida in tertiary teaching institutes of bihar. edta peripheral blood samples were run on sysmex xt-1800i and cbc ndings were noted, whenever needed peripheral blood smears were made to know morphology of red blood cells; serum samples of all cases were run for serum iron prole (iron, ferritin and transferritin saturation) and values noted and tabulated. result: all patients have both decreased serum iron and ferritin. they revealed classical microcytic hypochromic picture with raised rdw. female outnumbered male. male female ratio was 1:1.4. in this study cbc ndings (mcv, mch and rdw) were well correlated with iron prole ndings. minimum hemoglobin level was 5.4gm/dl. conclusion: iron deciency anemia is major public health problem worldwide .in majority of cases, cbc and iron prole study can clinch the diagnosis, however few cases need further investigations and clinical correlation. abstract keywords : ida, ferritin, iron, cbc, peripheral blood smear, hemoglobin volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra subhash chandra jha* dr subhash chandra jha, assistant professor, department of pathology, government medical college, bettiah, west champaran, bihar. * corresponding author 60 x gjra global journal for research analysis the clinical picture varies greatly from one case to another. pallor of varying grades may be found. it is produced both by the anemia and by the lack of iron, which is essential for cellular energy metabolism. symptoms depend greatly on the speed of onset of anemia, its severity and the characteristics of the patient. thus, ida or id can be detected in a person with symptoms that include general weakness, fatigue, irritability, poor concentration, headache, and intolerance to exercise. some iron-decient patients, with or without anemia, might have alopecia, atrophy of lingual papillae, or dry mouth due to loss of salivation. other symptoms, such as weakness or koilonychia, chlorosis, or the syndromes of plummer-vinson or paterson-kelly (dysphasia with esophageal membrane and atrophic glossitis) have virtually disappeared. these changes were caused by reduction of iron-containing enzymes in the epithelia and the gastrointestinal tract. pica can cause iron deciency.[17,18,19]. material and methods: we prospectively collected clinical data, cbc ndings and iron prole results of 11 patients of ida in tertiary teaching institutes of bihar. edta peripheral blood samples were run on sysmex xt-1800i and cbc ndings were noted, whenever needed peripheral blood smears were made to know morphology of red blood cells; serum samples of all cases were run for serum iron prole (iron, ferritin and transferritin saturation) and values noted and tabulated. further investigations were done in those patients that had normocytic and dimorphic blood picture with clinical features of iron deciency and or dimorphic anemia .in few cases, bone marrow study was also done to know cause of microcytic anemia, especially in oral iron refractory patients. table 1.iron profile in iron deficiency anemia result: male female ratio was 1:1.4. in this study cbc ndings (mcv, mch and rdw) were well correlated with iron prole ndings. minimum hemoglobin level was 5.4gm/dl. severity of anemia i.e. hemoglobin concentration was proportional to mcv and mch values. serum ferritin level was well correlated with severity of microcytic hypochromic anemia. minimum serum ferritin was 3.6mcg/l table.2 rbc indexex in iron deficiency anemia figure 1. pbs shows microcytic hypochromic picture and tear drop cell discussion: ferritin is the best indicator of iron deciency and a low ferritin alone is diagnostic of ida. iron is stored intracellularly as ferritin and in the presence of infection, malignancy or chronic inammation; the ferritin rises as acute phase protein. therefore, the diagnosis of ida is challenging when there is coexisting inammation, as the ferritin can be up to 100 �g/l , even in the presence of iron deciency. in this case, further tests can help clarify the diagnosis. total iron-binding capacity, transferrin saturation, serum iron, and serum transferrin receptor levels may be helpful if the ferritin level is between, 46 and 99 mcg/ l (12,13). iron prole studies include serum iron level, transferrin saturations and total iron-binding capacity (tibc) or transferrin concentration, in addition to ferritin. in the bloodstream, serum iron is carried bound to transferrin. the tibc (expressed in �g/dl ) is the maximum iron that can be bound by transferrin if this were 100% saturated. the transferrin saturation is the concentration of iron that is bound to transferrin, expressed as a percentage of the tibc in ida, . the ferritin, serum iron and transferrin saturations are low, but the tibc increases. the serum transferrin concentration (expressed in mg/dl) increases in ida, as the body tries to compensate for low iron levels and this correlates positively with the tibc. in contrast, in anaemia of chronic disease (acd) the ferritin is raised, owing to an increase in the iron regulator hepcidin (14, 15,16). studies have shown that hepcidin expression is unregulated when there is infection or inammation, via inammatory cytokines such as il-6. hepcidin binds to ferroportin (the iron exporter on cells) which results in internalization and degradation of this transporter, which reduces iron release from cells. this failure of release of iron from the ferritin stores results in a low iron, low transferrin saturation and low tibc, with a high ferritin the mean cell volume (mcv) and mean cell hemoglobin (mch) are very sensitive for ida in the absence of b12 deciency or folate deciency. however, they may also be reduced in acd, haemoglobinopathies and sideroblastic anemia. the mch may be more reliable than the mcv as it is less inuenced by storage and the counting machine. in patients with an mcv disproportionately low for the hb, hb electrophoresis should be performed to exclude a haemoglobinopathy. if iron deciency coexists with b12 or folate deciency, the mcv can be high, normal or low. the red cell distribution width (rdw) is a measure of the variation in the diameter of the red cells. the normal diameter of a red cell is 6–8��m. a high rdw occurs in conditions such as ida, b12 deciency and folate deciency. the rdw would be expected to be normal in acd and haemoglobinopathies. measurement of soluble transferrin receptor is more reliable at identifying ida than tibc and iron. the discovery of the iron-regulatory hormone hepcidin in 2001 has revolutionized our understanding of iron disorders. nevertheless, promising applications can already be glimpsed, ranging from the use of hepcidin levels for diagnosing iron-refractory iron deciency anemia to global health applications such as guiding safe iron supplementation in developing countries with high infection burden (18, 19, 20, 21). volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra case no. iron µg/dl ferritin ng/ml tibc transferrin saturation % retic % age/sex year 1 17 8.6 337 5.0 1.0 5/m 2 28 3.6 371 8.0 1.5 22/f 3 20 7.5 355 10.0 1.0 40/f 4 18 9.0 354 9.5 1.4 20/m 5 17 8.5 353 7.9 1.2 35y/f 6 19 8.0 355 7.6 1.5 3/f 7 18 9.0 388 8.6 2.0 78/f 8 17 8.5 380 8.7 2.0 80/m 9 16.9 7.4 389 7.7 1.0 67y/f 10 16.9 7.4 389 7.7 1.0 30/f 11 18 4.1 272 8.0 60y/m case rbc hb hct mcv mch mchc rdw 1 3.8 7.1 25.3 66.6 18.7 28.1 18.7 2 3.3 5.4 20.6 64.0 18.3 29.6 16.8 3 3.5 5.6 20.8 65.0 18.3 28.5 19.0 4 3.6 7.8 21.5 63.0 17.5 27.9 18.5 5 3.7 6.8 22.0 62.5 18.0 28.0 19.0 6 3.5 6.6 23.8 63.0 19.5 27.7 18.8 7 3.6 7.0 22.9 63.0 18.9 26.00 19.6 8 3.9 7.5 23.8 63.0 17.0 27.0 19.0 9 3.7 7.2 23.5 62.0 16.0 26.0 18.0 10 3.4 5.7 20.1 64.0 18.1 28.2 18.5 11 3.3 5.8 21.0 64.5 18.5 29.0 19.0 x 61gjra global journal for research analysis conclusion: iron deciency anaemia is major public health problem. in majority of cases, cbc and iron prole study(serum iron, transferrin, ferritin and tibc) can clinch the diagnosis, however few cases need further investigations and clinical correlation. ferritin is the best indicator of iron deciency and a low ferritin alone is diagnostic of ida. it has not diagnostic importance in clinical setting of chronic inammation and infection. references: 1. sayer jm, long rg. a perspective on iron deciency anaemia. gut. 1993;34:1297–1299. [pmc free article] [pubmed] [google scholar] 2. mcintyre as, long rg. prospective survey of investigations in outpatients referred with iron deciency anaemia. gut. 1993;34:1102–1107. [pmc free article] [pubmed] [google scholar] 3. beutler e, hoffbrand av, cook jd. iron deciency and overload. hematology am soc hematol educ program. 2003;34:40–61. [pubmed] [google scholar] 4. yates jm, logan ec, stewart rm. iron deciency anaemia in general practice: clinical outcomes over three years and factors inuencing diagnostic investigations. postgrad med j. 2004;80:405–410. [pmc free article] [pubmed] [google scholar] 5. kepczyk t, kadakia sc. prospective evaluation of gastrointestinal tract in patients with iron-deciency anemia. dig dis sci. 1995;40:1283–1289. [pubmed] [google scholar] 6. ioannou gn, rockey dc, bryson cl, weiss ns. iron deciency and gastrointestinal malignancy: a population-based cohort study. am j med. 2002;113:276–280. [pubmed] [google scholar] 7. hershko c, hoffbrand av, keret d, souroujon m, maschler i, monselise y, lahad a. role of autoimmune gastritis, helicobacter pylori and celiac disease in refractory or unexplained iron deciency anemia. haematologica. 2005;90:585–595. [pubmed] [google scholar] 8. barabino a. helicobacter pylori-related iron deciency anemia: a review. helicobacter. 2002;7:71–75. [pubmed] [google scholar] 9. sarker sa, mahmud h, davidsson l, alam nh, ahmed t, alam n, salam ma, beglinger c, gyr n, fuchs gj. causal relationship of helicobacter pylori with iron-deciency anemia or failure of iron supplementation in children. gastroenterology. 2008;135:1534–1542. [pubmed] [google scholar] 10. rector wg jr. pica: its frequency and signicance in patients with irondeciency anemia due to chronic gastrointestinal blood loss. j gen intern med. 1989;4:512–513. [pubmed] [google scholar] 11. skikne bs. serum transferrin receptor. am j hematol. 2008;83:872–875. [pubmed] [google scholar] 12. rockey dc, cello jp. evaluation of the gastrointestinal tract in patients with iron-deciency anemia. n engl j med. 1993;329:1691–1695. [pubmed] [google scholar] 13. sawhney ms, lipato t, nelson db, lederle fa, rector ts, bond jh. should patients with anemia and low normal or normal serum ferritin undergo colonoscopy? am j gastroenterol. 2007;102:82–88. [pubmed] [google scholar] 14. kautz l, nemeth e. . molecular liaisons between erythropoiesis and iron metabolism. blood 2014;124(4):479-482 15. young mf, glahn rp, ariza-nieto m, et al. serum hepcidin is signicantly associated with iron absorption from food and supplemental sources in healthy young women. am j clin nutr 2009;89(2):533-538. 16. roe ma, collings r, dainty jr, swinkels dw, fairweather-tait sj. plasma hepcidin concentrations signicantly predict interindividual variation in iron absorption in healthy men. am j clin nutr 2009;89(4):1088-1091 17. prentice am, doherty cp, abrams sa, et al. hepcidin is the major predictor of erythrocyte iron incorporation in anemic african children. blood 2012;119(8):1922-1928. 18. donker ae, raymakers ra, vlasveld lt, et al practice guidelines for the diagnosis and management of microcytic anemias due to genetic disorders of iron metabolism or heme synthesis. blood 2014;123(25):3873-3886 19. aue macdougall i, macdougall i, mast a iron deciency: what are the future trends in diagnostics and therapeutics? clin chem 2013;59(5):740-745. 20. l. a. cohen, l. gutierrez, a. weiss et al., “serum ferritin is derived primarily from macrophages through a nonclassical secretory pathway,” blood, vol. 116, no. 9, pp. 1574–1584, 2010. 21. f. m. torti and s. v. torti, “regulation of ferritin genes and protein,” blood, vol. 99, no. 10, pp. 3505–3516, 2002. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 62 x gjra global journal for research analysis introduction: mobile blast injuries are increasing in recent times. reports are coming from many places of mobile phones suddenly exploding in the hand or in the pocket or after receiving a call, causing disastrous consequences on the patient, family members and society both physically and psychologically. this increase in incidence in recent times is attributed mostly to the usage of cheap, low-quality phone and battery as well as the use of the mobile phone while charging. there are nonchargeable batteries (alkaline batteries, nickel, cadmium batteries) and chargeable batteries (lithium batteries, lead acid batteries). lithium ion batteries are the types used in 1almost all smartphones and electronics. engineers use lithium because it is light and can hold a lot of energy. batteries can explode when they are charged too much or too 2,3,4fast, shoddy manufacturing of devices, overheating etc. mobile battery blast is a highly underestimated aetiology for severe ocular morbidity. we present 3 cases of mobile blast injury that came to us from sep 2018 to aug 2019 case 1: a 29-year-old man sustained injury to both eyes due to mobile phone battery blast while using the device while being charged. at presentation, his re had open globe injury with limbal laceration from 3-5 o' clock and uveal tissue prolapse (figure 1). on le, he had central horizontal corneal tear and uveal tissue prolapse (figure 2). there were charring and few burn injuries of lid and adnexa. on examination, his vision was perception of light (pl) with inaccurate projection of rays in bes. corneal tear repair was done in bes, after a through exploration and taking care of the uveal tissue. after 15 days of follow up, b-scan of bes revealed no foreign bodies in posterior segment. after 3 months of follow up, vision in the re was hand movements (hm) with inaccurate projection of rays, and le pl+ve with inaccurate projection of rays. figure 1 (re) figure 2 (le) case 2: a 7-year-old male presented with pain, burning sensation and watering from both the eyes, following a smartphone battery blast. he was playing games when the mobile was in charge. his presenting visual acuity was 20/40 and 20/60 in right eye and left eye (le), respectively. examination revealed charred lashes, multiple soot particles embedded over conjunctiva, there was no limbal ischemia. the eyes were washed with copious ringer lactate and the debris were carefully removed under slit lamp and eyes were re-examined. fluorescein staining showed supercial corneal epithelial defects. posterior segments and intraocular pressures were normal, with no intraocular foreign bodies. he also had fracture of right forearm, for which he underwent treatment. topical preservative free lubricants, broad-spectrum antibacterial agent, and cycloplegic agent, were prescribed along with systemic nonsteroidal anti-inammatory drug for pain relief. the healing of epithelial defects started next day and was complete by the 3rd day. inammation subsided in 1 week with good nal outcome in both eyes unaided visual acuity 20/20. figure 3 disscusion: lithium-ion batteries are incredibly efcient but have issues mobile blast injury in eye original research paper sharmistha behera associate professor, vssimsar, burla, odisha pramod kumar sharma assistant professor, vssimsar, burla, odisha x 19gjra global journal for research analysis ophthalmology with advancing technology, use of mobile phones has become a routine. indiscriminate use of mobile phones, poor quality equipment, mishandling has resulted in an increased number of blast cases. we feel mobile blast injury is emerging as a new mode of ocular trauma ranging from corneal burn to open globe injury. here we present 2 cases of bombile. prevention is always better by observing mobile safety guidelines. abstract keywords : mobile blast injury volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra ankita mahapatra* rd3 yr. pg resident, vssimsar,burla,odisha *corresponding author jayashree dora professor & hod, vssimsar, burla, odisha satya sundar biswal rd3 yr. pg resident, vssimsar, burla, odisha 20 x gjra global journal for research analysis with heat. they stuff freakish amounts of energy in a tiny package. these batteries may overheat during charging leading to “thermal runaway,” an unregulated increase in 4internal battery temperature. inside the main line of defence against short circuiting is a thin and porous slip of polypropylene that keeps the electrodes from touching. if that separator is breached, the electrodes come in contact, and things get very hot very quickly. the batteries are also lled with a ammable electrolyte, one that can combust when it heats up, then really get going once oxygen hits it. thus, the mechanism of injury from battery blast could be a combination of mechanical (battery pieces), thermal, and 5chemical injuries . zieker aw et al., reported a case about 6 corneal injury due to watch battery explosion. the present data on ocular injury by mobile blast is insufcient. few case reports published from india had presented good outcome on timely and proper management of cases. a case report from 7india published by narang et al has reported grade 1 ocular surface burn with multiple soot particles over cornea and conjunctiva with charred eye. similar ocular injuries due to 8mobile blast were reported by ohri et al data present on morbidity due to mobile blast is underestimated as reported cases from india. had presented good outcome on timely and proper management of cases. a case series from india reporting severe ocular morbidity due to globe rupture with resultant vision of perception of light. only 1 of the 4 eyes could attain the visual acuity of counting nger at 4 feet in the series. 9 our cases were comparable with moderate visual outcome. conclusion: we think, mobile blast injury is emerging as a new mode of ocular injury and can cause fatal blinding complications. references : 1. karabagli y, köse aa, cetin c. partial thickness burns caused by a spontaneously exploding mobile phone. burns 2006;32:922-4. 2. ben d, ma b, liu l, xia z, zhang w, liu f. unusual burns with combined injuries caused by mobile phone explosion: watch out for the “mini-bomb”! j burn care res 2009;30:1048. 3. brown cj, cheng jm. electronic cigarettes: product characterisation and design considerations. tob control.2014;23(2):4–10. 4. shastry s, langdorf mi. electronic vapor cigarette battery explosion causing shotgun-like supercial wounds and contusion. west j emerg med. 2016;17:177–80. 5. a.t. moore, h. cheng, d.l. boase, eye injuries from car battery explosions. br j ophthalmol. 1982; 66(2):141-144. 6. a.w. zieker, j. wisnicki, corneal burns from watch battery explosion. am j ophthalmol. 1979:88 (4);798-799. 7. narang p, mittal v, mittal r, mathur a. ocular surface burn secondary to smart phone battery blast. indian j ophthalmol 2017; 65:326. 8. ohri n, dhiman i, mahendru b, dhiman u. injury following blast of mobile p h o n e b a t t e r y. i n t e r n a t i o n a l a n n a l s o f m e d i c i n e 2 0 1 7 ; 1(8).https://doi.org/10.24087/iam.2017.1.8.265 9. kumar a, gupta p, shukla a. ‘bombile’ [blast of mobile battery in living eye] eye injury – a newer threat to sight volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: retirement is a comprehensive component of the normative life cycle stage, so it is very important to plan for the golden years of life. deciding when to retire may be one of the most important decisions an individual makes during his or her lifetime. although the retirement decision occurs late in time, it can signicantly affect an individual's well-being for many years. when individuals decide to stop working, they must have a way to support themselves nancially, as their income from work will no longer be available. thus, the question of how to support oneself in retirement should be an important consideration in the retirement decision. in addition to the nancial and health aspects of the retirement decision, policymakers and those in the position to guide the choices of future retirees understand the possible behavioural and psychological features of the retirement decision. literature review: ÿ bahrami (2001), the paper examines the factors inuencing faculty members' retirement decisions for this the data from a random, national sample of faculty, ages 56 and older has been used. the impacts that nancial, personal, and institutional factors may have on faculty members' retirement decisions are explored. the paper suggests that the factors such as such as uncapping of the retirement age, current salary, eligibility for full retirement benets, other sources of income, early retirement incentives, social security income, preference for leisure, teaching effectiveness, type of institution, and the level of education of faculty have a signicant inuence on faculty members' decisions to retire. ÿ beh & folk (2012), the paper analyses the inuence of nancial learning on retirees' retirement nancial planning preparation.750 questionnaires were distributed with the return rate of 53.9% return rate. three hypotheses have been analysed using hierarchal regression analysis. in the results it was found that, some mediating effect existed between nancial learning and behavioural assessment of personal nance, and that the older age groups had mediating effect on the relationship between nancial learning and subjective perception of satisfaction with personal nance. within this context the respondents were satised with their nancial situation from behavioural assessment of personal nance, subjective perception and perceived nancial well-being perspective. the study also suggested that the older age groups (above 50 years) had mediating effect on the relationship between nancial learning and subjective perception of satisfaction with personal nance. ÿ chalmers, johnson, & reuter (2008), the study focuses on the factors that affect the choice of retirement date for the purpose of which a large sample of retirement-eligible oregon state employees were considered for the purpose of analyses between 1992 and 2003. as per the situation it was hypothesized that the individuals will infer their optimal retirement behaviour, in part, from the retirement behaviour of their co-workers. the ndings suggest that individuals are economically signicantly more likely to retire in months when more of their co-workers retire and it was also found that there is less effect of the peers in the case of employees whose salaries are in the bottom 25th percentile, where nancial literacy is likely to be the lowest. ÿ davey(2008), ageing of the workforce is likely to lead to labour and skills shortages. the factors inuencing retirement decisions are thus important in personal as well as policy terms. the factors including health and nancial circumstances has been reviewed i this paper with special reference to the new zealand sources, especially the health, work and retirement study. the ndings of the qualitative interviews suggest how the individuals interact and highlight the importance of life-course factors, both personal and contextual which serve as a key to the decisions about the workforce participation in mid and later life. objectives of the study: ÿ to analyse the preferences of individuals towards retirement planning. ÿ to analyse the level of satisfaction of the individuals to different avenues that may be used for retirement planning. ÿ to know the reasons behind not planning for retirement. research design descriptive research design and have been used in the project as it provides the opportunity to cover all the aspects that are required to conduct the research. sampling plan ÿ populationworking individuals from different age groups and occupations. ÿ sampling unitdivided on the basis of age groups under the following two categories: ÿ 21-39 years ÿ 40-59 years ÿ sample size – the total sample size of the project is 137. ÿ sampling methodstratied sampling ÿ sampling frame – ahmedabad city ÿ statistical toolsspss v20 and excel 2013 software have been used for data analysis. a study on individual's retirement planning behavior original research paper smruti vakil management keywords : dr. swati modi* *corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra data analysis: order of preferences 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 total public provident fund 26 5 6 4 2 1 1 1 2 48 post office monthly schemes 6 13 8 6 1 4 1 1 1 1 42 134 x gjra global journal for research analysis chi-square test age & awarness towards retirement savings hypothesis statement: h : there is no signicant association between age & o awareness towards early retirement planning. h : there is signicant association between age & awareness 1 towards early retirement planning. here from the table, if signicant value is less than 0.05, we reject null hypothesis. otherwise we fail to reject the null hypothesis. in the table above, as pearson chi-square value is 0.002 which is less than 0.05, we reject null hypothesis. hence, there is signicant association between age & awareness towards early retirement planning. hypothesis statement h : there is no signicant association between x & y.o h : there is signicant association between x & y.1 findings: ÿ the sources that most inuence people's decision about retirement planning are-family, friends, self-research and work. ÿ out of the total 137 respondents, according to majority of the respondents -i.e.77(i.e. 56.2%) respondents there is no adequate market awareness on early retirement planning and as per the 60 respondents i.e. (43.8%), there is an adequate market awareness on early retirement planning. ÿ out of the total 137 respondents, majority of the respondents i.e.-85 (i.e. 62%) respondents don't invest for their retirement savings and 52 (i.e. 38%) respondents invest for their retirement savings. ÿ out of the 52 respondents, who invest for their retirement savings, majority of the respondents i.e. 19 respondents think that they have an adequate quality of information about retirement, 18 respondents think that they have good quality of information about retirement, 10 respondents think that they have very good quality of information about retirement and 9 respondents think that they have poor quality of information about retirement. ÿ out of the 52 respondents, who invest for their retirement savings, majority of the respondents i.e.33 respondents have estimated the savings they would need at retirement considering their desired retirement age and life expectancy and 19 respondents have not estimated the savings they would need at retirement considering their desired retirement age and life expectancy. ÿ majority of the respondents i.e. 50 respondents have prioritized the statements“lump sum amount available to the legal heir” and “flexibility in terms of stable source of income or support to family in case of death” and from that too-25 respondents have rated“flexibility in terms of stable source of income or support to family in case of death” as most important in terms of planning for retirement. ÿ majority of the respondents i.e. 48 respondents have chosen public provident fund (ppf) as their preference for investment for retirement planning and amongst all the retirement planning that have been considered for analysismajority of the respondents have ranked ppf as sttheir 1 preference for investment for retirement. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra annuities 6 8 8 5 1 2 1 1 1 1 34 bank fd 19 12 7 1 3 1 1 2 46 gold 10 13 9 5 1 1 1 1 1 42 real estate 9 7 7 9 4 2 1 1 1 1 1 43 national pension schemes 8 8 10 3 2 4 1 1 1 1 39 order of preferences 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 total sovereign gold bonds 4 13 7 3 2 1 3 1 1 1 36 life insurance (endowment plans) 12 12 8 3 4 2 1 1 1 1 45 term plan insurance 8 14 5 5 4 1 1 1 1 1 41 employee provident fund 10 8 7 5 3 2 1 1 2 39 national savings certificates 11 7 8 4 1 1 1 1 1 1 1 1 38 shares 7 5 10 6 2 3 1 4 1 1 1 2 43 gratuity 7 9 8 5 2 1 2 1 1 36 mutual funds 11 7 10 6 3 2 2 1 2 44 particulars value df asymp. sig. (2sided) exact sig. (2sided) exact sig. (1sided) pearson chi-square 9.238a 1 .002 continuity bcorrection 8.178 1 .004 likelihood ratio 9.527 1 .002 fisher's exact test .004 .002 linear-by-linear association 9.170 1 .002 n of valid cases 137 demographic variables(x) investment-retirement savings(y) age investment for retirement savings gender investment for retirement savings marital status investment for retirement savings education level investment for retirement savings income level investment for retirement savings occupation investment for retirement savings particulars signifi cance accept/ reject h0 age & do you invest 0.883 accept h0 gender & do you invest 0.008 reject h0 marital status & do you invest 0.062 accept h0 education level & do you invest 0.435 accept h0 income level & do you invest 0.290 accept h0 occupation & do you invest 0.011 reject h0 x 135gjra global journal for research analysis ÿ 46 respondents have provided their preferences for investment in bank fixed deposits (fd's) for retirement stplanning and 19 respondents have ranked it as their 1 preference for investment for retirement planning. ÿ 45 respondents have provided their preferences for life insurance (endowment plans) as an avenue to investment in for retirement planning and 12 respondents have stranked it as their 1 preference for investment for retirement planning. ÿ 44 respondents have provided their preferences for mutual funds as an avenue to investment in for retirement stplanning and 11 respondents have ranked it as their 1 preference for investment for retirement planning. ÿ 43 respondents have provided their preferences for real estate and shares as the avenues to invest in for the purpose of retirement planning and 9 respondents have stranked real estate as their 1 preference and 7 strespondents have ranked shares as their 1 preference to invest in for the purpose of retirement planning. ÿ 42 respondents have provided their preferences for gold and post ofce monthly schemes as the avenues to invest in for the purpose of retirement planning and 10 strespondents have ranked gold as their 1 preference and 6 respondents have ranked post ofce monthly schemes stas their 1 preference to invest in for the purpose of retirement planning. ÿ 33 respondents have ranked their satisfaction for the bank fixed deposits and 12 respondents each are highly satised and satised, 6 respondents are neutral, 2 respondents are dissatised and 1 respondent is highly dissatised with the rate of interest provided by the fd's. ÿ 31 respondents have ranked their satisfaction from investment in mutual funds: ÿ 7 respondents are highly satised, 11 respondents are satised, 10 respondents are neutral, 3 respondents are dissatised with the factor“higher rate of returns than other avenues” for mutual funds. ÿ 8 respondents are highly satised, 12 respondents are satised, 9 respondents are neutral, 1 respondent is dissatised and 1 respondent is highly dissatised with the factor“more tax benets” of investment in mutual funds. ÿ 29 respondents have ranked their satisfaction from investment in gold: ÿ 9 respondents are highly satised, 11 respondents are satised, 6 respondents are neutral, 2 respondents are dissatised and 1 respondent is highly dissatised with the factor“the expected rate of returns” from investment in gold. ÿ 2 respondents are highly satised, 9 respondents are satised, 13 respondents are neutral and 4 respondents are highly dissatised with the factor “a safe mode of investment” gold. ÿ 29 respondents have ranked their satisfaction from investment in post ofce monthly schemes and 6 respondents are highly satised, 13 respondents are satised, 9 respondents are neutral and 1 respondent is dissatised with the factor“requirement of minimum investment” for making investment in post ofce monthly schemes. ÿ 29 respondents have ranked their satisfaction from investment in term plan insurance: ÿ 10 respondents are highly satised, 11 respondents are satised, 6 respondents are neutral and 2 respondents are dissatised with the factor“providing security at nominal cost” from making investment in term plan insurance. ÿ 5 respondents are highly satised, 17 respondents are satised, 5 respondents are neutral, 1 respondent is dissatised and 1 respondent is highly dissatised with the factor “flexibility to receive payout as monthly income or amount in lumpsum” by making investment in term plan insurance. ÿ 28 respondents have ranked their satisfaction from investment in public provident fund (ppf): ÿ 16 respondents are highly satised, 8 respondents are satised, 4 respondents are neutral and no respondents are dissatised with the factor“high tax benets” that an individual may get by making investment in ppf. ÿ 8 respondents are highly satised, 11 respondents are satised, 7 respondents are neutral and 2 respondents are dissatised with the factor “serves as a mode of collateral” for ppf. ÿ 13 respondents are highly satised, 6 respondents are satised, 8 respondents are neutral and 1 respondent is dissatised with the factor “easy withdrawal facility” for ppf. conclusion: one big reality of life is retirement, and planning for retirement is still a nascent concept in india. although it is thought about and talked about all over, but the actions for retirement planning are still not focused by individuals. retirement planning is very dynamic process and is affected by numerous factors. individuals need to keep an eye of the social, economic and political factors along with his requirements while planning for retirement. retirement is a comprehensive component of the normative life cycle stage, so it is very important to plan for the golden years of life. deciding when to retire may be one of the most important decisions an individual makes during his or her lifetime. references: 1. bahrami, b. (2001). factors affecting faculty retirement decisions. the social science journal, 38(2), 297-297chalmers, j. m., johnson, w. t., & reuter, j. (2008). who determines when you retire? peer effects and retirement (no. onb08-13). national bureau of economic research. 2. davey, j. (2008). what inuences retirement decisions?. social policy journal of new zealand, 33, 110. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 136 x gjra global journal for research analysis i. introduction: introduction micronance in informal system was in vogue in india in the form of chit funds, etc., since time immemorial. it came into existence under formal system with the advent of cooperative movement in india in the beginning of the last century. the micronance is primarily based on the principles of cooperation namely, mutual help, democratic functioning etc. though, the co-operative movement was initially envisaged with unlimited liability and small size of societies consisting of homogenous groups, over the years in the quest for improving the viability of co-operatives, large societies with limited liabilities were organized. this apart, the evolution of state partnership in co-operatives with entrenched bureaucracy etc., distanced co-operative movement from the spirit of micronance movement. the micronance industry's loan portfolio stood at rs.1.79 trillion in fy19, a growth of 40 per cent over the preceding scal year. of this share of nonbanking financial companies-micro finance institutions (nbfc-mfi) was the highest at 68,156 crore, 38 per cent of the portfolio; banks came next with rs.59,999 crore with a share of 34 per cent. nbfc-mfcs also have highest number of unique live customers and they top on parameters like the number of active loans, size of the portfolio and amounts. economic empowerment as nbfc-mfi micronance as provision of thrift, credit and other nancial services and products of very small amounts to the poor in rural, semi urban areas enabling them to raise their income levels and improve living standards in india. status of micro finance in india information from various sources on the sector has over the years come out as a credible document well received by policy makers as well as practitioners are availing loans from this micronance institutions from as a group, take loan from the bank collectively, promote saving habit and develop self and community assets among themselves. *senior fellow (icssr), department of statistics, s.v. university, tirupati 517502 in the process, india has become the fourth largest economy in the world. in the last two decades, a signicant proportion of the population across the country has reaped the benets of this economic growth. they have become part of the global economy and market, and their lives have been transformed with all the comforts and luxuries of modern nascence. apart from this burgeoning middle class in the country, the economic growth seemed to have touched the lives of the poor also. according to the national sample survey results, the number of people living below poverty line has dramatically come down during the post economic reform era. people living below poverty line (bpl) came down from 36 per cent in 19931994 (50th round, nsso) to 26 per cent in 1999-2000 (55th round, nsso). in the eleventh plan the target of reducing poverty ratio to 20 per cent by 2012 and 5 per cent by 2017. poverty is characterized by the vulnerability, powerlessness and dependency as well as by lack of income. collective organization and ownership of wealth-the capital fund and thus of a signicant economic and social structure both address the psychological consequences of being poor and challenged the wider structures of society. ii. impact of economic growth in nbfc-mfis the fruits of economic growth have not beneted everyone uniformly. some are left behind and some others are not touched by the benets of economic growth. it is proved globally that the so-called trickledown effect does not work in all the societies and india is no exception to this. there are various reasons for this uneven development in the society. modern economy is technology driven and not labourintensive. high volume of high quality goods and services are produced with fewer hands. in short, the modern economy is not generating much employment and sometimes it displaces and replaces labour with machines and tools. the period of 1999-2000 to 20172018 saw rapid economic growth in the country but it has not impacted on the unemployment problem of the country. during this period, the unemployment rate remained almost same for rural males and decreased by just one percentage for urban male. on the other hand, unemployment among females increased by one percentage for both urban and rural females. one-third of the country's population is still illiterate and the majorities are not educated up to the age of 15 years. even among the educated, all do not have employable skills needed by the modern economy. further, poverty is not uniformly spread in the country. states like orissa, bihar and madhya pradesh have high level of poverty and the levels have not come down signicantly in the post economic reform era. it is also pertinent to understand that some of them are unable to be part of the economic reform and do not have the capacity to participate in the economic development process. such groups need government intervention to ensure that they are not left behind in the development process and deprived of the benets because they do not have the capacity to be part of the global economy. the government needs to develop safety nets for such groups and try to mainstream them in the development process. they need welfare measures in the form of poverty alleviation programmes to ensure that they survive, if not prosper, in this era of economic reform. further, the poor are not a homogeneous population and their capacity to survive the economic reform varies from one group of poor to another. especially, those who are below the poverty line or the poorest among the poor need more government help. iii. non-banking finance companies – micro finance institutions the micronance industry's gross loan portfolio (glp) stood at rs 1,87,386 crore at the end of march, up 38 per cent year-onyear. the total number of micronance accounts was 9.33 crore at the end of march 2019, showing a growth of 21.9 per cent, micronance institutions network (mfin), an rbirecognised self-regulatory organisation and industry association of the micronance industry. non-banking finance company-micronance institutions (nbfc-mfis) hold the largest share of portfolio in micro-credit with the total loan outstanding of rs 68,868 crore, which is 36.8 per cent of total micro-credit universe. as on march 31, 2019, aggregated glp of nbfc-mfis stood at rs 68,207 crore, 47 per cent yearon-year growth compared to march 2018, said mfin. in 201819, micronance in india showed rapid, regionally-balanced and resilient growth. financial inclusion status of non-banking finance companies – micro finance institutions (nbfc-mfis) economic empowerment in india original research paper prof. r. abbaiah* *corresponding author x 25gjra global journal for research analysis arts keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 26 x gjra global journal for research analysis apart from the growth in loan size and loan accounts, the growth of the staff of nbfc-mfis was also heartening at 34 per cent, now totalling to 1,04,973 people. mfin members constitute 53 nbfc-mfis and, collectively, they have disbursed 3.25 crore loans worth rs.82,928 crore during 201819. compared with the nancial year 2017-18, there has been a year-on-year increase of 28 per cent in number of loans disbursed and 44 per cent in loan amount disbursed. in 201819, nbfc-mfis received a total of rs 35,759 crore in debt funding (from banks and other nancial institutions). "this represents a growth of 63 per cent compared to 2017-18. total equity grew by 42 per cent during the same period and is at rs 14,206 crore. mfin's current primary members consist of 53 nbfc-mfis along with 38 associates including banks, small nance banks and nbfcs. the muthoot finance has been recognised as one of the top 30 excellent workplaces in india by cnbc tv 18 and skill tree global knowledge consortium. our employee centric practices such as internal promotions to leadership roles, giving the employees ample opportunities for growth and development, encouraging innovation among others form a signicant part of this recognition. with a global presence, 20 diversied divisions and a customer base of over 6 million, the finance group provides its employees with innite growth opportunities. the finance group, which serves over 2 lakh customers on a daily basis, is a multi-dimensional conglomerate and also one of the leading industry players to work with. with its wide scale of operations and overseas presence, not only offers boundless growth but also gives its employees a chance to work beyond indian geographies. today over 30,000 employees constitute the ever increasing group family. the undying efforts and hard work of these employees have been instrumental in taking group where it stands today. we believe in the simple dictum of "progressing with the people". to become the preferred choice of nancial services partner for aspiring classes, meeting the full range of their credit requirements, and helping become a nancially inclusive society where every citizen has ready access to formal channels of nance. manappuram finance limited is dedicated to the mission of bringing convenience to people's lives and making their lives easier. we offer secured and unsecured credit to meet their varied nancial needs from instant gold loans to micronance, affordable home loans, vehicle nance and more. at finance we value our reputation for integrity in our dealings, treat our customers with the utmost fairness. no matter what their economic status is, we offer everyone prompt and courteous service, with high levels of transparency. micro credit continues to invest heavily in technology to enhance customer experience and drive efciency in operations. nbfcs believe in tech-led innovations to deliver seamless and responsive nancial services of ever greater value to customers. iv. work participation rate and employment there is an old sanskrit saying in india, viz., 'udyogam purusha lakshanam'. but in poor families like those of small and marginal farmers, agricultural labourers, where the two hands of husband are not sufcient to meet both the ends, women come out of homes and shoulder the responsibility along with their spouses. but in middle and high class societies women have been largely conned to their homes mainly due to social inhibitions. even the level of economic production is likely to be higher, other things being equal, in a society where their life is not conned to domestic work. studies conducted by the m.s. swaminathan research foundation have shown that most poor women work 18 hours a day. of this, seveneight hours go to economic activity, which fetches them a meager rs.30-35. the remaining time is taken up in household chores and other activities such as collecting fodder and fetching water soon which do not have any economic value. while the strenuous work of women in household and unorganized sectors largely goes economically unrecognized and unrewarded, the situation in organized sector is a different one. most women do not get even entry into the employment in organized sector. in fact gross inequalities are manifest in gender-wise employment in organized sector in india. one consoling feature, as could be observed from the table, is that gender disparities in employment seemed to be gradually narrowing down over the years 1997, 2003 and 2018. table-3.5 gender wise employment in organized sector in india source: govt. of india, economic survey 2018, p.s-42 www.eci2018.co.in. this apart, top administrative and management, positions are largely controlled by males as well as professional and technical cadres. while in industrial countries women accounted for 48 per cent of administrators and managers, and 52 per cent of professional and technical workers, the corresponding gures for india were 6 per cent and 28 per cent respectively. v. determinants of economic development empirical evidence shows that women have important impetus for growth and development of an economy. they have strong ability to save and invest in their families and, thereby, to contribute in the development, especially, of the rural economy. when involvement of women in income generating activities takes place, economic development also takes place. therefore, we assume that the economic development is a function of the involvement of women in income generating activities, and all factors that may affect the economic development are exogenous, and women have free access in income generating activities. thus we identify two variables, 'participation of women in income generating activities', and 'economic development', and try to assess the impact of income generated by working women on economic development through following econometric model. yi = b0 + b1 xi + ei where yi is expenditure, which is poverty for economic development. if the rural areas experience economic development, the standard of living of rural people will increase, and increased amount of household expenditure will reect higher level of economic development. yt = b0 + b1 xt + et the variable x is the monetary income generated by the self developed working women and is a proxy for income generating activities in selected rural areas. thus the equation 1 measures the impact of income generating activities in the economic development of selected areas of nellore district in andhra pradesh. besides we also test the following model to assess how the income generated by rural women accelerates small savings, and thereby, contributes in economic development. vi. poverty alleviation poverty is a state of deprivation. in absolute terms it reects the inability of an individual to satisfy certain basic minimum needs for a sustained, healthy and a reasonably productive life. conceptually, any attempt at quantifying the incidence of volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra year public sector private sector total male female male female male female 1997 86.06 13.94 78.02 21.09 83.53 16.42 2003 84.65 15.45 76.20 24.15 81.34 18.64 2018 85.10 19.24 76.09 29.20 87.40 26.35 poverty in any population requires taking into account the level and pattern of an individual's personal consumption expenditure, as well as his access to social transfers and public provisioning. however, it is not easy to measure the consumption shares of an individual in the publicly provided goods and services or the benet he or she derives from the overall social contexts, for often it is not possible to price them or they are provided free of charge, even through it all adds up to the well-being of the concerned individual. in general, therefore, for identifying the poor one looks at the level of personal expenditure (or more) that enables the individual to satisfy a certain minimum consumption level. india has reduced its poverty rate to 12.4 per cent from the 2013-14 estimates of 20 per cent, according to new data released by world bank, which identied rural electrication as an important driving factor for everything from greater rural spending to schooling for girls. against the earlier estimate of 269 million people living below the poverty line, according to government data, india now has 172 million people, although the world bank revised the line upwards. the proportion of population not able to attain the specied level of expenditure is then segregated as poor. planning commission, government of india, has been estimating the head count ratio of the poor at state level, separately for rural and urban areas for over three decades. it currently uses a minimum consumption expenditure, anchored in an average(food) energy adequacy norm of 2400 and 2100 kilo calories per capita per day to dene state specic poverty lines, separately for rural and urban areas. poverty, like other macroeconomic variables such as unemployment, can be reduced by economic growth, but requires special programs. agricultural research can make a contribution to this effort a critical, albeit small, one. on the basis of the poverty line as dened by india's planning commission, more than three-quarters of the poor in india are in rural areas and the severity of poverty, as measured by poverty gap measures, is much greater in rural areas. moreover, progress in overcoming poverty in rural areas has been slower in recent years, as the focus of economic policy has been shifting toward increased liberalization of the economy. in this way shgs have an – built mechanism where emphasis has been given over capacity building of women through developing their dialoguing skills. an nbfc-mfi functions through its regular meetings, where members perform transactional activities and discuss over different related issues. this discussion among the group members is the means through which they give voice to their needs and it proves to be a platform for addressing their social and economic problems and enlightening their inner selves as well. conclusion the biological sex differences men and women bring with them in all known societies enormous cultural divisions. in fact women and men see their own lives, from the inside, very differently. add to this, social institutions and attitudes everywhere divide up kinds of activity between the sexes and deprive women of their true role in society leading to denigration of intelligence, stiing of initiative and blocking of progress of man and women. this invariably gives rise to gender inequality. the gender inequalities build on each other; lower levels of female literacy and female labour force participation lead to signicantly higher level of infant mortality and push up fertility levels. these in turn cement circular causal links with low literacy, low female labour force participation, low income and low status of women. preventing women from participating in social, political and economic life hurts the people as a whole, not just women. gender inequality is not only a social failure in itself; it also leads to other social failures. any attempt to improve the status of indian women, any attempt to them wean away from the patriarchal bias, any attempt to undo the centuries of injustice meted out to the other half of the society, and aggressive movement towards women autonomy must necessarily carry an economic base. short of this, it would only be a political platitude. development is a long process. it has to pass through different stages. in the rst stage, women should be trained to look into the situation from different perspectives and recognize the power relations that perpetuate their oppression. at this stage, the women share their feelings and experiences with one another and build a common vision and mission. in the second stage, the women try to change the situation by bringing about a change in the gender and social relations. in the third stage, the process of empowerment makes them more mature to realize the importance of collective action. vii. references 1. nabard reports (2017, 2018 & 2019) poverty reduction project eshakti programme pilot survey report, p.18,22,26. 2. vasant desai (2016), “prole of a women entrepreneur, entrepreneurial development”, himalaya publishing house, new delhi. 3. v.g.s. brilliant series, current affairs: 2014-2015. 4. ch. hanumantarao & s. mahendra dev 2018, andhra pradesh development economic reforms and challenges a head, 2018. 5. govt. of. india 2018, economic survey. 6. oxford, national human development report – 2015. 7. vasant desai 2017, “economic reforms: a challenge for development”, himalaya publishing house, new delhi, pp.12-14. 8. economic and political weekly’s, 2018-19, and www.ies.gov.in. 9. govt. of india census reports 2011. 10. www.statisticalabstracts.org. 11. www.apstatisticalabstracts.org. x 27gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction headache also dene as pain located in the head, above the [1]orbitomeatal line and/or nuchal ridge. disorders of headache are one of the most common disorder in the central [2]nervous system. it may manifest as migraine, tension type headache, or cluster headache. headache may affect the social, functional & occupational-related works. there is a heightened risk of psychiatric comorbidity with cephalgia especially depressive [2]and anxiety disorders. there are numerous classication systems available for headaches. however, the most well-recognized is that of the international headache society which encompasses all probable aetiologies and is comprehensive. currently, we utilize the international classication of headache disorder 3rd edition (ichd-3) given by the international headache [1]society (ihs). previous studies have shown a high prevalence of headache among young age group, their lifestyle puts them at high risk to suffer from tiredness, tenseness and anxiousness which are the most common causes of tth and migraine. the prevalence of migraine and tth was reported to be higher among women. migraine and tth sufferers were found to have a higher risk to develop depression. psychiatric disorders as depression are associated with increased [3]headache-related disability. often overlooked is the high prevalence of psychiatric comorbidities associated primary headache, such as depression, anxiety. headache with psychiatric comorbidity have higher healthcare utilisation tendencies than headache without psychiatric comorbidity. if left untreated, these comorbid psychiatric conditions can increase the risk of headache to turn chronic in nature. in addition, if left untreated, the comorbid psychiatric conditions can increase headache-related disability, reduce quality of life and [4]negatively impact treatment outcomes. in the present study, we analysed the prevalence of primary headaches & depression. methodology & procedure this was a cross-sectional hospital-based study of 200 patients to cognize the prevalence of depression and anxiety in the patient suffering from primary headache. primary headache patients aged between 18-65 years were included in the study. patients having any other major physical, endocrinology, current scheduled use of any anti-psychotics, anti-depressants, pregnancy were excluded. written informed consent was obtained from all participants after complete description of the study to the subjects. a detailed physical examination was done to rule out major medical or neurological illness. evaluation of the samples was done as per procedure of methodology. subjects were included in the study from headache clinic of department of psychiatry, mgm, medical college, indore after meeting inclusion criterion. subjects not meeting inclusion criteria or meeting exclusion criteria were excluded from the study. department of psychiatry runs headache clinic on every tuesday during opd hours in opd block. socio-demographic data was collected. after obtaining the written consent from subject, subject were included in study. a detailed assessment of the patients complaint was done on the basis of headache questionnaire and diagnosis was formulated clinically in accordance with international classication of headache disorders. depression was diagnosed using icd-10. afterwards ham-d scale was used for assessment of severity of depression. all the collected information was stored and later digitalized for interpretation. resultstable 1. description of depression in different types of primary headache. to study the prevalence of depression in patients suffering from headache in psychiatry opd in a tertiary care institute original research paper prasad s m.d resident, m.g.m. medical college, indore x 147gjra global journal for research analysis psychiatry background: primary headache and psychiatric disorders are quite often comorbid, previous studies have reported that depression have bidirectional relationship with headache. the research in india in this eld strikingly scarce. aims: to investigate the subtypes of headache and correlation with depression in patients who comes in psychiatry opd. methodology: our study is a descriptive cross sectional study with 200 sample size. patients with headache in headache clinic of department of psychiatry, mgmmc, indore. patient aged between 18-65 years , either sex. diagnosis of headache was done clinically in accordance with international classication of headache disorders, while depression was diagnosed as per icd10. semi-structured headache questionnaire, hamilton depression rating scale were used for assessment of samples. results: among 200 patients, there were 73(36.5%) males and 127 (63.5%) females. the mean age was 33.35 ± 10.7 years. tension type headache was 73.5%, migraine was 22%,mixed headache was 4.5%. tension-type headache (73.5%) was the most predominate type of headache. depression in primary headache was 68%. depression was more in females (59.5%) than males(40.5%). it was also more in urban (60.3%) than semi urban areas (26.5%) & rural areas (13.2%). conclusion: patients with headache had higher comorbid depressive disorder. screening patients with headache for depression and timely psychiatric intervention can go a long way in improving the quality of life of headache patients with comorbid depressive disorder. abstract keywords : primary headache, depression, prevalence paliwal a* m.d, associate professor, m.g.m. medical college, indore*corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra tth migraine mixed n=200 depression present 103 28 5 136 (68%) depression absent 44 16 4 64 (32%) total 147 44 9 200 (100%) 148 x gjra global journal for research analysis in our study, of the 200 primary headache cases 68% had depressive disorder. table 2. sociodemographic variables of the patients suffering from depression primary headache with depression had 32.4 years as mean age of onset. primary headache with depression had more females, married, hindu religion, illiterates, housewife, urban based samples. table 3. description of different types of headache & depression tth cases had depression at 70.1% while migraine & mixed headache cases had depression in 63.6% & 55.6% respectively. table 4. description of age group(in years) of different types of headache & depression most of tth cases with comorbid depression belonged to age group between 18 – 31 years at 50.4% while 32% & 17.4% cases belonged to age group between 32 – 45 years & 46 – 60 years respectively. most of migraine cases with comorbid depression belonged to age group between 32 – 45years at 53.5% while 46.4% cases belonged to age group between 18 – 31years. most of mixed headache cases with comorbid depression belonged to age group between 18 – 31 years (60%) while 40% cases belonged to age group between 32 – 45 years. table 5. description of gender-wise distribution in different types of headache with comorbid depression most of tth cases with comorbid depression were female 59.2% while 40.8% cases were male. most of migraine cases with comorbid depression were female 64.3% while 35.7% cases were male. most of mixed headache cases with comorbid depression were male 60% while 40% cases were female. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra depression patients with primary headache (n=136) age(mean) in years 33.3 years f : m 1.47 marital status in %: married 73.5% unmarried 26.5% religion in %: hindu 69.1% muslim 30.9% education in %: illiterate 25.7% primary (5th ) 9.6% middle(8th) 15.4% high school 11.8% inter 14.7% diploma/graduate/post graduate professional 22.8% occupation housewife 53.7% private job 29.4% labour 16.9% locality urban 60.3% semi urban 26.5% rural 13.2% types of headache with depression(%) total tth 103 (70.1%) 147 migraine 28 (63.6%) 44 mixed 5 (55.6%) 9 total 136 200 types of headache age groups depression 18 – 31 32 45 46 60 count count count count(%) tth 52(50.4%) 33(32.0%) 18(17.4%) 103(100%) migraine 13(46.4%) 15(53.5%) 0(0%) 28(100%) tth with migraine 3(60%) 2(40%) 0(0%) 5(100%) types of headache sex depression male female count count % count n % count(%) tth 42 40.8% 61 59.2% 103(100%) migraine 10 35.7% 18 64.3% 28(100%) tth with migraine 3 60.0% 2 40.0% 5(100%) table 6. description of community of different types of headache with comorbid depression types of headache locality depression urban semiurban rural count % count % count % count(%) tth 60 58.3% 28 27.2% 15 14.6% 103(100%) migraine 20 71.4% 7 25.0% 1 3.6% 28(100%) tth with migraine 2 40.0% 1 20.0% 2 40.0% 5(100%) most of tth cases with comorbid depression belonged to urban locality at 58.3% while 27.2% & 14.6% cases belonged to semi urban & rural locality respectively. most of migraine cases with comorbid depression belonged to urban locality at 71.4% while 25.0% & 3.6% cases belonged to semi urban & rural locality respectively. most of mixed headache cases with comorbid depression belonged to urban locality at 40% while 20% & 40% cases belonged to semi urban & rural locality respectively. table 7. description of occupation of different types of headache with comorbid depression majority of tth cases with comorbid depression were housewife at 56.3% while 29.1% & 14.6% of cases were doing private job & labour work respectively. majority of migraine cases with comorbid depression were housewife at 46.4% while 35.7% & 17.9% of cases were doing private job & labour work respectively. majority of mixed headache cases with comorbid depression were doing labour work in about 60% cases while only 40% cases were housewife. types of headache occupation depression housewife labour private job count % count % count % count(%) tth 58 56.3% 15 14.6% 30 29.1% 103(100%) migraine 13 46.4% 5 17.9% 10 35.7% 28(100%) tth with migraine 2 40.0% 3 60.0% 0 0.0% 5(100%) x 149gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra table 8. description of different types of headache with comorbid depression & ham – d score the tth cases had a mean of ham -d score 16.5 ± 6.1. the maximum score were 28 respectively while minimum score was 8. migraine cases had a mean of ham -d score 15.9 ± 7.1. the maximum score were 27 respectively while minimum score was 8. the mixed headache had a mean of ham -d score 14.2 ± 7.3. the maximum score were 24 respectively while minimum score was 8. table 9. description of different types of headache with comorbid depression & severity of depression most of tth cases had mild depression at 36.8% while 25.2%,19.4% & 18.4% cases had severe depression ,moderate depression & very severe depression respectively. most of migraine cases had mild depression at 46.4% while 21.4%,21.4% & 10.7% cases had severe depression, very severe depression & moderate depression respectively. most of mixed headache had mild depression at 60% while severe depression & very severe depression found in 20% cases respectively. table 10. comparison of mean of ham -d score of different types of headache there were no statistical signicant differences between the mean of ham d scores of different types of headache p-value > 0.05. discussion in our study, of the 200 primary headache cases 68% had depressive disorder.(table 1). we established that tth cases had depression at 70.1% while migraine & mixed headache cases had depression in 63.6% & 55.6% respectively. (table 3) which were in agreement with the previous studies like bera et [5] [6] [7] [8] [9]al. ,shoib et al. , beghi et al. , jette et al. , desai et al. , aich [10]et al. who also found depression is comorbid with primary headache. in our study we observe that about half of the tth cases with comorbid depression were between 18 – 31 years of age at 50.4%, while about half of migraine cases with comorbid depression were between 32 – 45 years of age at 53.5% and about more than half of mixed cases were between 18 – 31 years of age at 60%.(table 4) similar ndings were found by [4] [10] [11] [12]sharma et al. , aich et al. ,bhachech et al. ,thomas et al. they also found that primary headache with comorbid depression more common between age group of 18 – 45 years. the depression is very much common in all three types of headache, it can be secondary to headache or headache can be the secondary to depression and depression is the psychiatric illness which is important in affecting the course and severity along with contributing to the effect of depression on morbidity of life. we found that about more than half cases of primary headache with comorbid depression were female and rest were male. about 59.2% of tth cases with comorbid depression were female while 64.3% of migraine cases with comorbid depression were female. in mixed headache cases with comorbid depression about 60% cases were male in abundance while 40% cases were female. it may be due to small sample size of mixed headache cases. (table 5). our study ndings also supported by previous literature gupta r, [13] [4]bhatia ms et al. 2011 , sharma h, shah s et al. 2006 , aich [10]tk, gupta u et al. 2018 which is demonstrated that primary headache is prevalent in the female. primary headache more frequent in female as compared to male is thought to be due to factors such as social expectations, social limitations and stress of life issues, sensitivity to the hormone, genetics, and differences in response to stress and pain perception can help to explain this difference. in our study, most of tth cases with comorbid depression belonged to the urban community at 58.3%, while 27.2% of cases belonged to semi-urban community & 14.6% cases belonged to the rural community. most of the migraine cases with comorbid depression belonged to the urban community at 71.4%, while 25% of cases belonged to the semi-urban community & 3.6% cases belonged to the rural community. most of the mixed headache with comorbid depression cases belonged to the urban community at 40%, while 20% cases belonged to semi-urban & 40% cases belonged to rural community. (table 6). the urban majority can be explained by the fact that our study centre is a tertiary healthcare institute which is based in an urban setting and most patients who [6]visited the hospital were urban dwellers. shoib s et al. shows a similar distribution of the community. we found that the majority of primary headache with comorbid depression cases were housewives (unemployed) at 40 – 60%. most of tth cases with comorbid depression were housewives at 56.3%, while most of the migraine cases with comorbid depression were housewives at 46.4% and about 40% cases of the mixed headache with comorbid depression were housewives. (table 7) which is backed by sharma h et [4] [11] [14]al. , bhachech et al. , shankar et al. . the higher prevalence of comorbid depression is thought to be due to factors such as social expectations, social limitations and stress of marital life issues. we concluded that the mean of ham -d score of tth cases with comorbid depression was 16.5 ± 6.1, while the mean of ham -d score of migraine cases with comorbid depression was 15.9 ± 7.1 and the mean of ham -d score of mixed headache cases with comorbid depression was 14.2 ± 7.3. (table 8) most of tth cases had mild depression at 36.8%, most of the migraine cases had mild depression at 46.4% and most of the mixed headache had mild depression at 60%.(table 9). we concluded that in our study most of the primary headache types of headache n minimum maximum mean std. deviation tth 103 8.00 28.00 16.5049 6.12592 migraine 28 8.00 27.00 15.9643 7.14652 mixed 5 8.00 24.00 14.2000 7.36206 types of headache mild moderate severe very severe total tth 38 (36.8%) 20 (19.4%) 26 (25.2%) 19 (18.4%) 103 (100%) migraine 13 (46.4%) 3 (10.7%) 6 (21.4%) 6 (21.4%) 28 (100%) mixed 3 (60%) 0% 1 (20%) 1 (20%) 5 (100%) types of headache n ham-d mean std. deviation std. error tth 103 16.5049 6.12592 .60361 migraine 28 15.9643 7.14652 1.35057 mixed headache 5 14.2000 7.36206 3.29242 total 136 16.3088 6.35553 .54498 anova ham d score sum of squares df mean square f sig. between groups 29.518 2 14.759 .362 .697 within groups 5423.512 133 40.778 total 5453.029 135 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 150 x gjra global journal for research analysis cases had mild depression, this nding is different from the [11]nding of bhachech et al. , which found that the majority of cases had moderate depression. however, they also found that mild depression was also quite commonly associated with primary headache, this nding was similar to the nding [9]of desai et al. . the mean of ham – d score (table 10) did not vary statistically within different categories of primary headache. (p-value is > 0.05). our ndings are similar to the ndings of bhachech et [11] [9]al. and desai et al. . conclusion in conclusion, this study has demonstrated that out of all three types of primary headache, there was a very high prevalence of tension-type headache. we concluded that the majority of patients with primary headache had depressive disorder. we conrm that the majority of patients with tension-type headache had comorbid depression at 70.1% while migraine & mixed headache cases had depression in 63.6% & 55.6% respectively. our study demonstrates a clear relationship between headache and depression in patients. also, depressive disorders are more likely to be found in young adults with more disabling headaches. after analysing the present study ndings, we concluded that primary headache should be assessed for comorbid depression and treated as a comorbid disorder because it might worsen the headache or psychiatric comorbidity or both. if both are not treated simultaneously. screening patients with a primary headache for depressive and welltimed psychiatric intervention can go a long way in improving the quality of life of headache with comorbid depressive disorder. limitation are small sample size, samples were recruited only from a headache clinic run by department of psychiatry in a tertiary care center which could increase the bias for obtaining comorbid psychiatric disorders. future studies with a larger sample size, longitudinal design are warranted as per our conclusions which would shed further light on the depressive disorder comorbid with primary headaches. financial support and sponsorship nil. conicts of interest there are no conicts of interest. references1). headache classication committee of the international headache society ,the international classication of headache disorders. cephalalgia. 2018; 38 (3rd edition): 1-211 2). "headache disorders fact sheet n°277". october 2012. archived from the original on 16 february 2016. retrieved 15 february 2016. 3). desouky de, zaid ha, taha aa. migraine, tension-type headache, and depression among saudi female students in taif university. j egypt public health assoc. 2019;94(1):7. doi: 10.1186/s42506-019-0008-7. 4). sharma h, shah s. psychiatric comorbidity of headache in a medical relief camp in a rural area. indian j psychiatry. 2006;48(3):185–188. doi:10.4103/0019-5545.31583 5). bera sc, khandelwal sk, sood m, goyal v. a comparative study of psychiatric comorbidity, quality of life and disability in patients with migraine and tension type headache.neurol india 2014;62:516-520 6). shoib s, mushtaq r, ahmad sr, arif t (2014) recognizing risk of psychiatric comorbidity in headache: looking for symptoms of anxiety and depression in headache: a study from general hospital in kashmir (india). j depress anxiety s1: 006. doi: 10.4172/2167-1044.s1-006 7). beghi, e., bussone, g., d'amico, d., cortelli, p., cevoli, s., manzoni, g. c., … salvi, s. (2010). headache, anxiety and depressive disorders: the hadas study. the journal of headache and pain, 11(2), 141–150. doi:10.1007/s10194010-0187-2 8). jette n,patten s,williams j, et al. comorbidity of migraine and psychiatric disorders—a national population-based study, headache ,2008 9). desai sd, pandya rh. study of psychiatric comorbidity in patients with headache using a short structured clinical interview in a rural neurology clinic in western india. j neurosci rural pract. 2014;5 (suppl 1):s39–s42. [pmc free article] [pubmed] [google scholar] 10). aich tk, gupta u, subedi s. mix headache: a valid clinical entity?. indian j psychiatry. 2018;60(1):78–83. doi:10.4103 / psychiatry. indian j psychiatry_349_17 11). bhachech j, jariwala m(2015) prevalence of major depressive disorder and anxiety in patients with primary headache paper id: sub156621 12). thomas tm, bileena k, karanath pm, swaroop am, srinivas r, a study on assessment of frequency, intensity, disability and severity associated with primary headaches. j app pharmsci, 2018; 8(02): 112-118. 13). gupta r., & bhatia, m. s. (2011). comparison of clinical characteristics of migraine and tension type headache. indian journal of psychiatry, 53(2), 134–139. doi:10.4103/0019-5545.82538 14). shankar, h., raj, k., keshari, p., & singh, p. (2016). prevalence of headache among adult population in urban varanasi, india 31.dr udit aggarwal.cdr introduction : dengue has been identied as one of the 17 neglected tropical diseases by who (who guidliness as reference ) approximately 1.8 billion population is at risk worldwide and in india various cases are reported from andhra pradesh, gujarat, karnataka, haryana, kerala, rajasthan , maharasthra. every year in the period of july 19–november 2019 an upsurge is seen. the agent of dengue infection, that is dengue virus, is categorized under the genus flavivirus. it contain single stranded rna and has a size of 50nm. there are four dengue virus serotypes which are designated as denv-1, denv-2, denv-3 and denv-4. these serotypes may be in circulation either singly, or more than one can be in circulation in any area at the same time. although all four serotypes are antigenically similar, they are different enough to elicit cross-protection only for a few months after infection by anyone of them. infection with any one serotype confers lifelong immunity to the virus serotype. dengue ns1 antigen, a highly conserved glycoprotein which is produced in both membrane-associated and secretion forms, is abundant in the serum of patients during the early stages of denv infection. it has been found to be useful as a tool for the diagnosis of acute dengue infections. it is a simple test that is more specic and shows high sensitivity.ns1 enables detection of the cases early, i.e. in the viremic stage, which has epidemiological signicance for containing the transmission. the ns1 antigen assay is commercially available for denv and many investigators have evaluated this assay for sensitivity and specicity. the ns1 assay may also be useful for differential diagnostics between aviviruses because of (1)the specicity of the assay. materials and methods : the study was conducted in s nijalingappa medical college and hsk hospital , the clinically suspected patients were admitted in wards and were included in the study during the period july-2019 to december 2019 since our laboratory works round the clock and hence the samples were tested immediately for ns1 , igg, igm.these tests were performed strictly as per manufacture instructions. sample for platelet count of all these study patients were collected and calculated using manual method. results: out of 152 samples tested , 68 samples tested positive for one or more serological markers of dengue. 28 of 68 (41%) were only ns1 positive , whereas 17 of 68 ( 25%) were only igm positive. platelet count of less than 1,00,000/cumm was seen in 64 of 68 dengue positive cases, however, of 84 dengue negative patients only 5 had platelet count less than 1,00,000/cumm. after subjecting these values for statistical analysis, p value was found to be <0.001 suggestive of highly signicant result. 2p value <0.001 (highly signicant), chi square x -117.8 discussion : ÿ in a study conducted by kulkarni rd, patil ss, ajantha gs, upadhya ak, kalabhavi as, shubhada rm, shetty pc, jain pa , of the 2104 serum samples tested, a total of 320 specimens were tested positive for either one or more of the three markers (ns1, igm and igg) tested. of the 320 serum samples, 95 (29.68%) patients were positive for ns1 only, 161 (50.3%) positive for igm only, while 9 patients had only igg. more than one marker was detected in the remaining 55 (17.18%) samples [table 1]. platelet count less than 1, 00,000/ml was noticed in 220 cases (68.75%). of the 150 cases presenting with fever that were negative for any of the dengue-specic parameters by ict, 45 showed (2)thrombocytopenia (30%) . ÿ in a study conducted by datta s, wattal c. dengue ns1 antigen detection , in group i, 140 (23.3%) and 235 (39.1%) samples were positive by ns1 assay and mac-elisa respectively. the detection rate increased to 320 (53.3%) when both the assays were used together on a single sample. ns1 ag positivity varied from 28.4% to 71.42% in acute and early convalescent sera, conversely igm detection rate was 93.61% and 6.38% in early convalescent and acute phase sera respectively (p < significance of serological markers and platelet count in diagnosing dengue infection with special reference to ns1 antigen original research paper dr mahesh chavan assistant professor,general medicine,snmc & hsk navnagar,bagalkot x 29gjra global journal for research analysis general medicine introduction: dengue , a viral infection with a potentially fatal outcome ,it has become an endemic in india and its outbreak occurs every year. since the mainstay of diagnosis is antibody detection which has high false positive and false negative values, newer parameters are upcoming for diagnosis. aim: to study the importance of newer accessory parameter platelet count in diagnosing dengue infections materials and methods: this is a retrospective study conducted in general medicine department of s nijalingappa medical college and hsk hospital, bagalkot. 4ml blood sample collected from admitted patients suspected with dengue fever and the samples screened for ns1 antigen by immunochromatography method and was compared to the platelet count. statistical analysis : appropriate statistical tests and software were used and calculated accordingly results : out of 152 samples tested , 36 were positive for ns1 antigen and 25 were positive for igm and these were compared to platelet counts of the respective patient conclusion: inclusion of ns1 antigen in the diagnosis algorithm increases the chances of early diagnosis and helps in anticipating fatal complications associated with dengue. thrombocytopenia was found more consistently in patients with dengue positive than with dengue negative. abstract keywords : dengue ; igm ; ns1 ; thrombocytopenia volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr udit aggarwal* post graduate,general medicine,snmc & hsk navnagar, bagalkot *corresponding author parameter total positive percentage ns1 only 28 41% igm only 17 25% age groups platelet count <1 lakh platelet count >1 lakh total dengue positive 64 4 68 dengue negative 5 79 84 total 69 83 152 30 x gjra global journal for research analysis 0.0001). in group ii, 66.66% (20) samples were positive by ns1 assay. all the samples in group iii were negative (3)showing 100% specicity of both the assays . ÿ in a study conducted by jyothi p, metri bc. correlation of serological markers and platelet count in the diagnosis of dengue virus infection, a total of 520 serum samples were collected from the suspected dengue fever patients. sixtytwo samples tested positive for one or more denguespecic parameters. out of the 62 samples, 39 (62.9%) were positive for the ns1 antigen, only seven (11.3%) were positive for igm, and only three (4.9%) were positive for igg. a platelet count < 1,00,000/ml was observed in 32 cases (51.6%). when the platelet count was done in 100 dengue parameter-negative fever patients (controls), (4)thrombocytopenia was observed in 30% of the cases . ÿ in a study conducted by badave gk, swaroop ps, rao pn. importance of ns1 antigen detection and its association with platelet count for early diagnosis of dengue virus infection , out of the 327 serum samples tested, a total of 126 (38.5%) specimens were positive for either one or more of the three serological markers (ns1, igm and igg) tested. of the 126 positive serum samples, 54 (42.9%) specimens were positive for ns1 only, 6 (4.7%) positive for igm only, while 30(23.9%) patients had only igg positive. platelet count less than 1,00,000/ml was noticed in 76 (60.31%) out of 126 cases. statistical analysis revealed a signicant association of ns1 antigen positivity and (5)thrombocytopenia . conclusion : ns1 is an excellent tool for evaluating febrile patients. use of immunochromatographic technique helps in easy, quick and dependable diagnosis of potentially fatal disease which has become an important public health issue. outbreak of dengue often occurs in resource poor areas where platelet count and immunochromatographic technique based tests might be the only support . references 1. dengue national guidelines 2014 2. kulkarni rd, patil ss, ajantha gs, upadhya ak, kalabhavi as, shubhada rm, shetty pc, jain pa. association of platelet count and serological markers of dengue infection-importance of ns1 antigen. indian journal of medical microbiology. 2011 oct 1;29(4):359. 3. datta s, wattal c. dengue ns1 antigen detection: a useful tool in early diagnosis of dengue virus infection. indian journal of medical microbiology. 2010 apr 1;28(2):107. 4. jyothi p, metri bc. correlation of serological markers and platelet count in the diagnosis of dengue virus infection. advanced biomedical research. 2015;4. 5. badave gk, swaroop ps, rao pn. importance of ns1 antigen detection and its association with platelet count for early diagnosis of dengue virus infection. int. j. curr. microbiol. app. sci. 2015;4(3):779-84. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction pharmacognosy which is science of the knowledge of plant is one of the important subject in the overall curriculum of the p h a r m a c e u t i c a l e d u c a t i o n i n i n d i a a n d w o r l d . pharmacognosy is an important link between pharmacology and study of medicinal plant. pharmacognosy is vital link between ayurvedic and allopathic system of medicine. it provides a system where in the active principle of crude drug derived from the natural origin can could be dispense, formulated and manufactured in dosage form acceptable to allopathic system of medicine. in nutshell pharmacognosy forms an important bridge between the pharmaceutical and basic science. about plant cassia is a large genus of around 500 species of owering plants in the family leguminosae (lodha et al 2010) . cassia species are annual under shrub, the genus cassia comprises of 580 species of herb, shrubs and trees, which are widely distributed throughout the world of which only 20 species are indigenous to india (anonymous 1950). medicinally, cassia angustifolia vahl is an important plant (harnischfeger and stilze 1983) is systematically placed in to the divisionmagnoliophyta, class-magnoliopsida subclass rosidae, order -fabales, family-caesaalpinaceae . taxonomical classication of senna synonyms of cassia angustifolia senna is one of the most commonly used laxative drugs in the eastern and western countries for the treatment of constipation. commonly available consist of the dried leaet of alexandria senna (cassia acutifolia delile) tinnevely senna (cassia angustifolia vahl) belongings to plant family leguminosae. cassia angustifolia is an ayurvedic herb more popularly known as senna. senna is an arabian name but it is native to sudan. it was brought into used by arabian physician for removing capillary congestion. it is small herb growing to a height of 2-3 feet. in india it is cultivated in tamil nadu, andhra pradesh and karnataka. it is commercially cultivation as recently come up in kutch (gujarat) and jodhpur (rajasthan). it is mainly used as a blood purier, laxative for relieving constipation and to treat skin diseases. it contains a powerful natural laxative called anthraquinone and is approved by the world health organization (who). senna consist of the leaet are golden brown in colour after drying. cassia angustifolia is one of the most widely used herbal laxatives (dermarderosian, 2005). cassia species well known in folk medicine for their laxative and purgative uses. they are also used for treating skin diseases such as ring worm, scabies, eczema and wounds. side effects & safety senna is likely safe for most adults and children over age 2 when taken by mouth, short-term. senna is an fda-approved nonprescription medicine. senna can cause some side effects including stomach discomfort, cramps, and diarrhea. senna is possibly unsafe when taken by mouth long-term or in high doses. don't use senna for more than two weeks. longer use can cause the bowels to stop functioning normally and might cause dependence on laxatives. long-term use can also phytochemical screening and pharmacological activity of cassia angustifolia bark original research paper a. s. dongarwar* manoharbhai patel institute of b. pharmacy gondia, 441614,maharashtra, india.*corresponding author pharmacology cassia angustifolia vahl. (leguminosae), commonly known as ' senna' or "sonamukhi"is employed in various indigenous system of medicine against several disease and almost every part of the plant has diverse medicinal properties. the bark and stem are used as an anti-inammatory and antipyretics and treat skin diseases and abdominal troubles. according to the ayurveda it has a property of reducing " kapha" and "vatta" .the current communication provide a detailed account of pharmacognostical investigation carried out on the bark of cassia angustifolia. the study includes macro and microscopical details physiochemical studies orescence study of the bark powder, tlc and hptlc ngerprint. the study reveal that bark of samples procured from the different places have similar morphological and physiochemical values. these observations are supported by tlc prole. abstract keywords : cassia angustifolia, pharmacognostical investigation, ayurveda, physiochemical values. n. h. indurwade manoharbhai patel institute of b.pharmacy gondia, 441614,maharashtra, india. pallavi sonwane manoharbhai patel institute of b.pharmacy gondia, 441614,maharashtra, india. t. p. nimbekar bajiraoji karanjekar college of pharmacy, sakoli, distbhandara, 441802 shubham selokar manoharbhai patel institute of b.pharmacy gondia, 441614,maharashtra, india. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra kingdom plantae subkingdom tracheobiota super division spermatophyta division mangnoliophyta class mangnoliopsida subclass rosidae order fabales family fabaceae genus cassia species angustifolia language names english indiansenna tinnevelly senna hindi senna ki patti sanskrit svarnapatri telugu nela tangedu malayalam sunnamukhi kannada nelavarika 4 x gjra global journal for research analysis change the amount or balance of some chemicals in the blood (electrolytes) that can cause heart function disorders, muscle weakness, liver damage, and other harmful effects. special precautions & warnings pregnancy and breast-feeding: senna is possibly safe during pregnancy and breast-feeding when taken by mouth, shortterm. it is possibly unsafe when taken by mouth long-term or in high doses. long-term, frequent use, or use of high doses has been linked to serious side effects including laxative dependence and liver damage. although small amounts of senna cross into breast milk, it doesn't seem to be a problem for nursing babies. as long as the mother uses senna in recommended amounts, senna does not cause changes in the frequency or consistency of babies' stools. electrolyte disturbances, potassium deciency: overuse of senna can make these conditions worse. dehydration, diarrhea or loose stools: senna should not be used in people with dehydration, diarrhea, or loose stools. it can make these conditions worse. gastrointestinal (gi) conditions: senna should not be used by people with abdominal pain (either diagnosed or undiagnosed), intestinal blockage, crohn's disease, ulcerative colitis, appendicitis, stomach inammation, anal prolapse, or hemorrhoids. heart disease: senna can cause electrolyte disturbances and might make heart disease worse. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra qualitative analysis total anthraquinones anti-pyretic activity: both the methanolic extract and water extract of cassia angustifolia showed signicant effect on pyrexia induced yeast. several test (acute and chronic) were employed in evaluating the analgesic effect of the methanolic and water extracts of cassia angustifolia. it is necessary to apply tests which differ with respect to stimulus quality, intensity and duration, to obtain as complete a picture as possible of the analgesic properties of a substance using behavioral nociceptive test. the results obtained indicate that the extracts possess a moderate dose dependent analgesic effect on the various pain models used. a potent inhibitory effect was extracted by both the extracts on the mouse writing assay. this suggests that the analgesic effect of the extract may be peripherally mediated. the extracts also had a signicant effect in the acid or indomethacin, only inhibit the late phase. antipyretic activity commonly mentioned as characteristics of drugs or compounds which have as inhibitory effect on prostaglandinbiosynthesis. both the methanolic extract and water extract of cassia angustifolia showed signicant effect on pyrexia induced by yeast. the result obtained in this study indicate that the extract possess mild antipyretic properties. even if further studies are needed this seems to provide rationale for the use of this plant in pain and inammatory disorders. table: effect of the cassia angustifolia leaves extract and paracetamol on yeast induced pyrexia in mice. material dose ( mg/kg) 0h 1h 2h 3h control 1.16 unit 42.61±0.12 40.63±0.16 39.41±0.11 39.7±0.14 water extract 10 41.47±0.14 39.83±0.15 39.57±0.15 38.56±0.14 paracetamol 10 37.63±0.11 37.08±0.15 37.06±0.24 36.93±0.14 x 5gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra antibacterial activity: natural antimicrobial agent have been more popular due to their efcacy against antibiotic resistant microorganism and campaign for consumption of natural product according to previous reports,various solvent extract of cassia angustifolia bark demonstrated antimicrobial activity against different microorganisms. ethanol extract of senna bark showed antibacterial activity against s.aureus and e.coli with zone of inhibition being 23 mm and 9 mm, respectively for 10 micron litre of extract solution. comparatively, in this study s. aureus exhibited lower zone of inhibition (15 mm) for boiled water extract of senna 10 micron litre of extract solution. the antimicrobial activity of senna barks anthraquinone glycosides. polygalacturonase inhibitory proteins in the plant cell wall of senna are suggested to play a role in resistant to bacterial attacks. however, the senna bark extract showed minimum activity against fungal pathogens investigated in present study. the oil has antibacterial activity particularly, staphylococcus aureus and escheria coli. while the overall inhibitory effect of essential oils in the experiment was less than for acetone, methanol and hexane its individual effect on s. aureus and e.coli was greater and effect of volatile terpenoids on bacteria that is staphylococcus aureus and escheria coli. conclusion the present study has helped in demonstrating the potential bioactive compound of natural plant extract that are ecofriendly, economical and available in bulk to the farmers with easy preparation protocols. cassia angustifolia vahl. plant parts are used for the development of various industrial and pharmaceutical products. in this paper attempt was made to medicinal property of bark of cassia angustifolia vahl. in various solvent extract against human bacterial pathogens. the extracts of senna leaves were shown better result against s. aureus than other pathogens. from the result it was concluded that extract of cassia angustifolia vahl. shown effective and efcient result against bacterial pathogen used. cassia angustifolia bark could serve as good source of antibacterial agents. references 1. anonymous (1996): indian pharmacopoeia, 2nd edition new delhi, govt. of india publication pp.367-370. 2. anonymous (1992): the wealth of india ll –raw materials. new delhi, publication and information directorate, csir, pp.354-363. 3. warier, ps (1994): indian medicinal plants, vol. 2. new delhi, orient longman publication p. 31. 4. gupta r.k. medicinal and aromatic plants 1st ed. india, cbs publishers and distributors: 2010, pp. 116-117. 5. kinjo j, ikeda t, watanabe k, nohara t. an anthraquinone glycosides from cassia angustifolia leaves , phytochem, 1994 ; 37(6) :1685-1687. 6. srivastava a, pandey r, varma r.k., liquid chromatographic determination of sennosides in cassia angustifolia leaves. j. aoac, 2006; 89(4): 937-941. 7. kokate, c.k, a.p. purohit and s.b. gokhale, ed. pharmacognosy, 25th ed. nirali prakashan: 77, (2003). 8. kokate c.k, a.p.purohit, s.b.gokhale (2000).text book of pharmacognosy , 14th edition, nirali prakashan, pune 123-124. 9. kapoor vp., farooqi mih, kapoor ld, chemical investigations of seed mucilages from cassia species, indian for 1980; 106 (11): 810-812. 10. patel rp, patel kc. antibacterial activity of cassia species and cassia obovata. indian journal of pharmacy 1957; 19:70-73. 11. k .r. sini, m. karpakavalli and p.t. sangeetha, analgesic and antipyretic activity of cassia occidentalis linn. 12. k. r. khandelwal, practical handbook of pharmacognosy, technique and experiment by nirali prakashan. p. 66. 13. a.v. kasture, s. g. wadodkar, textbook of pharmaceutical analysis, vol.2, p. 4.1. zone of inhibition in mm zone of inhibition in mm ethanolic extract s. aureus e. coli water extract s. aureus e. coli 25 8 21 10 24 7 23 7 22 5 28 9 18 3 22 11 19 4 24 8 20 5 19 6 average 21.34 5.34 23 9 6 x gjra global journal for research analysis introduction: anemia as a co morbidity of chronic heart failure (hf) has been frequently observed by almost every clinician involved in the care of affected patients. interestingly, its existence and clinical signicance have been greatly neglected in these patients, unless the situation was deemed life threatening the cardio renal anemia syndrome is a terminology that was coined by silverberg et al to explain the link between chronic 2,3heart failure, chronic kidney disease and anemia. it describes a process involving the deterioration of heart and kidney function linked with worsening anemia, which is contributed to, by the interaction between both physiological conditions. there is paucity of indian epidemiology data on cras. one indian study by abdullah et al reported the 4prevalence of cras to be 40% . cardiorenal anemia (cra) syndrome, dened as anemia (hemoglobin <130 g/l for men, <120 g/l for women) and stage 3 or greater chronic kidney disease (estimated glomerular ltration rate <60 ml/min/1.73 m), with heart 5failure. the cardio renal anemia syndrome, therefore, is a vicious cycle where worsening of one factor negatively impacts the others. correction of the anemia, may prevent the 3deterioration of both the heart and the kidneys .the only effective treatment is erythropoietin stimulating agents (esa) 6with replenishment of iron stores. kdigo recommends to give oral iron trial in ckd patients whenever transferrin saturation 7is less than 30% and serum ferritin is less than 500ng/l . ferric citrate is an fda-approved oral phosphorus binder that has been shown to be effective in reducing serum phosphorus and broblast growth factor 23 (fgf23) concentrations and increasing iron stores and hemoglobin in individuals with non-dialysis-dependent ckd who have iron-deciency 8anemia. it is an intestinal phosphate binder that has been shown previously to replete iron stores, increase hemoglobin levels, and reduce serum phosphate levels in patients with 9,10esrd undergoing hemodialysis. if ferric citrate is shown to not only improve phosphorus levels, but also the overall iron status, as compared to conventional ferric fumarate. thus, the present study was initiated to test the efcacy of ferric citrate in indian patients of cardio-renal syndrome. materials and methods: this prospective, comparative study was done in department of nephrology, dy patil hospital, navi mumbai. the study duration was of one year (january 2018 to december 2018). the inclusion criteria of the cras patients were age 18 years or greater, moderate to severe ckd (egfr < 60ml/min/1.73 m2 by ckd-epi), hemoglobin <130 g/l for men, <120 g/l for women, absolute iron deciency (serum ferritin <300ng/ml and transferrin saturation < 30%) nyha class 3 and 4 and lvef-<40%. the exclusion criteria were patients with known disorder of iron homeostasis, gastrointestinal disorder, liver disease, isolated dd, valvular heart disease, recent mi (<12weeks),serum phosphorus concentrations < 3.0 mg/dl, any known cause of anemia other than iron deciency or ckd, symptomatic gastrointestinal bleeding within 12 weeks prior to the screening visit, pregnancy or lactation ,receipt of erythropoiesis stimulating agents within 4 weeks of screening, receipt of intravenous iron therapy within 8 weeks of screening, blood transfusion within 4 weeks of screening, known allergies or severe adverse reactions to previous oral iron therapy. heart failure was diagnosed according to framingham criteria.. all the relevant data was fed in excel format by independent investigator. the patients were randomly assigned by a centralized interactive voiceresponse system with allocation generated by an independent biostatistician. ferric citrate as 1-g ferric citrate caplets containing 210 mg of ferric iron and ferrous fumarate of 300mcg was administered to the patients after random selection. patients were seen at weeks 1 and 2 and subsequently at 2-week intervals for any side effects, followed a comparative study of ferric citrate in patients of cardio renal anemia syndrome original research paper avinash chaudhari professor&head, department of nephrology ,d y patil college & hospital, navi mumbai x 57gjra global journal for research analysis nephrology keywords : cardiorenal anemia syndrome, phosphate, ferric citrate volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra amar kulkarni* senior resident, department of nephrology ,d y patil college & hospital, navi mumbai *corresponding author mehak trikha junior resident,department of general medicine, d y patil college & hospital, navi mumbai dinesh gupta professor, department of general medicine, d y patil college & hospital, navi mumbai introduction: the cardio renal anemia syndrome is a process involving the deterioration of heart and kidney function linked with worsening anemia. hyperphosphatemia is crucial indicator of poor prognosis in cardio renal anemia syndrome. ferric citrate has proven to be effective in reducing serum phosphorus and increasing iron stores and hemoglobin in individuals with non-dialysis-dependent ckd who have iron-deciency anemia. materials and methods: after the approval of ec, this prospective study was conducted in d.y patil hospital navi mumbai. 50 patients were enrolled in the study and randomized into two treatment groupsone group receiving oral ferric citrate and other ferrous fumarate. results: out of 50 patients, 18 (36%) were females and 32 (64%) were male. most common sub type of cras was type 2 comprising of 25 patients (50%). the rise in mean biochemical parameters in ferric citrate group at week 52 were statistically signicant as compared to baseline. serum phosphate levels were reduced towards normal level in ferric citrate group at week 52, as compared to in ferrous fumarate group at same time point in the study(p<0.05). conclusion: the present study has shown ferric citrate to be superior to ferric fumarate in improving the hemoglobin, iron, rbc indices and as a phosphate binder in patients with cras. abstract 58 x gjra global journal for research analysis by 12 weekly testing of hematological parameters. statistical analysis: the descriptive and analytical statistics were done. all the data was analyzed using statistical software (ibm spss v20.1, ibm corporation, armonk, ny, usa). results was expressed as mean ± standard deviation and proportions. comparisons between categorical variables was performed with fisher's exact and chi-square tests. the statistical signicance was determined at p<0.05. ethics committee approval was taken .a written signed informed consent was taken prior to enrolling the subjects in the study. figure 1: showing ow of methodology adopted for the present study. results: demographicthe mean sex wise, age-wise and distribution of patients according to sub types of cardio renal anemia syndrome (cras) is shown in table1 table 1: demographic results biochemical: on comparing the mean biochemical parameters (hemoglobin (hb), pcv, mcv, serum ferritin, tsat, and phosphorus levels) in ferric citrate and ferrous fumarate groups, it was found that ferric citrate effectively improved the iron and blood cell indices. there is statistically signicant improvements on all the parameters as compared to baseline and week 52 in the ferric fumarate group. ( p < 0.05) [ table 2,3 table 2: mean biochemical changes with ferric citrate table 3: mean biochemical chages with ferric fumarate discussion: in the present study, males outnumbered females. similar 11rates were reported in an indian study by shah et al. 12however, chertow et al and fishbane et al reported more 6female sex predilection towards cras . this can be attributed to increased occurrence of risk factors like coronary vascular events, diabetes, hypertension, etc. in males, which are 11comparatively less prevalence in female sex . the mean age in the present study was found to be around 60 years. similar trend was noted in clinical studies by nitya 1 11nand et al and shah et al . this can be due to the fact that prevalence of major risk factors for cras and their complications increase with advancing age. in the present study, most common subtype of cras was type 2 comprising of 25 patients (50%). these ndings were different than that reported by shah et al in their cardio-renal syndrome: clinical outcome study, in which type 1 was most 11common . in the present study, the rise in hb in ferric citrate at week 52 was highly statistically signicant as compared to baseline and in ferrous fumarate group at week 52 (p <0.001) which is consistent with nitya nand et al¹ fishbane et al in their clinical study on ferric citrate in ckd have reported similar rise in hemoglobin. they have additionally found that sustained rise in hb was more in patients treated with ferric citrate as 6compared to placebo . the signicant rise in mean serum ferritin level in patients taking ferric citrate was found to be similar to ferritin rise 13 1reported in studies done by panicker et al , nitya nand , 12chertow et al . ferritin is the storage form of iron. in cases of anemia, iron stores are already exhausted, and so is 18ferritin .thus, it is clear from the ndings of the present study that ferric citrate is effective in creating and maintaining positive iron balance in patients of cras, as indicated by rise in hemoglobin, iron indices like ferritin and transferrin saturation values, which were statistically signicant in patients taking ferric citrate. there are multiple reasons of iron deciency in patients of ckd, especially those undergoing hemodialysis chronically. reduced iron are reected as 17reduced hb levels due to diminished erythropoiesis . in the present study, serum phosphate levels were reduced towards normal level in ferric citrate group with similar results 14reported by koyama et al . the researchers of this clinical trial concluded that long term use of ferric citrate controls serum phosphorus concentrations and reduces the need for esas and intravenous iron in patients receiving hemodialysis. hyperphosphatemia in ckd leads to persistently increased fgf 23 levels. it is found in various clinical studies that ferric citrate reduces serum phosphate as well as fgf 23 levels in 15,16ckd, thus better outcomes . conclusion: in the present study, ferric citrate has been found to be effective in reducing hyperphosphatemia ,as well as maintaining positive iron balance in patients with cras. the improvement in the hemoglobin, iron and rbc indices volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra ferric citrate ferric fumarate sex female male 10 15 8 17 age (years) 60±3.5 59 ±2.9 weight (kg) 72.16 72 7 cras sub type type 2 type3 type4 13 5 9 12 3 17 baseline mean± sd week52 mean± sd p value haemoglobin 8.7±1 12.0±1.3 <0.001 pcv 29.4±4.1 43.6 ±6 <0.05 mcv 69.2±1.8 92.1±2.4 <0.05 s.ferritin 10.5±1.5 74.4±10.3 <0.05 tsat 9.3±1 35.6±3.9 <0.05 s.po4 7.5±1 5.1± 0.7 <0.05 baseline week52 p value haemoglobin 8.5±1 10.3±1.2 >0.05 pcv 27.9± 4.5 41.3±6.6 >0.05 mcv 70.9±1.6 91.2±2.1 >0.05 s.ferritin 10±1.6 56.9±9.1 >0.05 tsat 9.1±1 35±4.0 >0.05 s.po4 6.2±1 6.4±1 >0.05 has proven to be superior to ferric fumarate. thus, the dual action of ferric citrate in cardio renal anemia is feasible choice for managing anemia and hyperphosph atemia of cardio renal syndrome. the dual role also reduces pill load and improved adherence in cras patients. source of funding: none declared. conicts of interest: none declared by the authors. references: 1. nand n, giri k, jain d. role of ferric citrate in hyperphosphatemia and iron deciency anemia in non dialysis ckd patients. j assoc physicians india. 2019 apr; 67(4):53-56. 2. silverberg d, wexler d, blum m. the correction of anemia in severe resistant heart failure with erythropoietin and intravenous iron prevents the progression of both the heart and renal failure and markedly reduces hospitalization. clin nephrol. 2002; 58(1):37 – 45. 3. silverberg d, wexler d, blum. the interaction between heart failure, renal failure and anemia – the cardio renal anemia syndrome. blood purify. 2004; 22(3):277 – 84. 4. bilal b a, nida n, khalid m, chirajit s. cardiorenal syndrome type i a-a study of its incidence, risk factors, laboratory parameters and outcome. j cardiol & cardiovasc ther. 2019; 14(3): 555887. doi: 10.19080/ jocct. 2019.14.555887. 5. lu k, kearney l, hare d. cardiorenal anemia syndrome as a prognosticator for death in heart failure. am j cardiol. 2013; 111(8): 1187-1191. 6. fishbane s, spinowitz b . update on anemia in esrd and earlier stages of ckd: core curriculum 2018. am j kidney dis 2018; 71:423-3. 7. iain c, macdougall aj, bircher, kai-uweeckardt, gregorio t, obrador carol a, et al. iron management in chronic kidney disease: conclusions from a “kidney disease: improving global outcomes” (kdigo) controversies conference. kidney international 2016; 89:28-39. 8. clinicaltrials.gov.in [internet]. bethesda (md): national library of medicine (us). 2016 september 21. identier nct 02888171, impact of ferric citrate vs ferrous sulfate on iron parameters and hemoglobin in individuals with ckd and iron deciency; 2017 march 22 [cited 2017 october 18] available from : https://clinicaltrials.gov/ct2/show/nct02888171. 9. lee c, wu i, chiang s, et al. effect of oral ferric citrate on serum phosphorus in hemodialysis patients: multi center, randomized, double-blind, placebocontrolled study. j nephrol. 2014; 28(1): 105-13. 10. yokoyama k, hirakata h, akiba t, et al. effect of oral jtt-751 (ferric citrate) on hyperphosphatemia in hemodialysis patients: results of a randomized, double-blind, placebo-controlled trial am j nephrol. 2012;36(5): 478-487. 11. shah hr, singh np, aggarwal np, singhania d, kumar a. cardiorenal syndrome: clinical outcome study. j assoc physicians india. 2016 dec; 64(12):41-46. 12. chertow gm, block ga, neylan jf, pergola pe, uhlig k, fishbane s. safety and efcacy of ferric citrate in patients with non dialysis-dependent chronic kidney disease. plos one. 2017 nov 29;12(11):e0188712. 13. panicker n, hridya a, prabhu r. comparison of efcacy and safety prole of oral iron formulations in patients with iron deciency anemia. int. j. pharm. sci. rev. res. 2016; 41(2): 248-252 14. hiratsuka m, koyama k, sengo k, yamamoto j, narita a, ito c, et al. longterm iron accumulation in dialysis patients treated with ferric citrate hydrate: a single-center, 80-week retrospective study in japan. renal replacement therapy 2017; 3:37:1 15. ospina m, holguín m, escobar d , res t repo . impor tance o f hyperphosphatemia in chronic kidney disease, how to avoid it and treat it by nutritional measures. rev. colomb. nefrol. 2017;4(1): 24 – 41. 16. ganz t, bino a, salusky i. mechanism of action and clinical attributes of auryxia ® (ferric citrate). drugs 2019; 79:957–968. 17. al-atrakji mq. the effects of ferrous sulfate as an iron supplement on ejection fraction in patients with iron deciency anemia associated with decompensated heart failure. mustansiriya med j 2018;17:22-8 18. pinto-sietsma sj, navis g, janssen wm, de zd, gans ro, de jong pe. a central body fat distribution is related to renal function impairment, even in lean subjects. am j kidney dis. 2003;41:733-741. x 59gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction peripheral intravenous (iv) cannulation,most common invasive procedure , not easily obtained in all. ÿ multiple unsuccessful attempts associated with risks nerve damage, paresthesia, hematoma, arterial puncture. ÿ so necessary to have a predictive scale which identies high probability of a difcult iv access. ÿ adult-difcult intravenous access (a-diva) score, proportionally weighted ve-variable. ÿ 0-1 low risk , 2-3 medium risk & >4 high risk ÿ clinical rule, has been developed to predict failure of intravenous (iv) placement in adult. aim of the study ÿ to externally validate a-diva scale ÿ to rene the predictors of a-diva scale methodology prospective cross-sectional, clinical observational study. february 2019 to september 2019, mvj medical college ethical committee approval and informed consent was taken. 500 subjects randomly selected inclusion criteria: aged >18 years irrespective of asa grade undergoing peripheral iv placement before surgery exclusion criteria : unresponsive patients and whose cannulation already gained in ward sociodemographic prole sheet clinical prole sheet adiva scale the outcome of interest was dened as failure of cannulation on rst attempt. scoring of the vein done according to a-diva scale proposed renement predictor variables : age skin shade vein valves tortuous vein thrombosed vein operator experience site & side of cannulation. statistical analysis to compare patients regarding primary outcome, chi-square test and unpaired sample t-test were performed as appropriate ÿ potential risk factors identied in a univariate logistic regression analysis ÿ items with a p <0.001 were considered as statistically signicant with 95% condence interval(ci). results ÿ mean age of patients was 42.55 years (sd= ± 15.06 yrs) ÿ 28%(140) subjects failed rst iv attempt. the original ve-variable model tested statistically signicant. ÿ hence additive 5-variable a-diva scale is a reliable predictive rule that implies the probability to identify patients with a difcult iv access prospectively. ÿ the scoring system was applied in 3 risk groups as they failed rst attempt iv accessvalidation and refinement of the adult difficult intravenous access score: a clinical prediction rule for identifying adults with difficult intravenous access original research paper dr rahul kishore x 55gjra global journal for research analysis anaesthesiology keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra adiva score risk grading (n) iv failure (%) 0 or 1 low risk (424) 97 (22 %) 2 or 3 medium risk (68) 36 (53 %) 4 plus high risk (8) 7 (87 %) 56 x gjra global journal for research analysis addition variables predict failure of iv are:discussion ÿ difcult intravenous access is a frequently encountered clinical challenge, which has been subject of research in various previous publications. ÿ reported success rates of rst attempt peripheral iv cannulation varies from 98% to as low as 51%, whereas our study shows an 72% success rate. ÿ failure to obtain a peripheral iv access can delay diagnosis and treatment, and may expose patients to risks associated with central venous cannulation. ÿ no scoring system will precisely predict the outcome for a patient. though, risk stratication helps eliminating bias against patients at high-risk for difcult intravenous access and may reduce complications related to the procedure. ÿ early recognition of patients at risk could help in applying alternative approaches, such as infrared(ir) assisted/ ultrasound guided iv catheter placement, to achieve a successful peripheral intravenous access. ÿ in general, we believe it would not improve efcacy nor be cost-efcient to apply ir/ usg devices in all patients. ÿ furthermore, the proposed a-diva score may also be valuable in the evaluation of (cost-) efcacy and validation of the many venous access devices available in the market ÿ as this study is a clinical observation study number of success and failure of iv access may alter depending on experience of operator. conclusion this study validated the previously derived ve variable adiva score. ÿ applying the a-diva scale to surgical patients may increase the success rate of inserting a peripheral intravenous catheter on the rst attempt. otherwise, it creates a possibility to use other techniques, such as ir/usg, in an earlier time frame. ÿ certain newer renement variables are also found signicant may also be helpful. references 1. fredericus h. j. van loon, lisette a. p. m. puijn, saskia houterman, et al. development of the a-diva scale: a clinical predictive scale to identify difcult intravenous access in adult patients based on clinical observations. md-journal. medicine _ volume 95, number 16, april 2016;1-8. 2. yen k, riegert a, gorelick m. derivation of the diva score: a clinical prediction rule for the identication of children with difcult intravenous access. pediatr emerg care. 2008; 24:143–7. 3. riker mw, kennedy c, winfrey bs, et al. validation and renement of the difcult intravenous access score: a clinical prediction rule for identifying children with difcult intravenous access. acad emerg med. 2011; 18: 1129– 1134. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra variables iv success iv failure t/ chi square value pvalue tortous vein yes 70 49 13.449 0.000* no 290 91 phlebitis yes 14 13 5.747 0.017* no 346 127 valves + 68 86 85.584 0.000* 292 54 1)introduction internal herniation is a rare cause of small bowel obstruction. it should form part of the differential diagnosis especially in a previously unscarred abdomen. paravesical hernia is exceedingly rare. this type of hernia involves herniation of a viscus between the median and medial umbilical ligament. preoperative diagnosis of these internal hernias is extremely difcult. computed tomography (ct) scan may suggest the diagnosis but often the ndings are not specic and the diagnosis is only made on ot table . 2)case report a 45 year old male presented with a one week history of abdominal pain. he had associated bilious vomiting, abdominal distension and obstipation. no signicant past medical or surgical history was noted. on examination the patient was dehydrated with a blood pressure 139/89, pulse rate of 99, temperature of 37.2 °c. his abdomen was distended, no masses were palpable. the abdomen was tympanic on percussion. sluggish bowel sounds were auscultated. there was no evidence of peritonism. rectal exam revealed an empty rectum. chest xray and abdominal x-ray revealed no free air. features suggestive of small bowel obstruction most likely at level of terminal ileum was noted. there were multiple air uid levels with an absence of air in rectum.(pic 1) pic 1. blood results were within normal range except for a mildly elevated serum tlc count. the patient was resuscitated and taken to theatre for exploration via a midline laparotomy. a loop of terminal ileum was trapped in paravesical hernia causing small bowel obstruction (fig. 2). the bowel was necrosed and the containing segment of ilium was resected and anastmosed. the hernial ring was a 2 cm × 2 cm defect in the prevesical fascia. on digital exploration of defect after reduction of the incarcerated bowel, the sac was found to run laterally to the bladder and no communication to vesicle cavity was noted . the paravesical hernia was repaired with 2/0 polydioxanone (pds). pelvic drain was placed and abdomen closed. the patient made an uneventful post operative recovery. 3)follow up at surgical outpatient department two weeks post operatively the patient was well and discharged from surgical care. 4)discussion an internal hernia (ih) is a protrusion of intestines or other abdominal organs through a normal or abnormal orice in the peritoneum or mesentery, occasionally leading to strangulation or incarceration. internal hernias (ih) are a rare cause of acute abdomen and intestinal obstruction in adults. ih has a reported autopsy incidence of 0.2 to 0.9% and is the [1]cause of small bowel obstruction in 0.6 to 5.8% of the cases . internal abdominal herniations can be either acquired through a trauma or surgical procedure or related to congenital peritoneal defects. the classication system of internal abdominal herniations by ghahremani is now well accepted. internal abdominal herniations can be separated into six groups: paraduodenal hernias (50–55% of internal abdominal herniations), hernias through the foramen of winslow (6–10%), transmesenteric hernias (8–10%), pericecal hernias (10–15%), intersigmoid hernias (4–8%), and [2]paravesical hernias (<4%) . the supravesical fossa lies between the median umbilical ligament and the medial umbilical ligament. the inferior boundary is formed by a peritoneal fold, part of which is the transverse fold of the bladder. the fossa may go on to form a deep sac. if the hernia occurs in the superior portion of the fossa it may result in an external hernia. the internal hernias extend into the space of retzius. these hernias can be prevesical, paravesical or even [3]intravesical . supravesical hernias are the cause of most pelvic hernias. approximately 60 cases of supravesical hernias have been reported to date. paravesical hernias have not specically been documented. preoperative diagnosis of these hernias may be challenging and the vast majority of cases are diagnosed at exploration in theatre. preoperative diagnosis is possible with ct scan or [4]mri . ct is currently the best imaging technique for detecting these hernias. the ct scan may show loops of bowel near the [5]bladder . however if obtaining a ct scan will signicantly delay exploration of the patient then it is better to proceed to small bowel obstruction secondary to paravesical hernia original research paper dr deepak kumar jha senior resident deptt. of gen surgery nbmc west bengal general surgery bowel obstruction in the setting of the unscarred abdomen can be due to a wide variety of causes. internal hernias are a rare cause of bowel obstruction with paravesical hernia being exceedingly rare. paravesical hernia should form part of the differential diagnosis in the patient presenting with bowel obstruction. prompt management and reduction of the incarcerated bowel are essential. this will prevent further complications especially related to bowel ischemia. abstract keywords : volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 34 x gjra global journal for research analysis exploration as further delay may compromise already marginal bowel. if prompt resuscitation and exploration are not carried out the bowel may become gangrenous and require bowel resection. this will add to overall morbidity of [6]the procedure . this condition has been reported to be diagnosed and treated [7]laparoscopically . in our patient however this would have been impossible due to the severe distension of small bowel. the treatment is release of the intestinal obstruction and closing the hernia defect. attempts to excise the hernia sac are probably unnecessary. freshening of the edges and simple closure of the defect using continuous or interrupted stitches [8]with non-absorbable sutures is sufcient . pic 2 pic 3 5)conclusion the case demonstrates a rare cause of small bowel obstruction. the descriptions in the literature of small bowel obstruction secondary to internal supravesical hernia are limited to case reports. preoperative diagnosis of these internal hernias remains challenging. the main learning point from this case is that in the setting of complete bowel obstruction delay in denitive management should be avoided. imaging has been of limited utility in cases of acute intestinal obstruction; moreover, interpretation of imaging features is operator dependant. speed is essential as bowel that incarcerated may become gangrenous. ethical approval ethics committee approachedno need for ethics approval as this is a case report which involved standard care. consent written informed consent was obtained from the patient for publication of this case report and accompanying images. a copy of the written consent is available for review by the editorin-chief of this journal on request. author contribution dr deepak kumar jha—compiled the manuscript and was involved in the primary management of the case; references 1. meyers m.a. 4th edition. springer verlag; new york, ny: 1994. dynamic radiology of the abdomen: normal and pathologic anatomy. [google scholar] 2. ghahremani g.g. abdominal and pelvic hernias. in: gore r.m., levine m.s., editors. textbook of gastrointestinal radiology. 2nd edition. saunders; philadelphia, pa: 1994. [google scholar] 3. skandalakis j.e., gray s.w., burns w.b., sangmalee u., sorg j.l. internal and external supravesical hernia. am. surg. 1976;42(february (2)):142e6. [pubmed] [google scholar] 4. chou c.k., liu g.c., chen l.t., jaw t.s. the use of mri in bowel obstruction. abdom. imaging. 1993;18:131–135. [pubmed] [google scholar] 5. sasaya t., yamaguchi a., isogai m., harada t., kaneoka y., suzuki m. s u p r a v e s i c a l h e r n i a : c t d i a g n o s i s . a b d o m . i m a g i n g . 2001;26(january–february (1)):89e91. [pubmed] [google scholar] 6. saravanan balakrishnan. supravesical hernia—a rare cause of intestinal obstruction. int. j. surg. 2016;6(6):471–472. [pubmed] [google scholar] 7. mehran a., szomstein s., soto f., rosenthal r. laparoscopic repair of an internal strangulated supravesical hernia. surg. endosc. 2004;18(march (3)):554e6. [pubmed] [google scholar] 8. koksoy f.n., soybir g.r., bulut t.m., yalcin o., aker y., kose h. internal supravesical hernia: report of a case. am. surg. 1995;61(november (11)):1023e4. [pubmed] [google scholar] volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 35gjra global journal for research analysis introduction nucleic acid testing (nat) is a molecular technique for screening blood donations to reduce the risk of transfusion transmitted infections (ttis) in the recipients, thus providing an additional layer of blood safety. it was introduced in the developed countries in the late 1990s and early 2000s and presently around 33 countries in the world have implemented nat for human immunodeciency virus (hiv) and around 27 countries for hepatitis b virus (hbv). nat technique is highly sensitive and specic for viral nucleic acids. it is based on amplication of targeted regions of viral ribonucleic acid or deoxyribonucleic acid (dna) and detects them earlier than the other screening methods thus, narrowing the window period of hiv, hbv and hepatitis c virus (hcv) infections. nat also adds the benet of resolving false reactive donations on serological methods which is very important for donor notication and counseling. this study is one such effort to nd the best way to diagnose. large number of blood transfusions are carried out globally to save countless lives,() but unsafe practices risks the recipient of transfusion transmittable infections((tti's). tti's can be reduced by improving donor selection, donor awareness regarding tti and implementing sensitive screening tests.() in india, it is mandatory to test each donated unit of blood for markers of hivi and ii, hbv, hcv, malaria and syphilis.() currently, in india all the blood donations are screened for various infectious markers using elisa or rapid methods. ttis can be responsible for causing considerable burden on the health status and economy of the country.() hence there is need to introduce better methods for testing blood units. even after being seronegative the blood transfusions are still at risk of transmitting infections. in order to reduce the residual risk sensitive screening tests are needed and as a result nat has been considered. in india nat testing is not mandatory but many private blood banks and hospitals and state governments of few states have started implementing nat for blood safety.(, ) it increases the possibility of identifying the infection in window period and thus reducing the residual risk of ttis.() nat is highly sensitive and specic for viral nucleic acids and is based on amplication of targeted regions of rna and dna and thus is the technique of choice. by early detection than serology, the window period of hiv, hbv and hcv infections narrows. but the issue of higher cost accounts for its limited use especially in developing countries.() the present study is designed to understand the role of nat in detecting the risk acquiring ttis as compared to conventional methods currently in use for detection of hbv, hcv and hiv infections amongst blood donors. materials and methods the present study was carried out at blood bank, a.j institute of medical sciences, mangalore. it was a two years (july 2008 to december 2010) non-interventional, retrospective, observational study. the blood collections were carried out from the voluntary donors at outdoor blood donation camp and in-house blood bank as well as from replacement donors at blood bank. trained personnel carefully selected the donors for donation after a complete physical examination and satisfactorily answering the donor's questionnaire according to blood donor selection criteria and guideline from drug and cosmetic act and naco. on completion of blood donation, the units were screened for the ve commonest ttis namely hiv i & ii, hbsag, hcv, syphilis and malaria. screening test elisa and rapid kit were used for hiv i & ii, hbsag, hcv. screening test rapid kit and peripheral smear were used for malaria. vdrl is used for screening syphilis. the reactive sample was retested in duplicate before considering it seropositive. seropositive blood bags were discarded. all non-reactive samples are sent to bowring and lady curzon hospital, bangalore for conrmation testing by nat technique for hiv i & ii, hbsag, hcv to reduce the risk of transfusion transmitted infections (ttis) in the recipients, thus providing an additional layer of blood safety. the data were recorded on specially formed proforma, the recorded data were tabulated and analysed. for comparing nat and elisa as suggested by the statistician cohen's kappa coefcient, statistical test is used. results our study was a 2 years non-interventional retrospective study and the data was collected from the blood bank. during the study period total of 3183 donors donated the blood. out of 100 blood donors, all were voluntary donors. out of the total donors 50 were females and rest that is 50 were male. the age of the blood donors in the present study ranged from 20 50 years out of the total 100 screened blood units 07 were seropositive for the transfusion transmitted infection. among the 7 seropositive donors, 4 were positive for hbv infection and out of those 3 were hbsag positive and 4 seropositive donor which was not detected by the serological test was detected by the nat. statistically using cohen's comparison of elisa and nat techniques among blood donors original research paper dr praveena kumara* assistant professor, department of medicine, a.j.institute of medical sciences, mangalore. * corresponding author general medicine nucleic acid testing (nat) is a molecular technique for screening blood donations to reduce the risk of transfusion transmitted infections (ttis) in the recipients, thus providing an additional layer of blood safety. it was introduced in the developed countries in the late 1990s and early 2000s and presently around 33 countries in the world have implemented nat for human immunodeciency virus (hiv) and around 27 countries for hepatitis b virus (hbv). nat technique is highly sensitive and specic for viral nucleic acids. it is based on amplication of targeted regions of viral ribonucleic acid or deoxyribonucleic acid (dna) and detects them earlier than the other screening methods thus, narrowing the window period of hiv, hbv and hepatitis c virus (hcv) infections. nat also adds the benet of resolving false reactive donations on serological methods which is very important for donor notication and counseling. this study is one such effort to nd the best way to diagnose. abstract keywords : nucleic acid testing, transfusion transmitted infections, blood transfusion volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 90 x gjra global journal for research analysis kappa coefcient, it was noted that the strength of agreement between elisa and nat can be considered to be very good. discussion blood transfusion is most important part of medical treatment and it's also associated with risk of transfusion transmitted infections (ttis). hence screening of blood bags is important to ensure safe blood transfusion. an effective donor screening, sensitive screening tests can reduce the risk of acquiring tti's. conclusion blood banks are likely to work more efciently if the nat technologies are implemented which will help in intercepting potentially harmful infectious pathogens while continuing to provide on time blood availability for patients and to the hospital. as nat implementation reduces the rate of ttis, its implementation will gain more speed in many more countries as a valuable addition to existing safety efforts. references 1. jasani j, patel v, bhuva k, vaihhani a, patel h. seroprevalence of transfusion transmissible infections among blood donors in a tertiary care hospital. int j biol med res. 2012;31:1423-5. 2. bihl f, castelli d, marincola f, dodd ry, brander c. transfusion-transmitted infections. journal of translational medicine. 2007;5(1):25. 3. standards for blood banks & blood transfusion services, [1] national aids control organization, ministry of health and family welfare, government of india, new delhi 2007. . 4. shrivastava m, mishra s. nucleic acid amplication testing (nat): an innovative diagnostic approach for enhancing blood safety. 5. hans r, marwaha n. nucleic acid testing-benets and constraints. asian journal of transfusion science. 2014;8(1):2. 6. makroo r, choudhury n, jagannathan l, parihar-malhotra m, raina v, chaudhary r, et al. multicenter evaluation of individual donor nucleic acid testing (nat) for simultaneous detection of human immunodeciency virus-1 & hepatitis b & c viruses in indian blood donors. indian journal of medical research. 2008;127(2):140. 7. o'brien sf, yi ql, fan w, scalia v, kleinman sh, vamvakas ec. current incidence and estimated residual risk of transfusion-transmitted infections in donations made to canadian blood services. transfusion. 2007;47(2):316-25. 8. giri pa, deshpande jd, phalke db, karle lb. seroprevalence of transfusion transmissible infections among voluntary blood donors at a tertiary care teaching hospital in rural area of india. journal of family medicine and primary care. 2012;1(1):48. 9. chandrasekaran s, palaniappan n, krishnan v, mohan g, chandrasekaran n. relative prevalence of hepatitis b viral markers and hepatitis c virus antibodies (anti hcv) in madurai, south india. indian journal of medical sciences. 2000;54(7):270-3. 10. jain r, aggarwal p, gupta gn. need for nucleic acid testing in countries with high prevalence of transfusion-transmitted infections. isrn hematology. 2012;2012. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra hiv hbv hcv hbsag nat hbv 0 03 4 0 x 91gjra global journal for research analysis introduction pls are rare neoplasms which compose approximately 12% of all liposarcomas; and mostly originate in spermatic cord 1followed by testicular tunics and epididymis. no more than 2200 cases of pls have been reported till date. giant pls is 3-7more rare with only a few case reports. due to the rarity of the disease, there is no standardized guideline as regards its 8incidence, diagnosis, recurrence and treatment. we present a case of a giant well differentiated pls measuring 26x24x12 cm. case study a 70-year-old man, presented with a painless and slow-growing mass in the right scrotum without conspicuous promoting or alleviating factors. there were no other signs or symptoms. a rm non-tender mass present in the right scrotum, of size 26cm x 24cm x 12cm, was the only positive nding on physical examination. there were no specic abnormalities in the laboratory and imaging figure 1: clinical photograph reports (hemogram, urinalysis, stool routine, esr, β-human chorionic gonadotropin, a-fetoprotein, liver and kidney function tests and chest x-ray). a provisional diagnosis of testicular malignancy was made. the patient underwent a radical resection of figure 2: excised specimen the tumor with a right orchiectomy. on gross pathological examination, the tumor was 26x24x12cm in size. figure 3: microscopic pathology the cut surface showed grey yellow homogenous areas alternating with brous bands. microscopy revealed mature bro-adipose tissue alternating with brous areas comprising of collagen bres admixed with spindle cells. some of them were lobulated and had hyperchromatic pleomorphic nuclei giant paratesticular liposarcoma: a rare entity original research paper manish verma* associate professor, department of surgery, pgims, rohtak, haryana, india. *corresponding author x 27gjra global journal for research analysis surgery paratesticular liposarcoma (pls) are rare malignant neoplasms; which are derived from mesodermal tissues. they are slow growing tumors and tumors of size greater than 10cm are quite rare. there is no standardized guideline for management. a case of a giant well differentiated pls measuring 26x24x12cm was encountered and is being described. abstract keywords : paratesticular tumor, liposarcoma, scrotal mass. naman purohit junior resident, department of surgery, pgims, rohtak, haryana, india. m g vashist senior professor, department of surgery, pgims, rohtak, haryana, india. sudhir kumar senior resident, department of surgery, pgims, rohtak, haryana, india. abhijit singha senior resident, department of surgery, pgims, rohtak, haryana, india. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 28 x gjra global journal for research analysis with incompicous nucleoli (i.e. atypical stromal cells). lipoblasts and atypical mitotic gures were not conspicous. the right testis and spermatic cord were normal and free from tumor. a diagnosis of atypical lipomatous tumor, sclerosing sub type (well differentiated liposarcoma) was conrmed. discussion 9liposarcoma was rst reported in 1845 by lesauvage. it 10accounts for 5-7% of paratesticular sarcoma. liposarcoma are malignant tumors of soft tissue origin and frequently 11involve the adult patients aged 50 to 60 years. usual sites of involvement are the lower extremities and retroperitoneum in 12about 70% of cases. paratesticular involvement by 2liposarcoma has been reported in just 200 cases till date. also, there are only few case reports of size more than 10cm and none more than 20cm. we encountered a giant liposarcoma of size 24x20x14cm. liposarcoma presents as a painless, slow-growing mass and 2,9may be clinically misdiagnosed as testicular malignancy. although, ultrasonography, computerized tomography and magnetic resonance imaging are advised for diagnosis of 13paratesticular liposarcoma; mri is the golden standard. diagnosis of pls mainly depends on histopathology, immunohistochemistry and cytomorphological features. three histological types of liposarcoma have been described, which include well differentiated (wdlps), myxoid/round cell 13type and pleomorphic type. myxoid variety is the most 14common type and account for about 50% of all liposarcoma. the histological subtypes of wdlps are adipocytic, sclerosing, inammatory and spindle cell type. the sclerosing type is more commonly seen in retroperitoneum and spermatic cord. microscopy of sclerosing type of wdlps reveals brocollagenous tissue with a brillary appearance. scattered amongst it are mature adipocytes and bizarre hyperchromatic stromal cells, with few lipoblasts. ihc analysis of liposarcomas shows s100 positivity, while cd 34, 15actin, keratin, desmin all show negativity. in our case, the histopathological features were diagnostic and in favour of wdlps sclerosing subtype. due to paucity of data in literature, on patients with paratesticular liposarcoma, there are no standardized 2guidelines for the management. multimodality therapy has 16been suggested in literature. there is a general consensus that radical orchiectomy with wide local excision and high ligation of the spermatic cord is the current standard treatment strategy due to frequent recurrence that associated 9,13,17with incomplete excision. role of routine postoperative radiotherapy therapy remains to be discussed because recurrent tumor after radiotherapy is found to be more 18aggressive. chemotherapy has been recommended for high grade lps. in conclusion, pls represent a rare tumor, often misdiagnosed preoperatively. the diagnosis depends on histopathology. radical orchiectomy with wide local excision is recommended due to high risk of recurrence. huge sized, rare paratesticular liposarcoma prompted us to report such a case which is one of the largest in size amongst its category. references [1] noguchi h, naomoto y, haisa m, yamatsuji t, shigemitsu k, uetsuka h, hamasaki s and tanaka n: retroperitoneal liposarcoma presenting a indirect inguinal hernia. acta med okayama 55: 51-54, 2001. [2] schoonjans c, servaes d and bronckaers m: liposarcoma scroti: a rare paratesticular tumor. acta chir belg 116: 122-125, 2016. [3] sopena-sutil r, silan f, butron-vila mt, guerrero-ramos f, lagaron-comba e and passas-martinez j: multidisciplinary approach to giant paratesticular liposarcoma. can urol assoc j 10: e316-e319, 2016. [4] fernandez f and garcia ha: giant dedifferenciated liposarcoma of the spermatic cord. arch esp urol 62: 751-755, 2009 (in spanish). [5] cariati a, brignole e, tonelli e and filippi m: giant paratesticular undifferentiated liposarcoma that developed in a long-standing inguinal hernia. eur j surg 168: 511-512, 2002. [6] kin t, kitsukawa s, shishido t, maeda y, izutani t, yonese j and fukui i: two cases of giant testicular tumor with widespread extension to the spermatic cord: usefulness of upfront chemotherapy. hinyokika kiyo 45: 191-194, 1999 (in japanese). [7] martin c, olivier cm, rengifo d, hernandez lao a, ondina lm and carballido j: giant liposarcoma of the spermatic cord. actas urol esp 17: 361365, 1993 (in spanish). [8] alyousef h, osman em and gomha ma: paratesticular liposarcoma: a case report and review of the literature. case rep urol 2013: 806289, 2013. [9] vukmirović f, zejnilović n and ivović j: liposarcoma of the paratesticular tissue and spermatic cord: a case report. vojnosanit pregl 70: 693-696, 2013. [10] coleman j, brenman mf, alektiar k et al. adult spermatic cord sarcomas: management and results. ann surg oncol 2003;10:669-675. [11] fitzgerald s and maclennan gt: paratesticular liposarcoma. j urol 181: 331332, 2009. [12] vinayagam k, hosamath v, honnappa s and rau ar: paratesticular liposarcoma-masquerading as a testicular tumour. j clin diagn res 8: 165166, 2014. [13] pergel a, yucel af, aydin i, sahin da, gucer h and kocakusak a: paratesticular liposarcoma: a radiologic pathologic correlation. j clin imaging sci 1: 57, 2011. [14] goverdhane p, zafar fa, geelani ia, girish h, sharma dvsln, rajagopal v, swain m, swamalatha g. liposarcoma of spermatic cord – a rare entity. apollo medicine 2013;10:83-84 [15] fletcher cdm. soft tissue tumours. in: diagnostic histopathology of tumours. fletcher cdm, 3rd ed, churchill livingstone, elsevier; philadelphia: 1527-92. [16] sherman kl, wayne jd, chung j, agulnik m, attar s, hayes jp, laskin wb, peabody td, bentrem dj, pollock re and bilimoria ky: assessment of multimodality therapy use for extremity sarcoma in the united states. j surg oncol 109: 395-404, 2014. [17] khandekar mj, raut cp, hornick jl, wang q, alexander bm and baldini eh: paratesticular liposarcoma: unusual patterns of recurrence and importance of margins. ann surg oncol 20: 2148-2155, 2013. [18] raza m, vinay hg, ali m and siddesh g: bilateral paratesticular liposarcoma-a rare case report. j surg tech case rep 6: 15-17, 2014. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction non-alcoholic fatty liver disease (nafld) consists of fat accumulation in the liver (hepatic steatosis) and affects about 1.8 billion people .nafld can progress towards non-alcoholic steato-hepatitis (nash), which is a more severe condition characterized by necro-inammation with or without brosis. this can ultimately lead to cirrhosis and hepatocellular carcinoma (hcc). in addition, the related cardiovascular risk cannot be underestimated. to note, nafld is considered the hepatic manifestation of the metabolic syndrome, which is mainly characterized by obesity, dyslipidemia, insulin resistance, hypertension, and type 2 diabetes. in particular, in asymptomatic morbidly obese patients, there is a very high prevalence of approximately 90% of nafld (adams la, angulo p et, al 2006) non‐alcoholic fatty liver disease (nafld) encompasses a spectrum ranging from simple steatosis to non‐alcoholic steatohepatitis, which causes an increased risk of cirrhosis, type 2 diabetes, and cardiovascular complications. with the worldwide growing incidence of obesity, sedentary lifestyle, and unhealthy dietary pattern, nafld has currently been recognized as a major health burden. dietary patterns and nutrients are the important contributors to the development, progression, and treatment of nafld and associated metabolic co morbidities. generally, hyper caloric diet, especially rich in trans/ saturated fat and cholesterol, and fructose‐sweetened beverages seem to increase visceral adiposity and stimulate hepatic l ipid accumulat ion and progression into non‐alcoholic steatohepatitis, whereas reducing caloric intake, increasing soy protein and whey consumption, and supplement of monounsaturated fatty acids, omega‐3 fatty acids, and probiotics have preventive and therapeutic effects. in addition, choline, ber, coffee, green tea, and light alcohol drinking might be protective factors for nafld. currently, nafld/nash is the most common cause of liver disease worldwide and the third most common indication for liver transplantation in north america.1 the management of patients with nafld consists of treating steatohepatitis and the associated metabolic co morbidities (jian‐gao fan et, al 2000) methodology 100 samples were diagnosed denovo nafld were recruited as subjects in this study. questionnaire method was used to collect data regarding general information such as-gender, age, income, family size, education, region, anthropometry, water consumption, past medical history of noncomm unicable problems, physical activity status, stress status etc., thereafter, the condition of the subjects was assessed for every 3 months and 6months. the end results were evaluated, analyzed and maintained. dietary intakes were assessed using 24hr recall method, frequency of food consumption. the amounts consumed were recorded in house hold units by measuring with a ruler, katori and measuring cups. records were validated according to corresponding food table and nutrient data base, nutritional values. physical activity was assessed using 7-day physical activity diary. participants were instructed to document all activities for 7 consecutive days. after every 3months and 6months the absolute minutes spent on various physical activities were calculated for each participant. statistical analysis was completed and graphs were produced and obtained p-values and chi-square signicance for majority of variables. results and discussion total subject fig.1. distribution of subjects based on gender it is evident from fig.1 that the majority of the subjects in the present study are females compared to the female population. about 56 % of female case studies are said to be having nafld when compared to the 44% of male case studies. nonalcoholic fatty liver disease (nafld) has been recognized as a major health burden. estimates suggest that about 20–30% of adults in developed countries have excess fat accumulation in the liver [propst et al. 1995; bellentani et al. 2000; falck-ytter et al. 2001; bedogni and bellentani, 2004; zelber-sagi et al. 2006], 50% among people with diabetes and about 80% in obese and morbidly obese people [bellentani et al. 2000; del gaudio et al. 2002; gupte et al. 2004] age group fig.2. age group of the subjects nutrition status and nutrient intake of denovo nafld patients original research paper k. vasundhara padma r.d., m.sc., p.g. diploma in nutrition and dietetics clinical research non-alcoholic fatty liver disease (nafld) is one type of fatty liver which occurs when fat is deposited (steatosis) in the liver . it is a common and potential serious complication in the patient, who does not abuse or consume little to no alcohol. non-alcoholic steatohepatitis (nash) is the most extreme form of nafld. it is related to insulin resistance and the metabolic syndrome and may respond to treatment originally developed for other insulin-resistant states (e.g.: diabetes mellitus type2) such as weight loss, metformin , and thiazolidinediones. it is marked by liver inammation, which might progress to scarring and irreversible damage. this damage is similar to the damage caused by heavy alcohol use. abstract keywords : dr. gowri sankar* pharm., ph.d., fic.*corresponding author volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 20 x gjra global journal for research analysis fig.2 shows that the majority of the subjects are between 40years to 50years of age. body mass index fig.3. classication of subjects based on bmi bmi was calculated as per their height and weight. fig.3 shows majority of them are normal, only 39% of them are overweight and 16% of them are obese. dietary habits fig.4. dietary habits of the selected subjects the above gure shows that the majority of them are non vegetarians, they are 76% high when compared to the vegetarians, who are 24%. there are no jains observed during this study. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra physical activity data n energy carbohydrates protein fat intially 100 2626.5 ± 291.9 427.8 ± 46.8 64.4 ± 10.8 71.7 ± 12.3 rd3 month 100 1550.5 ± 74.0 251.9 ± 12.0 56.5 ± 7.19 34.6 ± 1.8 th6 month 100 1406.5 ± 22.08 210.8 ± 2.9 70.2 ± 0.9 31.2 ± 0.4 energy fig.6. energy (kcal/d) intakes of nafld patients carbohydrates fig.7. carbohydrates (kcal/d) intakes of nafld patients protein fig.8. protein (kcal/d) intakes of nafld patients fat fig.9. fat (kcal/d) intakes of nafld patients the above gure shows the evident that there is a gradual increase in the physical activity like walking and running. initially it was 31% and after an intervention in their diet and life style, nafld subjects are having an increase in their physical activity. table.1. macro nutrients intake of denovo nafld patients table.2. clinical parameters of the nafld patients range clinical parameters blood sugars (%) htn+(%) lft (%) fatty liver (%) hyperpidemia (%) initially normal 81 86 92 0 88 above normal 19 14 8 100 12 rd3 month normal 91 96 98 13 95 above normal 9 4 2 87 5 th6 month normal 100 100 99 70 100 above normal 0 0 1 30 0 fig.5.the total mean of physical activity done by the nafld subjects x 21gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra the above table.2. shows the clinical parameters of nafld patients . initially the clinical parameters were high and in the rd3 month of intervention all the clinical parameters had slightly changed and improved. in the last intervention i.e. in ththe 6 month , the clinical parameters had been drastically changed when compared with the intial data. the results were highly satised. fatty liver fig.10. nafld patients with fatty liver normal and above normal fig.10. the above graph explains the gradual change of the impression of fatty liver in the nafld pateints, who are abnormal intially, with the help of diet intervention,frequent coucelling on life style changes showed to normal levels. perdomo et .al explained about the impact of nutritional changes on nafld is a major global health threat due to its growingincidence and prevalance . theraputic aproaches emphasise lifestyle modications including phsical activity, healthy eating habbits that intend to controlbody weight and other factors. the purposeof this article is to assess the impact of dietary recommendations against nafld. during the study it was observed that, there was high consumption of simple sugars from soft drinks, soda, sodapop, coca-cola etc., heavy intake of fructose from juices,jellies,jams, high fructosecorn syrup(hfcs) based products,and caramel colorant among the subjects, which allivited the risk for liver steatosis. studies have assumed that fructose can be linked to nafld through both indirect and direct mechanisms. indirectly, fructose may lead to adverese metabolic effects which can increase the risk of developing nafld.directly, fructose might cause hepato toxic damage such as that observed inheriditary fructose intolerance. the evaluated group presents a health risk situation considering the indicators of nutritional status. the regular diet of the subjects appeared to be rich in carbohydrates-simple sugars, fructose, high calories, high fat etc., which triggers risk for nafld. conclusion counseling had a great impact on their life style, dietary modications and physical activity level. patients were further advised to avoid consumption of rened processed foods which are high in fat(trans fat) and low ber content e.g. biscuits, cake, etc. such foods are a source of empty calories and would worsen insulin resistance and may also promote weight gain. references 1. adams la, angulo p (2006). “treatment of no-alcoholic fatty liver disease”. post-graduation medical journal-82, (page no: 315–22). 2. bellentani s, saccoccio g, masutti f, prevalence and risk factors for hepatic steatosis in northern italy, annual international medical journal 2000, 132: (page no: 112-117). 3. carolina m perdomo , gema fruhbeck and jevier escaladaimpact of nurtional changes on nafld. march -2019. 4. chalasani n. et al. the diagnosis and management of fatty liver disease: practise guideline by the american gastroenterological association, american association for the study of liver diseases, and american college of gasteroenterology. 2012; (page no: 1592-1609). 5. clark jm, diehl am (2003), “non-alcoholic fatty liver disease: an underrecognized cause of cryptogenic cirrhosis”. jama, 289 (22). 6. gupta p, amarapurkar d, agal s, et al. non-alcoholic steatohepatitis in type 2 diabetes mellitus. journal of gastroenterology hepatology,2004, (page no: 854-858). 7. non-alcoholic fatty liver disease and nutritional implications: special focus on copper laura antonucci,1 cristiana porcu, 8. rinella me (june 2015), “non-alcoholic fatty liver disease: a systematic review”. jama, (226-373). 9. role of diet and nutritional management in non‐alcoholic fatty liver disease jian‐gao fan ,hai‐xia cao 10. sanjay kalra, manojvithalini, gurjeetgulati, brahmananda das. original article study of prevalence of non-alcoholic fatty liver disease (nafld) in type 2 diabetes patients in india. journal of association of physicians of india. july-2013, vol-61. 22 x gjra global journal for research analysis introduction: asthma is heterogeneous disease, usually characterized variable airow obstruction, chronic airway inammation and bronchial hyper-responsiveness. until recently bronchospasm was considered cardinal feature of asthma but now in addition to bronchospasm, airway inammation is recognized as an essential component of the disease. asthma prevalence is rising in both the developed and developing world with >3 million people affected world wide. now a days asthma prevalence is increasing in the developing countries also. vitamin d: vitamin d is fat soluble nutrient and a secosteroid hormone produce endogenously in the skin from sun exposure or obtained from foods that naturally contains vitamin d including cod liver oil. vitamin d deciency is diagnosed by the concentration of blood s.25(oh)d (vitamin d) level, the 3 primary circulatory form of vitamin d and then 1,25(oh)d .low 3 serum level of vitamin d have been linked to increased risk of asthma exacerbation in children and adults . vitamin d deciency is also associated with increased risk of cardiovascular disease, allergic disorder, autoimmune disease and cancer. vitamin d deciency is a risk factor for allergic disorder and immune mechanism. vitamin d has been shown to have role in both innate and adoptive immunity by promoting phagocytosis and modulating the effect of th1, th2 and regulatory t cells. this study is done to assess the relationship between the severity of asthma and severity of vitamin d deciency. material and method: this is observational study conducted at smt. scl hospital on the 50 indoor patient of asthma between july 2015 to june 2016. inclusion criteria: age > 18 years, diagnosed with asthma according to gina guideline with written consent. the study group was divided as: group a: asthma in between attack (intermittent attack) and vitamin d deficiency and its effect on severity of asthma in adult original research paper dr. anikumar vaja rd3 year resident, department of medicine, shardaben general hospital, saraspur, ahmedabad-380018. dr. vikramsinh anand rd3 year resident, department of medicine, shardaben general hospital, saraspur, ahmedabad-380018. x 75gjra global journal for research analysis medicine aim: this study aimed to assess vitamin d status in asthmatic patients and to assess the relationship between vitamin d level and asthma severity. introduction: asthma is heterogeneous disease, usually characterized by variable airow obstruction and bronchial hyper-responsiveness. the world health organization stated that approximately 300 million people have asthma. recently the effects of vitamin d appear to have regulatory effect on every part of immune system, vitamin d deciency being linked to an array of immunologically based disease focusing on asthma. method: the present study included 50 patients diagnosed as bronchial asthma. the asthmatic patient group was divided into group a asthma in between attack and group b exacerbated asthma, that was again divided in subgroup (i), (ii), and (iii) mild , moderate and severe exacerbated asthma according to symptoms and fev1. serum 25 hydroxy vitamin d level in all 3 groups was measured by radio immunoassay method and compared between this groups. result : this study shows statistically signicant correlation between vitamin d level and severity of asthma. the mean levels of serum 25 hydroxy vitamin d in asthmatic patients are: group a 28.24 ± 1.35 ng/ml, mild persistent: 22.6 ± 11.5 ng/ml, 3 moderate persistent: 18.33 ± 1.31 ng/ml, and severe persistent: 10.45 ± 1.84 ng/ml. p value of <0.01 which is highly signicant. conclusion : there was a correlation between asthma severity and vitamin d level. further studies are needed to determine the role of vitamin d in treatment of bronchial asthma. abstract keywords : dr. archit parikh rd3 year resident, department of medicine, shardaben general hospital, saraspur, ahmedabad-380018. dr. bhagyashree chaudhari nd2 year resident, department of medicine, shardaben general hospital, saraspur, ahmedabad-380018. dr. gayatri patel rd3 year resident, department of medicine, shardaben general hospital, saraspur, ahmedabad-380018. dr. apurva patel* st1 year resident, department of medicine, shardaben general hospital, saraspur, ahmedabad-380018. *corresponding author dr. shyam katariya st1 year resident, department of medicine, shardaben general hospital, saraspur, ahmedabad-380018. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 76 x gjra global journal for research analysis group b: exacerbated asthma group, that was further divided into subgroup mild (i), moderate (ii), and severe (iii) exacerbated asthma according to severity of symptoms and fev (gina criteria).1 all patients were admitted and detailed history and assessment was done. all necessary investigations were done in form of complete blood count, plain chest x-ray, pulmonary function test was done by using spirometer. it included fvc % of predicted, fev % of predicted, fev /fvc.1 1 in all subjects s.25 (oh) d3 (vitamin d) was measured using the immunodiagnosis enzyme immunoassay (eia). in this study vitamin d level were categorized as insufcient (<30 ng/ml) or sufcient (>30 ng/ml). data collected were tabulated and analyzed by spss (stastical package from the social science software). a chi square test was performed to determine correlation between categorical variable. p value <0.5 was considered signicant. observation & result: 1. comparison between demographic data (age, sex, smoking status) among study group. this table shows that there was non signicant relation between demographic data (age, sex, smoking status) among study group. 2. comparison of serum vitamin d levels between asthma in between attack group (a) and exacerbated asthma group (b). this table shows that, serum vitamin d is highly signicantly lower in the exacerbated asthma group (b) compared to asthma in between attack group (a) (p value < 0.01). p < 0.01 highly signicant relation. 3. comparison of serum vitamin d levels between asthma in between attack group (a) and severe exacerbated asthma subgroup (iii). this table shows that, serum vitamin d is highly signicantly lower in the severe exacerbated asthma subgroup (iii) compared to asthma in between attack group (a) (p value < 0.01). p < 0.01 highly signicant relation. 4. comparison of serum vitamin d levels between mild (i), moderate (ii) and severe (iii) exacerbated asthma subgroups. this table shows that serum vitamin d is highly signicantly lower in moderate exacerbated asthma subgroup b compared to mild and severe compared to mild and moderate, (p value < 0.01). p < 0.01 highly signicant relation. result: a total of 50 patients (28 males, 22 females) were enrolled in this study whose age ranged from 23 to 58 years with a mean age of 41.2 ±9.6 years. active smoking was found in 23 cases (46%). a total of 50 patients 20 patients were of group a with mean age 40.75 ± 10.7 years and 30 patients were from group b with mean age of 41.65 ± 8.3 years. there was statistically signicant negative correlation between vitamin d level and severity of asthma. the mean levels of serum 25(oh)d (vitamin d) in asthmatic patients 3 are: group a:28.24 ±1.35 ng/ml,mild persistent :22.6± 11.5 ng/ml,moderate persistent :18.33 ± 1.31 ng/ml,severe persistent :10.45 ± 1.84 ng/ml.p value of <0.01 which is highly signicant. discussion : bronchial asthma is a major health problem. it has dramatically increased worldwide over last few decades, in both developed and developing countries. vitamin d deciency may predispose to allergic phenotype of asthma and epidemiological evidence suggests that lack of vitamin d has been linked to increased incidence of asthma in adult. vitamin d is a potent modulator of immune system. result of our study shows that serum vitamin d level is signicant lower in asthmatic patient and lowest value was observed in severe persistent group b (group b iii). also shaaban and hashem investigated serum vitamin d levels in 75 adults with asthma and 75 adult healthy controls and demonstrated that, vitamin d deciency was observed in 78.66% asthmatic patients whereas 85% of healthy control subjects expressed sufcient levels. this study is also in agreement with that of emanshebl et al who conducted a study on 66 non-smoking adult asthmatic patients and 30 healthy adult volunteers and found that 40% asthmatic patients suffered from vitamin d insufciency, while in the control group vitamin d insufciency was present in 20% of them with a signicant increase in the number of severe asthmatic patients with vitamin d insufciency compared with those with sufcient vitamin d. also stephanie korn et al. studied serum vitamin d levels in 280 adults with asthma and found that, vitamin d concentrations in adult asthmatics were low and vitamin d insufciency or deciency was signicantly related to asthma severity. similarly montero arias et al. demonstrated that, serum vitamin d levels were examined in 121 adults with asthma and volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra studygroup (%) age mean± sd 41.22 ± 9.6 sex male 28(56%) female 22(44%) smoking smoker 23(46%) non-smoker 27(54%) asthma in between attack group (a) exacerbated asthma group (b) p value serum vitamin d level 28.24 ± 1.35 16.05 ± 5.47 <0.01 asthma in between attack group (a) severe exacerbated asthma subgroup (iii) p value serum vitamin d level 28.24 ± 1.35 10.45 ± 1.84 <0.01 mild (i) exacerbated asthma subgroup moderate (ii) exacerbated asthma subgroup severe (iii) exacerbated asthma subgroup p value serum vitamin d level 22.6 ± 11.5 18.33 ± 1.31 10.45 ± 1.84 <0.01 noted that, in asthmatic patients with low vitamin d levels, there was a signicant association between vitamin d levels and the risk of severe asthma, the risk of hospitalization or visit to the emergency department due to asthma. shaaban and hashem demonstrated that, there was a signicant association between higher serum vitamin d concentration and better lung function. vitamin d has been shown to have a role in both innate and adaptive immunity by promoting phagocytosis and modulating the effect of th1, th2 and regulatory t cell. further evidence suggests that vitamin d alters human airway smooth muscle expression of chemokines and 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"vi tamin d2 formation and bioavailabil i ty f rom agaricusbisporus button mushrooms treated with ultraviolet irradiation". j agric food chem. 57 (8): 3351–5. doi:10.1021/jf803908q. pmid 19281276 73. m.f. holick, vitamin d status: measurement, interpretation and clinical application, ann. epidemiol. 19 (2) (2009) 73–78. 74. morton et al., medical statistics. in: r.f. morton, j.r. hebel, r.j. mccarter (eds.), a study guide to epidemiology and biostatistics, 5th ed. aspen publication: gaithersburg maryland. 2001, pp-71 74 75. f. li, m. peng, l. jiang, et al, vitamin d deciency isassociated with decreased lung function in chinese adults withasthma, respiration 81 (2011) 469–475. 76. mostafa m. shaaban, manal hashem, serum 25 hydroxyvitamin d levels in adult asthmatic patients, egypt. j. hosp.med. 49 (2012) 946–952. 77. r. emanshebl, samah m. shehata, mahaelgabry, salah a.i.ali, hanaa h. elsaid, vitamin d and phenotypes of bronchial asthma, egypt. j. chest dis. tuberc. (2013) 201–205. 78. stephanie korn, marisa hu¨bner, matthias jung, mariablettner, roland buhl, severe and uncontrolled adult asthmais associated with vitamin d insufciency and deciency, respirres. 2013 (14) (2013) 25. 79. felicia montero-arias, giovanni sedo´-mejıa and allan ramos esquivel: vitamin d insufciency is associated with asthmaseverity, allergy asthma immunol. res. 5 (2013) 283–288. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 78 x gjra global journal for research analysis introducti̇on: colorectal cancer (crc) is the third most common cancer and nearly one million new cases has been diagnosed annually(1) colorectal cancer pogression is a multistep process, in which many genes and proteins are involved. the function of extracellular matrix in many kinds of cancers have been revealed and their role of the clinical signicance in colorectal cancer is under investigation. the matrix metalloproteinases (mmps) are a family of zincdependent endopeptidases that are involved in degrading extracellular matrix and facilitating tumor invasion(2,3) mmp9 and mmp-2 are gelatinases of mmp family and degrade substrates of type iv collagen and gelatin. previous studies have demonstrated that mmp-2 is associated with invasion and metastasis in colorectal carcinoma (4,5,6) e-cadherin is a key mediator of cell–cell adhesions in epithelial tissues, and loss of e-cadherin can promote invasive and metastatic behaviour in many epithelial tumours, also (7 ). the cytoplasmic domain of e-cadherin interacts with catenin molecules, including β-catenin. β-catenin which is major mediator cadherin-associated protein play important role in wnt signalling pathway. mutations in adenomatous polyposis coli (apc) which is a tumour suppresser gen leads to enhances β-catenin gene expression. (8). when β-catenin accumulates ,it translocates to the nucleus, and associates with tcf/lef, leading to its binding to dna and subsequent transcription of genes associated with crc development. wnt/β‐catenin signaling pathway is aberrantly activated and responsible for upregulating mmps expression (9,10) . disturbance of the e-cadherin/catenin complex during tumor progression is correlated with the onset of an invasive phenotype (11) . in addition , studies suggested that the matrix metalloproteinase leads directly or indirectly to shedding of the e-cadherin (12) . in our study, we aim to investigate the expression of ecadherin and mmp-2 in colorectal cancer and their associations with clinical pathological features. materi̇al and methods: tissue samples and patients the study was designed as retrospectively and due to retrospective nature of the study informed consent was not required. this research did not receive any specic grant from funding agencies in the public, commercial, or not-forprot sectors. our study consisted of 48 patients with colorectal cancer who had undergone surgical resections at baskent university hospital between 2014 and 2018 . the study group consisted of 24 classic adenocarcinomas and 24 mucinous adenocarcinomas . tumor staging and histological classications were assessed according to world health organization classication (13). of the patients, 35 were men ( 62,867% ) and 13 were women (37,14%). , the patients ranged in age from 30–84 years (mean, 57,52 + 14,98 years).the investigated tumors were classied as pt1 tumor was observed in (n:3) 6,25 % of patients, pt2 tumor in (n:20) 41,66 % of patients, pt3 tumor in (n:18) 37,59 % of patients and pt4 tumor in (n:7)14,585% of patients . among them (n:4) 8,33 %were located at right colon and (n:44) 91,67% were located at left colon. the control group consisted of 20 normal colon mucosa. the clicopathologic features of cases has been listed in table i . immunohistochemical staining: immunohistochemistry was performed using antibodies to mmp-2, (novo castra, clone 17c2, 1/100 dilution), e cadherin ( biogenex, clone ep ,1/300 dilution) immuno staining were performed by using manuel method. in manuel method, tissue sections (4 µm thick) were cut, deparafnized in xylene, dehydrated with graded ethanol and then the sections were placed in 10 mm citrate buffer solution (ph 7,3) and processed in an autoclave for 1,5 minutes at 120°c for antigen retrieval. after washing in distilled water (5 minutes) and in phosphate-buffered saline (pbs) (5 minutes) immersed in methanol with 0,3 % peroxidase for 5 minutes to inhibit endogenous peroxidase activity. antibody was applied, and incubations were performed 2 hours at room temperature. after washing ve times in pbs, slides were incubated with biotinylated second antimouse antibody (zymed, diluted 1:200 ) after ve washes with washing buffer, the sections were incubated with aec. the sections were counterstained with meyer's hematoxylin. evaluation of immunostaining: mmp-2 expression: mmp-2 staining was restricted to the stromal broblasts and inammatory cell, with no staining of evaluati̇on of e-cadheri̇n , mmp-2 i̇n colorectal carci̇noma original research paper hilal erinanç* baskent university, faculty of medicine, department of pathology *corresponding author medicine background : colorectal cancer pogression is a multistep process, in which many genes and proteins are involved. matrix metalloproteinase and loss of-e-cadherin has been considered to be associated with cancer invasion and metastasis. in our study, we aim to evaluate the expressions of e-cadherin and mmp-2 in colorectal carcinoma . material and methods: expressions of ecadherin and mmp-2 in specimens from 48 colorectal adenocarcinomas ( 24 classic adenocarcinomas and 24 mucinous adenocarcinomas) were detected by immunohistochemistry. results: mmp-2 expression was found 45,84% in classic adenocarcinoma while e-cadherin was found 33,33% in mucinous carcinomas. conclusion: our ndings demonstrate that e-cadherin and mmp-2 expression contributes to tumor development. it sems that mmp-2 expression was more associated with classic adenocarcinomas while e-cadherin was related with mucinous adenocarcinomas .further studies are need to nd the correlations between e-cadherin ,mmp-2 and epithelial-mesenchymal transition. abstract keywords : colorectal cancer, e-cadherin, mmp-2 emin turk baskent university, faculty of medicine, department of general surgery volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 22 x gjra global journal for research analysis tumor cells. staining intensity was graded as follows: 0, no staining; 1, weak staining; 2, moderate staining; and 3, intense staining. e-cadherin expression: e-cadherin immunoreactivity was localized in the cytoplasm and plasma membrane in normal mucosa. cytoplasmic expression of e-cadherin was recorded when staining was absent from the cancer cell membrane and preserved in cancer cell cytoplasm and nucleus. (0) negative, no detectable staining. weak but detectable discontinuous staining graded as (1) ; moderate, but discontinuous staining graded as(2) ; intense and continuous staining graded as (3) . statistical analysis the associations between expressions of the two items with clinicopathological variables were assessed by chi-square test. p-values were calculated with signicance level <0.05. all calculations were performed with spss software package, standard version 17.0 (spss inc., chicago, il, usa). results: mmp-2 staining: mmp-2 was localized in stromal broblast in colon adenocarcinomas (figurei) . mmp-2 staining was also weakly observed in inammatory cells, macrophages, endothelial cells and muscularis mucosa. while mmp-2 was weakly expressed in 21,7% of normal mucosa, higher expression seen in 45,84% of classic adenocarcinomas . in mucinous tumors, the rate of positive cases were similar to normal mucosa . the staining intensity was scored as (range: 0 to 3) and the percentage of positive casess as (range: 0 to 3 [0, {n:13, 54,16%}, 1 {n:8,%33,3%}, 2 {n:2, %8,33%}, 3 {n.1, 4,16%}]). the mean level of mmp-2 was between 0,200,52 and 1,661,41. staining was increased from normal mucosa (0,621,03) to carcinomas group (0,730,98) however there was no statistical difference . there was no correlation between mmp-2 staining and tumor grade and stage. table i shows mmp-2 expression according to staining intensity. e-cadherin staining: all of the classic adenocarcinomas showed the membranous and cytoplasmic expression pattern of e-cadherin (figure ii) . of the 24 tumors, 12 (50%) were considered as grade 3 staining intensity and 12 (50) were considered as grade 2 staining intensity. there were no decreased in e-cadherin expression in classic adenocarcinomas. loss of e-cadherin expression was seen in 33,33% of patients with mucinous tumors (figure iii). of the 24 tumors, 16 patient (66,67%) were considered as grade 3 staining intensity and 8 patient (33,33% ) were considered as grade 0. table ii shows e-cadherin expression according to staining intensity. di̇scussi̇on: in this study, we evaluated the expressions of e-cadherin and mmp-2 and their relation with clinocopathologic features. numerous studies were performed to determine how mmps contribute to colorectal carcinogenesis. in colorectal cancer, mmp-7( matrilysin), mmp-2(gelatinase a), mmp-9(gelatinase b) and mmp-1 have demonstrated to be overexpressed ( 46,14-16) . mmp-2 has the ability to degrade basement mem brane type iv collagen, which would facilitate tumor cells invasion. the present study showed that the expression of mmp-2 was higher compare to normal mucosa however its correlation with tumor stage and grade was not obtained. studies on the functions of mmp-2 in cancer progression were quite controversial waas and colleagues similarly showed . that low stage (i and ii) disease showed higher mmp2 expression than more advanced stages (iii and iv) (17). wong et al demonstrated that lack of mmp2 expression was associated with poorer outcomes in stage iii rectal cancers, including the risk of local recurrence ( 18 ) . matrix metalloproteinases are synthesized by neoplastic and stromal cells (19) in the present stuy the source of mmp-2 was only broblasts and inammatory cells. our research has demonstrated that weak expression of mmp2 in the inammatory inltration and a much stronger response in stromal broblast in tumor tissue. groblewska et al found a signicant correlation between mmp-2 immunoreactivity in inammatory cells and the presence of distant metastases. (20) in the present study mmp-2 expression was mostly seen in classic adenocarcinomas while stromal mmp-2 expression could not obtained in majority of mucinous tumors . we thought that mmp-2 expression coul not pooperly evaluated due to mucinous nature of stroma in mucinous tumors. cellular adhesion molecules also plays an important role in the invasion and metastasis of the tumour (21) loss of ecadherin expression was reported to promote cancer cell proliferation and invasion and proved to correlate with cancer progression and unfavorable prognosis in various cancer. (22,23,24) loss of e-cadherin has been associated with colorectal cancer, before (25). however conicting results exist on the role of e-cadherin in tumor progression. authors reported that decreased expression of e-cadherin correlated with poor prognosis (26,27,28) while unaltered ecadherin level has been found in in patients with inammatory bowel disease (ibd) or early stage colorectal tumors (29). in this study, loss of e-cadherin was demonstrated to be found more frequently in mucinous tumors. we found that ecadherin expression were similar to normal mucosa in majority of classic adenocarcinomas . the ability of matrix metalloproteinases to enhance tumor cell invasion has been thought to be a result of the degradation of the extracellular matrix. authors found that that matrix metalloproteinase mediated induction of cellular invasion also can be independent of direct matrix degradation and, instead, a result of the release of e-cadherin fragments (30). in addition, authors found that the increase in the metastatic potential of tumour cells is associated with an increased expression of mmp-2 and a decreased expression of ecadherin(31). however we did not nd the relation betwwen mmpand e-cadherin , in the present study. we thougt that the present study may indicates that the extracellular matrix transition (emt) process may be different in classic adenocarcinomas and mucinous tumors. recent studies described wnt signaling pathway is aberrantly upregulated in both mss and msi colorectal cancers . the msi pathway is often associated with, mucinous morphology, proximal colon(32) . the limitation of our study , study we did not evaluate molecular msi status and tumor site. in conclusion our nding prove that mmp-2 and loss of ecadherin play role in colorectal carcinogenesis however there is no relation between the mmp-2 expression and loss of e cadherin. it seems that mmp-2 expression was more related with classic adenocarcinomas while loss of e-cadherin expression was more related with mucinous adenocarc volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 23gjra global journal for research analysis inomas. we thought that further studies needs to nd the underlying mechanism of extracellular matrix transition in colorectal cancer . figure i: figure shows mmp-2 expression in stromal broblast (mmp-2x100) figureii: figure shows grade 3 e –cadherin expression (ecadherin x40) figure iii fıgure shows loss of membranous expression in mucinous adenocarciomas (ecadherin x20) table i: the distrubution of mmp2 staining intensity table ii: the distrubution of e-cadherin staining references 1bhandari a, woodhouse m, gupta s. colorectal cancer is a leading cause of cancer incidence and mortality among adults younger than 50 years in the usa: a seer-based analysis with comparison to other young-onset cancers. j investig med. 2017 feb;65(2):311-315. 2 gialeli c, theocharis ad, karamanos nk. roles of matrix metalloproteinases in 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22 wijnhoven bp, dinjens wn and pignatelli m: e-cadherin-catenin cell-cell adhesion complex and human cancer. br j surg 2000; 87: 992–1005. 23 chao yl, shepard cr and wells a: breast carcinoma cells re-express ecadherin during mesenchymal to epithelial reverting transition. mol cancer 2010; 179, . 24 bae k-m, parker nn, dai y, vieweg j and siemann dw: e-cadherin plasticity in prostate cancer stem cell invasion. am j cancer res 2011; 1: 71–84. 25 he, x.; chen, z.; jia, m.; zhao, x. downregulated e-cadherin expression indicates worse prognosis in asian patients with colorectal cancer: evidence from meta-analysis. plos one 2013, 8, e70858 26 karamitopoulou, e.; zlobec, i.; patsouris, e.; peros, g.; lugli, a. loss of ecadherin independently predicts the lymph node status in colorectal cancer. pathology 2011; 43, 133–137. 27 tóth, l.; andrás, c.; molnár, c.; tanyi, m.; csiki, z.; molnár, p.; szántó, j. investigation of _-catenin and e-cadherin expression in dukes b2 stage colorectal cancer with tissue microarray method. is it a marker of metastatic potential in rectal cancer? pathol. oncol. res. por 2012; 18, 429–437. 28 khoursheed, m.a.; mathew, t.c.; makar, r.r.; louis, s.; asfar, s.k.; al-sayer, h.m.; dashti, h.m.; al-bader, a. expression of e-cadherin in human colorectal cancer. surg. j. r. coll. surg. edinb. irel. 2003; 1, 86–91 29 weiss, j.v.; klein-scory, s.; kübler, s.; reinacher-schick, a.; stricker, i.; schmiegel, w.; schwarte-waldho, i.soluble e-cadherin as a serum biomarker candidate: elevated levels in patients with late-stage colorectal carcinoma and fap. int. j. cancer 2011; 128, 1384–1392 30 noë v, fingleton b, jacobs k, crawford hc, vermeulen s, steelant w, bruyneel e, matrisian lm, mareel m. release of an invasion promoter e-cadherin fragment by matrilysin and stromelysin-1. j cell sci. 2001;j14(pt 1):111-118. 31nowak m, madej ja, pula b, dziegiel p, ciaputa r.expression of matrix metalloproteinase 2 (mmp-2), e-cadherin and ki-67 in metastatic and nonmetastatic canine mammary carcinomas. ir vet j. 2016 aug 2;69:9. 32cong luo, shuyi cen, guojun ding, and wei wu mucinous colorectal adenocarcinoma: clinical pathology and treatment optionscancer commun (lond). 2019; 39: 13. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 0 1 2 3 classic adenocarcinoma n:13 54,16% n:8 33,3 % n:2 8,33 % n:1 4,16 % mucinous adenocarcinoma n:20 83,33% n:2 8,33 % n:2 8,33% 0 0 % 0 1 2 3 classic adenocarcinoma 0 0 % 0 0 % n:12 50% n:12 50 % mucinous adenocarcinoma 8 33,33% 0 0 % 0 0 % 0 66,67 % 24 x gjra global journal for research analysis introduction each application that is running today requires large size of databases such that huge amount of data that is being generated within them can be stored in them. there is a need to generate new and highly efcient tools which can manage such huge databases and the data present within them. for facilitating the large number of users as well as their applications several techniques have been proposed by researchers. amongst such techniques is the data mining and knowledge discovery approach that is used in order to manage all such data. data mining is known as the automated approach of identifying interesting patterns from huge databases [1]. this technique helps in generating descriptive, understandable and predictive models from the existing data within the databases. the main reason behind the development of this work is to store data which is generated each day due to all the applications has been utilized by humans. in the computer databases, this data is stored so that it becomes easy to access data whenever it is required. the similar objects are separated from each other amongst different groups this process is known as clustering. cluster is dened as the group in which similar objects are placed within the same group [2]. similarly, objects having different properties and are dissimilar with each other are placed in separate cluster. the representation of data using less clusters leads to loss of essential information. with the help of this approach, it becomes easy to simply data in controlled manner. in the databases large amount of data is present which is stored from long time. the extraction of this information is very important in order to utilize it in useful manner [3]. the process of data mining extracts the useful information with quality and also provides effective sharing. the discovery of predictive intelligence has been done with the help of uncovering patterns and relationships present within structured as well as unstructured data in case of data mining and text analytics [4]. according to researchers, it is required to have deep knowledge or creative skills so that models can be generated within predictive analytics. hence, this approach is developed with the help of some basic functions. the use of credit card is common nowadays due to change in technology from moderate to modern. therefore, it is necessary to develop a model for the detection of frauds in credit cards in all regions. fraud in credit cards is done by any unauthorized account activity of a person [5]. thus, it is necessary to take some appropriate steps by which increasing frauds and threats can be minimized timely. for the protection of the clients various methods are facilitated that provide the risk management that eliminates the misuses of credit cards misuse. the credit card fraud took place when user as well as issuer has no knowledge that other use tries to use card. hence, this is known as frauds in which one card is used by another. the person who tries to use card of another person is not having good intention as that person want to withdraw all money from user account. the unauthorized user is identied with the help of fraud detection system, if one could commit the fraud. in order to minimize all these frauds and to attract criminals various fraud detection methods has been developed so far using various strategies [6]. the development of new mechanism for fraud detection is becomes difcult due to the limitations of exchanging the ideas of fraud detection. literature review kuldeep randhawa, et.al (2017) presented the use of machine learning algorithm has been utilized for the detection of the fraud in the credit card by developing a system [7]. the standard models was utilized initially after which the use of hybrid methods is followed in which adaboost is present. the efciency of the model has been evaluated with the help of credit card dataset which is available everywhere. in the data samples noise is embedded in order to evaluate the robustness of algorithms. on the basis of performed experiments, it is concluded that fraud detection methods provides the higher accuracy rates. with the help of this approach online learning models will be proposed in future to extent the work. hence, it becomes easy to identify fraud cases quickly using online learning mechanism. suman arora, et.al (2017) presented various issues are faced by individual while selecting appropriate fraud detection models as per done study [8]. the implementation of an effective process coefcient sum mechanism was done whole set of selection criteria and fdms are introduced. for the analysis of various scenarios, this proposed approach has been utilized using decision maker's criterion. there is no fraud detection model till yet which satises all the needs by which frauds can be detected easily. they proposed a method in this paper which is based on the integration of different comparison so that fraud can be detected ranked easily. with the help of this proposed method, the complex multi-attributes decision issues can be resolved easily. s md. s askari, et.al (2017) presented the use of fuzzy logic which is the combination of mathematical process by which an id3 decision tree system is generated in this paper. they machine learning approach for credit card fraud detection original research paper geetika student, department of computer engineering, punjabi university, patiala computer engineering the extraction of the useful information from the raw data is done a technique known as data mining. the prediction of new things from the current data has been done using the prediction analysis which is the application of data mining. classications techniques are most commonly used which are implemented for the prediction analysis. hence, prediction of the credit card fraud detection is the main objective of this work. author proposed various credit card fraud detection mechanisms and techniques to prevent and detect fraud timely. the fundamental of the proposed technique in the base paper is based on the conventional neural networks. this system drives the new values and learns from the previous experiences. for the detection of the credit card fraud, svm classier is proposed in this research work using which input data is classied into normal and fraud transactions. test and training sets are the two sub-parts of the input data. in terms of precision and recall, the normal and fraud transactions have been predicted on the basis of test and training sets. abstract keywords : fraud detection, svm, knn, naïve bayes dr. gaurav gupta* assistant professor, department of computer engineering, punjabi university, patiala *corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 96 x gjra global journal for research analysis implemented the fuzzitree algorithm on the normalized training data [9]. as per performed experiments, it is demonstrated that all the performed transaction was classied correctly except for the transaction number 7. they performed various tests on different transactions so that detection rate can be determined easily in different situations. on the basis of achieved results, it is identied that the detection rate is around 89%. in future, advanced concepts of fuzzy will be utilized so that fraud detection can be identied easily. luis vergara, et.al (2017) presented in order to enhance the performance of credit card fraud detection systems, they proposed various methods which are based on signal processing on graphs [10]. in this paper, they proposed iterative amplitude adjusted fourier transform along with iterative surrogate signals on graph algorithms as an alternative. it is necessary to do a reliable augmentation of the target inadequate population of frauds due to the present issues. these issues are labeling cost, algorithm testing, data condentiality and consistent modication of patterns. with the help of legitimate and non-legitimate transaction ratios, they evaluated the detection capabilities feasibility using receiver operating characteristic (roc) curves and several key performance indicators (kpi) are utilized. fabrizio carcillo, et.al (2017) presented for the detection of frauds and to enhance the accuracy of fraud detection ratio they combine the previously proposed techniques with new methods in this paper [11]. they mentioned the development or investigation of tradeoff, in terms of fraud detection. with the help of corresponding machine learning techniques, they performed the widespread analysis. this can be done by transacting millions of real-world dataset which has been provided by an industrial system. on the basis of performed experiments, it is concluded that high risk query mechanism is achieved here for the enhancement using semi-supervised leanring. rajeshwari u, et.al (2016) presented for the prevention and detection of frauds timely, they proposed a mechanism in this paper. with the help of this method, alert related to fraudulent transactions will be sent to the card owner and credit card is blocked immediately [12]. the value generated for hidden markov model outcome is the basis that decides whether the transaction is fraudulent or not. with the help of this system, all the marked fraud cases among the actual transactions can be minimized using this by comparing the rate of false alarms that are achieved. in order to minimize the false alarm rates and to prevent frauds they utilize the streaming analytics. they proposed a model and update it regularly on the basis of collected information of genuine card holder. research methodology the credit card fraud detection algorithm and data classication methods were evaluated by conducting a detailed literature study in the rst step. this was done to know their advantages and limitations. the limitation of the existing schemes is overcome by the design of proposed security solution that improves the structure of this method. in order to build a robust system, it combines all the advantages of the system together. for the simulation process, they utilize the python simulator in which the proposed solution is implemented using all essential input and output parameters. after, implementation of the proposed method they analyze the performance and compared this method with the existing. from last 10 years, the historical data of the credit cards has been utilized for the process of input data acquisition. in the historical data, all the details of transactions of every day is present which provides the information to user when the amount is withdrawn and by what time and from which location. by collecting the regression models with squared distance, they designed the proposed model during the process of implementation for classication. this was done for processing of historical data which has been utilized for the long term prediction. the classication of the input data into the normal and fraud transactions can be done using svm classier in this research work. the svm classication is also known as a predictive model which has been utilized for the text categorization. the used input here is data and output is the classied data given in two categories. with the help of svm training algorithm, a model is implemented for the amount of text where each training example belongs to one of the two classes. the data is divided into two categories by constructing n-dimensional hyperplane. on the each side of the hyper plane, they generated two parallel hyper planes so that data can be separated easily. hence, by separating the hyper planes, there is increase in the distance between the two hyper planes. in association to the partitioning hyper plane f(x) divides the two classes when it passes through middle. for the creation of the linear classication function, there is a linearly separable data set. the testing of sign of function f(xn) easily test and classify the new data instance, xn when it determine the function.: where xn belongs to a positive class if f(xn) > 0 the generalization of the error of the classier for the larger distance or margin can be done in an optimal way. this algorithm functioning is very good in concern with high dimensional feature set. for the creation of the new linearly separable data they utilize the kernel trick in which nonlinearly separable data is transferred. svm classication has been utilized for the calculation of regression analysis and to perform numerical calculations. this algorithm is also useful in ranking the elements. there are various attributes present on the dataset of the svm and it performance is good as only specic cases can be accessed for training purpose which is considered as the advantage of svm. but, it has limitation of speed and size which occur during the training and testing phase of svm. it is not easy to choose the parameters of kernel function hence, consider as disadvantage of algorithm. fig 1: proposed flowchart experimental results the proposed technique has been implemented in python and the results have been analyzed in terms of accuracy as shown below. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 97gjra global journal for research analysis figure 2: accuracy comparison as shown in gure 2, the accuracy of proposed and existing algorithms is compared and it is analyzed that proposed algoirhtm performs well in terms of accuracy. figure 3: recall analysis as illustrated in gure 3, the recall of voting based classication method is compared hybrid classication model. the hybrid classication model is more recall as compared to voting based classication method for credit card fraud detection. figure 4: execution time the execution time of the voting and hybrid classication is compared in the gure 4. the execution time of the hybrid classication method is low as compared to voting based classication method for credit card fraud detection conclusion data mining is the technique using which essential information can be easily extracted from the large amount of data. prediction analysis is considered as the application of credit card fraud detection. the prediction of future data in the prediction analysis has been done using current information. the implementation of neural networks was done in the existing techniques by which input data is learned that drive the future values. for the classication of normal and fraud transactions, they implemented the classication technique in this work. the whole data is divided into test and training sets, by applying the svm classier in this work. here, input is the test and training set which provides the future values. experimental results, evaluated the performance of proposed modal as compared to existing technique in terms of accuracy. references [1] k. c. tan, e. j. teoh, q. yu, k. c. goh., “a hybrid evolutionary algorithm for attribute selection in data mining”. expert system with applications 2008, elsevier [2] pardeep kumar, nitin, vivek kumar sehgal, durg singh chauhan. “selection of evolutionary approach based hybrid data mining algorithms for decision support systems an business intelligence”, icacci acm august 2012 chennai, india [3] mrutyunjaya panda, ajith abraham, “hybrid evolutionary algorithms for classication data mining”, springer, 10 august 2014 [4] rana forsati, mohammadreza meybodi, mehrdad mahdavi, azadehghari neiat. “hybridization of k means and harmony search methods for web page clustering” ieee international conference of web intelligence and intelligent agent technology, 2008 [5] yao yu, fu zhong-liang, zhao xiang-hui, cheng wen-fang. “combining classier based on decision tree” ieee international conference on information engineering vol 2. july 2009 [6] a. shen, r. tong, and y deng, “application of classication models on credit card fraud detection”, 2007, service systems and service management, 2007 international conference on, pp. 1-4. ieee [7] kuldeep randhawa, chu kiong loo, manjeevan seera, chee peng lim, asoke k. nandi, “credit card fraud detection using adaboost and majority voting”, 2017, ieee [8] suman arora, dharminder kumar, “selection of optimal credit card fraud detection models using a coefcient sum approach”, international conference on computing, communication and automation (iccca2017) [9] s md. s askari, md. anwar hussain, “credit card fraud detection using fuzzy id3”, international conference on computing, communication and automation (iccca2017) [10] luis vergara, addisson salazar, jordi belda, gonzalo safont, santiago moral, sergio iglesias, “signal processing on graphs for improving automatic credit card fraud detection”, 2017, ieee [11] fabrizio carcillo, yann-ael le borgne, olivier caelen and gianluca bontempi, “an assessment of streaming active learning strategies for reallife credit card fraud detection”, 2017 international conference on data science and advanced analytics [12] rajeshwari u, dr b sathish babu, “real-time credit card fraud detection using streaming analytics”, 2016, ieee volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 98 x gjra global journal for research analysis introduction the visible aspects of the transformation are proliferating shopping malls, e-commerce operators, modern retail, foreign retailers and fast upgrading traditional retailers. retailers are increasingly investing in developing countries like india and china to boost their sales and revenues. it is too early to predict how the sector would look like in future, but certain broad trends are visible, such as the slow but steadily rising importance of modern retail and e-commerce. this would impact the traditional retailers who are still the main stay of indian retail and have implications for employment and livelihood. retailing is the last link in the process of supply chain management. retailer is the person who is in direct contact with the customers because of this it gains its importance for the manufacturer. the word 'retail' is derived from the french word 'retaillier', which means 'to cut a piece of' or 'to break bulk'. the retailer unlike wholesaler did not buy products for further resale but to provide them to the end consumers. a number of activities are performed by retailers such as assorting, sorting, merchandizing, storing, providing credit facility, packing etc. the sector is facing big transformation from mom & pop stores, local kiryana store to big malls and hypermarkets. the customer is demanding products as never before. they possess good knowledge about pricing strategies, quality of the product and its usage. the consumer is now attracted towards big glitzy malls, eye catching interiors, one stop shopping experience. the concept of eretailing has resulted in one touch shopping real for customers. the customers are now demanding products from a place which is convenient to them. therefore, it is becoming difcult for retailers to nd loyal customers for themselves. the customers will be attracted towards those stores which tend to offer good quality products at attractive prices with convenience facility, in an attractive manner. the presence of retail sector in india can be felt way back from the time of melas and haats, these were meant to cater the need of local people living nearby. the emergence of kiryana stores and mom & pop stores were observed after sometime. the government also started supporting the retail sector and as a result a number of indigenous retail stores came into existence. with the passage of time, economy started becoming more open and a changed face of retail sector came into existence. the rst few companies which came into existence to set up retail chains were from textile sector. indian retail sector is gradually inching its way towards becoming the next boom industry and is emerging as the most dynamic and fast paced industries of these times (yuvarani, 2009). retailing plays an important role in marketing channels as every year retailer�s account for more than 4.5 trillion of sales of product. retailer is the last stage in the movement of goods in distribution channel who passes on products from manufacturer and wholesaler to consumer by adding of services at convenient location and conducive environment of retail store. in india, the retail sector is emerging as one of the largest sectors in the economy. the indian retail industry is expected to grow to us$1.1 trillion by 2020, registering a cagr of 8.79% between 2000 and 2020. to incentivise international retailers, the government of india (goi) has allowed 100% fdi through automatic route in ecommerce entities engaging only in business-to-business model of operation. however, it has been claried that retail trading by means of e-commerce is not permissible for companies with fdi engaged in the activity of multi brand retail trading. these measures have provided some level of clarity on the existing businesses of e-commerce companies 5operating in india . evolution of retail in india the evolution of retail trade in india can be traced to the times when majority of trade was routed through formats such as haats, mandis and melas. mostly organised on a periodical basis and limited to a particular locality/village, such formats gained prominence. almost everything from vegetables, household necessities to cattle's were bought and sold, either through monetary means or the barter system. contemporary organised retail industry evolution in india can be broadly classied in four phases; perspective planning for the development of retail sector in india original research paper hem chandra jha head, department of commerce, g. d. college, begusarai, l. n. mithila university, darbhanga commerce retail is sector in india is undergoing a denite transformation in terms of its structure and scale. the sector has been on a path of steady growth since the last decade and half due to many factors such as growing urbanisation, rapid economic growth and the resultant rise in purchasing power and consumerism. the above developments are also reected in the at kearney global retail development index 2017, in which india is ranked no. 1, replacing china, among top 30 developing countries where the markets are not only attractive today, but also offer future potential. the burgeoning middle-class population, spread of information and communication technology, globalisation and rising aspirations of consumers have all contributed to the transformational changes taking place in this sector. abstract keywords : volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 150 x gjra global journal for research analysis chart 2.3: evolution of retail in india source: www.ibef.org the indian brand equity foundation (ibef) estimates the industry to grow at a cagr of over 17% over the next 4 years and reach usd 1,300 billion by 2020. however, with the private final consumption expenditure expected to grow by about 12.5% y-o-y till 2020 (has grown at about 10-12% historically) and gdp by ~ 8.5-9%, care expects the retail industry to register a growth rate of about 12-14% over the next 4 years and reach about usd 1,150 billion by 2020. organised retail formats in india modern retailing in india has entered in form of huge malls and super markets offering shopping, entertainment, leisure to the consumer while the retailers experiment with a variety of formats, such as discount stores, supermarkets, hypermarkets to specialty chains. however, kirana shops still continue to score over modern formats primarily due to the convenience factor. the organized segment typically comprises of a large number of retailers, greater enforcement of taxation mechanisms and better labour law monitoring system. retailing is no longer only stocking and selling but is about efcient management of supply chain, developing distributor and vendor relationship, customer service quality, efcient merchandising and timely promotional campaigns. over the past few years, many prominent players in the country like tata, reliance industries, aditya birla and many others are investing signicantly in the indian retail market as a result of which there has been a tremendous growth in the organised segment. many other progressive players stepped into the territory with long term goals to expand their business across verticals, cities, formats and segments. growth drivers for retail in india chart: growth drivers for retail in india source: ibef retail report 2018, p.19 multiple drivers are leading to strong growth in indian retail through a consumption boom. signicant growth in discretionary income and changing lifestyles are among the major growth drivers of indian retail. easy availability of credit and use of 'plastic money' have contributed to a strong and growing consumer culture in india. acceptance and usage of e-retailers by consumers are increasing due to convenience and secured nancial transactions. expansion in the size of the upper middle class and advertisement has led to greater spending on luxury products and high brand consciousness. in fy18, gdp at current prices was us$ 2,848.23 billion and gdp per capita at current prices was us$ 2,134.8. conclusion the data from private consulting company reports suggest that growth in the retail market has been rapid despite major restrictions on fdi. in the third-quarter report of 2014, the bmi india retail report forecasted that the total retail sales will grow from us$ 353 billion in 2010 to us$ 543.2 billion by 2014. in an important consideration, the report suggested that there is need to unlock potentialities of fast growing middle and upper-class consumer base. the analysis also suggests that in the next few years there will be major opportunities in india's smaller cities. at kearney, a global management consulting rm, rates india as the most attractive nation for retail investment. the study, presented in the global retail development index of 2013, is carried out annually for 30 emerging markets, and has rated india highest four times in the last ve years. this report expresses even more optimism and estimates that suggests that india's retail market is expected to be about us$ 735 billion by 2015, with around 13 percent coming from organised retail. other estimates are more conservative, though still impressive. according to mckinsey, a search and consulting rm, organized retail in india is expected to increase from 5 percent of the total market in 2008 to 14-18 percent of the total retail market and reach us$ 450 billion by 2015. even if growth is more conservative than estimated, the spill-over effects of this rapid expansion could be felt by many other sectors of the economy. a report published by knight frank india in may 2014 looks at the question of land and available retail space. it estimates that, during 2014-15, around 55 million square feet of retail space will be ready in the major cities like mumbai, the national capital region (ncr), bengaluru, kolkata, chennai, hyderabad and pune. furthermore, between 2013 and 2015, the organised retail real estate stock is expected to grow from the existing 41 million square feet to 95 million square feet.4 arguably, this could drive up real estate prices, with consequent knock-on effects. despite the current policy and regulatory environment not being perfect for foreign investors, there are clearly moves towards improving the current position and facilitating fdi inows without having a detrimental impact on various sectors of the economy. the current policy is trying to encourage joint ventures in multi-brand retailing so as to boost the domestic retailer's growth in this area. in our view, the advantages outweigh the disadvantages of allowing unrestrained fdi in the retail sector, as successful experiments in countries like thailand and china demonstrate. in both countries, the issue of allowing fdi in the retail sector was rst met with incessant protests but allowing such fdi led to gdp growth and a rise in the level of employment. the international business times (us edition) has already conrmed that walmart is to launch its rst indian store within 12-18 months. thus, being the rst to enter the us$500 billion retail market of india. the government has approved the walt disney company india to increase foreign equity. besides disney's proposal, the government has also approved nine other fdi proposals amounting to approximately inr 2.59 billion. with this, a plethora of business opportunities in india has been thrown open to the volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 151gjra global journal for research analysis foreign investors. india has seen an eightfold increase in its fdi in march 2012, at a time when the aforesaid norms were not even approveda sign that suggests india is set to be one of the favoured destinations for foreign investors in the retail sector. references: 1. kearay, a t (2017), the 2017 global retail development index, p.1www.atkearny.com 2. sebastian, valiaparampil joseph and gupta, rakesh (2018), retail ecosystem in india-an overview of the regulatory framework and the emerging paradigm, theoretical economics letters, 8th february, pp.183-184 3. chawla, jyotsana, agrawal, rachna and sharma, bhavna (2016), fdi in indian retail sector: a review, international journal of bric business research, vol.5, no.2, may, p.1 4. saran, priyanka kochhar and sing, madhulika (2018), inow of fdi in indian retail industry: an overview, international journal of research in social sciences, vol.8, no.6, june, p.197 5. talreja, anil, khaire, pushkar and ghosh, suvasis (2018), retail fdi in india: leaping forward, deloitte, august 2018-www.deloitte.com 6. ibef retail report 2018, india brand equity foundation-www.ibef.org 7. ibid 8. sabnavis, madan, kansara, darshini and mishra, mradul (2017), indian retail industry-structure and prospects, credit analysis and research limited, june 2-www.careratings.com 9. ibef retail report 2018, india brand equity foundation, p.19 10. www.imf.org 11. ibid 12. murali, d (2010), assign industry status to the retail sector, the hindu dated february 15, 2010-www.thehindu.com volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 152 x gjra global journal for research analysis introduction: severe acute malnutrition (sam) is one of the major public health issues, affecting an estimated 8.1 million under-ve children in india (1). nearly 0.6 million deaths and 24.6 million disability adjusted life years are attributed to this condition. diarrhea and pneumonia account for approximately half the under-ve deaths in india and malnutrition is believed to contribute to 61% of diarrheal deaths and 53% pneumonia deaths (2). india is at the epicenter of this crisis despite the country's recent economic progress (3)..severe acute malnutrition is dened as: (i) weight/height or weight/length < -3 z score, using who growth charts; or (ii) presence of visible severe wasting; or (iii) presence of bipedal edema of nutritional origin; or (iv) mid-upper arm circumference (muac) <115 mm (4). childhood undernutrition is an underlying cause in the estimated 45% of all deaths among under 5 children. according to the national family health survey 4, carried out in 2015-2016, 36% of indian children under the age of ve are underweight, 38% are stunted and 21% are wasted (5,6). although the prevalence of stunting and underweight among children under-ve years of age worldwide has decreased since 1990, overall progress is insufcient and millions of children remain at risk. proper nutrition contributes signicantly to declines in under-ve mortality rates. improving nutritional status is essential for achieving the millennium development goals (mdgs) (7). material and methods: the present study, a observational study, was conducted in the post graduate department of pediatrics, smgs hospital, government medical college, jammu on children of either gender from 6–59 months of age admitted in hospital from 1 november 2013 to 31 october 2014 to describe various morbidities associated with severe acute malnutrition .a total of 120 children were selected. out of these 57 children had weight for weight/height above -2 sd/z score of who growth standards. these were taken as controls. rest 63 children with inclusive criteria were selected. case denition of severe acute malnutrition as oultlined by who was used (any one of the following): ÿ weight for height/length or weight/length <-3 sd/z, ÿ visible severe wasting(of nutritional origin), ÿ presence of bipedal edema and /or mid upper arm circumference <11.5 cm inclusion criteria children age 6 months to 59 months both male and female with who case denition on admission were included in the study. exclusion criteria children with acute secondary problems like cerebral palsy, meningitis, inltrative disorders, congenital malformations, chronic systemic disease were excluded. methods a thorough history including following risk factors was taken: ÿ socioeconomic factors ÿ feeding practices) ÿ immunization ÿ including detailed anthropometric measurements: height/length, weight, mid upper arm circumference by uniform measuring tools was done and then plotted on standard who growth charts. length was measured by infantometer, height by stadiometer, to the nearest mm. weight using a standard electronic weighing scale kept on rm horizontal surface which weighs up to the difference of 1 gm. muac was measured by exible measuring tape wrapped around the mid-upper arm (between the shoulder and elbow) to measure its circumference, measured to the nearest 0.1cm..with the left arm bent, string was used to nd the midpoint of the arm between the shoulder and the tip of the elbow. muac was then measured on the left upper arm while the arm was hanging down the side of the body and relaxed. ÿ detailed general physical and systemic examination was done. ÿ all children were subjected to appropriate investigations like complete blood counts, blood sugar , serum electrolytes, serum protein, urine routine , blood and urine culture , stool routine ,pbf for malaria parasite , chest x ray, gastric aspirate for afb , hiv serology in cases of high index of suspicion . ÿ a questionnaire was used to interview the caregivers of the study population and all information was collected. statistical analysis the data was analyzed with the help of statistical program spss version 17.0. chi square test was applied to compare the proportions and p value <0.05 was considered as statistical signicant. the odd's ratio (or) > 1 is positively correlated with malnutrition and or <1 negatively correlated. qualitative variables were represented as percentages. results and observations: table -1 variables found to be signicant risk factors for severe acute malnutrition to find the various comorbidities associated with severe acute malnutrition among hospitalized children of either gender from 6–59 months of age original research paper sheikh quyoom hussain registrar, department of paediatrics, gb pant hospital, government medical college srinagar , india. x 69gjra global journal for research analysis medical science keywords : juvera gul wani* registrar, department of gynecology and obstetrics, lal ded hospital srinagar, india. *corresponding author priyanka sharma registrar, department of paediatrics, smgs hospital, government medical college jammu, india volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra risk factors cases (%) odd's ratio 95% ci pvalue mother illiterate 77.77 28.55 10.59-87.13 <0.01 father illiterate 58.25 21.65 7.87-68.33 <0.01 father's occupation (labourer/unem ployed) 68.25 21.64 7.87-68.33 <0.01 70 x gjra global journal for research analysis *signicant p value less than 0.05 table 2 various morbidities observed with severe acute malnutrition *more than one morbidities were seen in all children ÿ out of all the 63 cases most common comorbiditty seen was persistent diarrhea (22.22%), and recurrent rti (20.63%), followed by sepsis (17.46%), and measles (14.28%) recurrent otitis media (12.69%). and the least common was, and skin infections (7.96%), whooping cough (6.35%) was the least common.associated comorbidity. bar chart showing various associated morb idities discussion: a total of 120 children were taken up for study. out of these 57 children had weight for height/length above 2 sd/z score of who growth standards. these were taken as controls. rest 63 children fullling the inclusive criteria were included in the study.(10) sex-wise distribution of the cases in our series showed slight male preponderance (68.25%). (8,9,10).. %). variables found to be signicant risk factors for severe acute malnutrition include mother illiterate in 77.77% cases, father illiterate 58.25% , father labourer or unemployed in 68.255 caeses, large family > 5 siblings 93.65%, household income < rs 200/day in 52.385 cases, birth order >3 35.09%, low birth weight 76.19%, lack of breastfeeding 82.53%, deprivation of colostrums 60.32%, received prelacteal feeds 74.6%, breastfeeding < 9 months 49.2%,put to breast after 1 hour in 79.84%, improper dilution 55.88%, incomplete vaccination in 60.38% cases, drug addiction in 12.69% cases.out of the total cases of sam cases, marasmi-kwashiorkar was the most common type of pem seen in 49.21% of cases, followed by marasmus in 34.92% and kwashiorkar in 15.87% of cases. children with severe malnutrition are more prone to infections than others due to the immunosuppressive effect of malnutrition and the loss of the protective mucosal barrier in the gastrointestinal tract. moreover, studies have shown that severely malnourished children are more prone to gut barrier dysfunction escherichia coli bacteraemia and higher , mortality from invasive bacterial infection. among the medical risk factors recurrent diarrhea, recurrent respiratory tract infections, sepsis, skin infections, measles were the most commonly associated comorbidities in the order of prevelance. out of all the 63 cases most common comorbiditty seen was persistent diarrhea (22.22%), and recurrent rti (20.63%), followed by sepsis (17.46%), and measles (14.28%) recurrent otitis media (12.69%). and the least common was, and skin infections (7.96%), whooping cough (6.35%) was the least common.associated comorbidity. this was similar to the previous studies by irena et al. (2011) and kumar et al. (2014).(11) though previous reports have described malnutrition as an important risk factor for pneumonia than for diarrhea, however, diarrhea was the major co-morbid condition found in our study (22.22%), followed by recurrent rti (20.63%). studies by laghari et al (2013) found some higher percentage of cases with diarrhea in 61% and rti in 51% of cases. measles also has severe consequences on the nutritional status. previous studies by bhaskaram et al. (1999) showed 3-4% of children with past history of measles, kumar et al. (2014) found 3.8% cases, but we found it in higher number of cases (9%). in a colombian study by bernal et al. (2008) sepsis was found to be in 9% of cases. similarly in our study, sepsis was seen in 11% of cases. conclusion we infer that signicant morbidities are associated with severe acute malnutrion ,hence preventive measures against the signicant risk factors would go a long way in reducing the morbidity and mortality of severe acute malnutrition. references: 1. iips (international institute for population sciences). national family health survey 3, 2005-2006. india. mumbai. international institute of population sciences; 2006. 2. black re, allen lh, bhutta za, de onis m, ezzati m, mathers c, et al. maternal and child undernutrition: global and regional exposures and health consequences. lancet 2008; 371: 243-60. 3. uncef (united nations children’s emergency fund). child malnutrition and household food insecurity remain major concerns for bangladesh. press centre, 2009a. available from: http://www.unicef.org/media/media_48981 4. unicef. tracking progress on child and maternal nutrition. unicef, 2009. 5. ghai textbook of pediatrics 9th edition. 6. national family and health survey 4. 7. unicef-who-the world bank. levels and trends in child malnutrition. joint child malnutrition estimates, 2012. 8. amsalu s, tigabu z. risk factors for severe acute malnutrition in children volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra large family >5 siblings 93.65 65.08 20.57-253.7 <0.01 drug addiction 12.69 8.03 0.30-4.05 0.02 household income ≤rs 200/day 52.38 3.48 1.79-8.46 <0.01 birth order >3 35.09 2.61 1.25-5.56 <0.01 medical factors low birth weight 76.19 31.91 11.34-105 <0.01 lack of exclusive breast feeding 82.53 38.25 13.76-120.7 <0.01 deprivation of colostrums 60.32 3.25 1.54-7.04 <0.01 received prelacteal feeds 74.60 9.96 4.5923.23.01 <0.01 breast feed period<9 months 49.20 2.08 0.99-4.46 0.05 put to breast after rst hour 79.36 16.26 6.79-41.93 <0.01 inadequate complementary feeding 69.84 23.28 8.43-75.08 <0.01 improper dilution 55.88 2.72 0.72-10.47 <0.01 incomplete vaccination 60.31 3.01 1.45-6.46 <0.01 associated morbidities observed* cases (n=63) no. % persistent diarrhea 14 22.22 recurrent rti 13 20.63 sepsis 11 17.46 recurrent otitis media 5 12.69 skin infection 10 7.96 measles 9 14.28 whooping cough 4 6.35 under the age of ve: a case control study. ethiop j health dev 2008; 22(1). 9. williams af. pediatric nutrition. in: the nutrition society textbook series, clinical nutrition. united kingdom: blackwell publishing, 2005: pp. 378-411. 10. basit a, nair s, chakraborthy kb, darshan bb, kamath a. risk factors for under-nutrition among children aged one to ve years in udupi taluk of karnataka, india: a case control study. australasian med j 2012; 5(3): 163-67 11. irena et al. (2011) and kumar et al. (2014 x 71gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction according to world health organization, worldwide cervical cancer is the fourth most common cancer among females and the disease burden is estimated to be 570,000 new cases in 2018 i.e. attributing to 6.6% of all female cancers and leading [1,2]to approximately 311000 deaths in 2018. the age standardised incidence of cervical cancer was estimated to be 13.1 per 100000 women globally and the incidence is different in different countries ranging from less than 2 to 75 per 100000 [2]women. the occurrence of new cases of cervical cancer in india was reported to 106000 and contributing to 60000 [2]deaths. cervical cancer is the major public health problem affecting middle-aged women, particularly in low and middle income [2] countries. usually the cases with cervical cancer have favorable prognosis if diagnosed and treated in early stage with estimated 5 year survival rate of 80-90%. however, [3]advanced disease are associated with poor prognosis. current treatment for locally advanced cancer cervix where surgical treatment is not indicated include cisplatin-based concurrent chemoradiation (crt) based on ve randomized [4,5,6,7,8,9] 2trials. weekly cisplatin in a dose of 40 mg/m is the most widely accepted standard regimen of crt because of its convenience, equal effectiveness, and favorable toxicity in [10]comparison to other 5-fu combined regimens. however, [11,12,13]various trials have used 3 weekly cisplatin in a dose of 275–100 mg/m as this form of chemotherapy is easy to administer and is associated with better patient compliance. the present study was conducted to assess the efcacy and toxicity prole of concurrent weekly cisplatin dosing as compared to 3 weekly cisplatin alone with radiotherapy in patients of cervical cancer and also to evaluate the compliance among them. methodology the present study was conducted as a prospective randomized comparative study at sanjay gandhi memorial hospital shyam shah medical college rewa, for a period of 1 st styear i.e. from 1 april 2018 to 31 march 2019. the inclusion criteria of the study were patients with histopathologically proven locally advanced squamous cell carcinoma cervix; locally advance disease. (figo stage ib2-iva); age >18 but <70 years; ecog performance 0-1-2; consenting for the study and karnofsky performance status at least 40. whereas patients with haematological, cardiac, renal or liver function abnormalities; hypersensitivity to cisplatin with distant metastasis; prior radiotherapy; karnofsky performance status <40; pregnant and lactating; with history of prior chemotherapy (neoadjuvant), metastatic cancer and other synchronous malignancies were excluded from the study. a total of 80 patients met the inclusion criteria and thus were included in the study. after obtaining ethical clearance and consent from study participants, all the included patients were randomly divided into 2 groups using random number tables. patients of group 1 received external beam radiotherapy 2(ebrt) along with weekly cisplatin 40 mg/m followed by highdose rate intracavitory brachytherapy (hdr icbt) whereas patients of group 2 received ebrt with 3 weekly cisplatin 75 2mg/m followed by hdr icbt. radiotherapy treatment protocol schedule in both arms included external beam radiotherapy delivered by co60 teletherapy machine and hdr brachytherapy. cases were treated by conventional radiotherapy schedule as follows: ebrt = 5000 cgy; hdr icbt = 700 cgy x 3 # point a; total dose = 8000 cgy. ebrt was given 5 days a week with total duration of 35 days and after completion of ebrt 3 fraction of weekly icrt was given. portals for ebrt of pelvis: parallel opposed (anterior posterior elds) /four eld box technique. radiation was delivered by conventional fractionation to a total dose of 46–50 gy at the rate of 2 gy per fraction, 1 fraction per day and 5 fractions per week in 23–25 fractions over a period of 5–6 weeks. cisplatin was given concurrently with ebrt once weekly (40 2mg/m ) for a total of ve cycles in group 1 and once in 3 weeks 2(75 mg/m ) for a total of two cycles in group b during the course of ebrt. premedication in both the groups consists of dexamethasone 8 mg iv, ranitidine 50 mg iv and a 5ht3receptor antagonist as antiemetic with hydration for two hours before and after chemotherapy with d5-ns at 150 cc/hr. after chemotherapy, patients in both the groups were given 2 ampoules (300 mg) potassium chloride in 500 ml of 0.9% ns over 1 h followed by 2 ampoules of 50% w/v magnesium sulphate in 500 ml of 5% dextrose over 1 h. also hydration was concurrent weekly cisplatin vs triweekly cisplatin with radiotherapy for treatment of locally advanced cervical cancer original research paper dr ajit kumar sanjay gandhi memorial hospital, shyam shah medical college rewa. x 55gjra global journal for research analysis medical science introductionthe present study was conducted to assess the efcacy and toxicity prole of concurrent weekly cisplatin dosing as compared to 3 weekly cisplatin with radiotherapy in patients of cervical cancer and also to evaluate the compliance among them. methodologythis was prospective randomized comparative study at tertiary centreon patients of locally advanced cervical cancer. patients were randomly divided into 2 groups and patients of group 1 received ebrt with weekly cisplatin whereas patients of group 2 received ebrt with 3 weekly cisplatin. all the patients were followed up for assessment of compliance, acute toxicities and treatment response. resultsthe study included 80 patients which were randomized into 2 groups. the population in two groups was comparable in baseline characteristics. no statistically signicant difference in occurrence of acute toxicities between the participants of two groups was observed (p>0.05). clinically, complete response was noted in 82.5% and 90% patients in group 1 and group 2 respectively. however the observed difference in response was not statistically signicant (p>0.05). conclusionthe present study documented similar response and toxicity prole of both the regimens and thus concurrent weekly or 3 weekly cisplatin along with radiotherapy can be used with equal effectiveness in the treatment of cervical cancer. abstract keywords : concurrent cisplatin, weekly, triweekly, central india, cervical cancer volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr aradhna tripathi* sanjay gandhi memorial hospital, shyam shah medical college rewa. *corresponding author 56 x gjra global journal for research analysis maintained in post chemotherapy phase. all patients were enquired about sociodemographic details and were subjected to thorough general examination. all patients were subjected to complete blood examination, rbs, renal function test, liver function test, chest x-ray (pa view), usg abdomen and pelvis. ct/mri abdomen and pelvis was conducted when required. follow up : all the patients were followed up at 6 weeks after completion of treatment and then they were followed up every 1 month for rst 3 months, every 3 monthly for 9 months then for every 4 months for 2 years. follow-up procedures include general, systemic and pelvic examination, palpation of inguinal and supraclavicular nodes. imaging studies, such as radiograph, computed tomography, ultrasonography and bone scan were done when required. statistical analysis the data was compiled using msexcel and analysed using spss software version 20 (ibm spss statistics, somers ny, usa). frequencies and percentages were calculated using grouped data. all the descriptive data was represented as mean ± sd. student independent 't' test was used to compare the means of different continuous variables whereas pearson's chi-square test was applied to assess the association among different categorical variables. p < 0.05 was taken statistically signicant. results the present study included a total of 80 patients diagnosed with locally advance cervical cancer. these patients were randomly allocated into 2 groups of 40 patients each. patients in group 1 received cisplatin concurrently with ebrt once weekly (40 mg/m2) for a total of ve cycles whereas patients in group 2 received cisplatin once in 3 weeks (75 mg/m2) for a total of two cycles in group b during the course of ebrt. table 1distribution according to baseline characteristics above table represents baseline characteristics of participants of two groups. the population in two groups was comparable in age composition, residence, ecog status, socioeconomic status and stage of cervical cancer. table 2distribution according to chemotherapy in both the groups patients in the group 1 received a mean dose of 45.5 mg per cycle, whereas patients in group 2 received mean dose of 110.5 mg per cycle and the observed difference was statistically highly signicant (p<0.01). however, total cumulative dose in both the groups was statistically similar with a mean of 220 mg in group 1 as compared to 198 mg in group 2 (p=0.94). compliance of the treatment can be dened in terms of completeness of chemotherapy and radiotherapy within the prescribed time limits. for radiotherapy 56 days (8 weeks) was taken as standard and chemotherapy as per the schedule. in the group 1 the average time of completion of radiotherapy was 60 days, with maximum of 80 days and minimum of 50 days; 15 patients (37.5%) completed their radiotherapy within 56 days (8 weeks) of starting treatment, whereas 8 (20%) completed within 63 days (9 weeks) and 17 (42.5%) took more than 63 days (9 weeks) to complete the same. in the group 2, in which the average treatment time was 61 days, maximum time being 83 days and minimum 45 days; 12 patients (30%) completed within the prescribed time of 56 days (8 weeks), 15 (37.5%) within 9 week and 13 patients (32.5%) took more than 63 day (9 weeks) to complete the same. about 34 patients (85%) and 37 (92.5%) in group 1 and group 2 respectively completed the full course of chemotherapy i.e. 5 cycles. 4 cycles were taken by 4 (10%) cases in group 1 and 2 (5%) patient in group 2. however, 2 (5%) and 1 (2.5%) patient respectively completed only3cycles of chemotherapy in group 1 and group 2. table 3: acute toxicities in participants of 2 groups in present study, all patients were evaluated for toxicities based upon the guidelines of national cancer institute common terminology criteria for adverse events (nci [13]ctcae) version 4.0. no treatment related deaths were observed in present study. no statistically signicant difference in occurrence of acute toxicities between the participants of two groups was observed (p>0.05). table 4distribution according to response to treatment in both the groups the patients were followed up at specied interval and nal response was observed at 6 weeks after completion of therapy. clinically, complete response was noted in 82.5% and 90% patients in group 1 and group 2 respectively. however the observed difference in response was not statistically signicant (p>0.05). volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra sociodemographic variables group 1 (%) group 2 (%) p value age group (years) <40 9 (22.5) 6 (15) 0.78 40-49 16 (40 ) 20 (50) 50-59 11 (27.5) 10 (25) 60-69 4 (10) 4 (10) residence rural 25(62.5) 30 (75) 0.22 urban 15(37.5) 10 (25) ecog status 0 0 (0) 0 (0) 0.61 1 29 (72.5) 31 (77) 2 11(27.5) 9 (22.5) socioeconomi c status low 22(55) 24 (60) 0.65 middle 17 (42.5) 16 (40) high 1(2.5) 0 stage iib 22 (55) 30 (75) 0.06 iiib 18 (46) 10 (25) chemotherapy group 1 (%) group 2 (%) p value dose per cycle (mg) 45.5 110.5 0.003 cumulative dose (mg) 220 198 0.94 acute toxicities group grade 1 grade 2 grade 3grade 4 p value nausea 1 28 (70) 12 (30) 0 (0) 0 (0) 0.24 2 23 (57.5) 14 (35) 3 (7.5) 0 (0) vomiting 1 19 (47.5) 13 (32.5) 0 (0) 0 (0) 0.07 2 13 (32.5) 22 (55) 0 (0) 0 (0) diarrhea 1 22 (55) 7 (17.5) 2 (5) 0 (0) 0.2 2 29 (72.5) 5 (12.5) 0 (0) 0 (0) nephrot oxicity 1 3 (7.5) 0 (0) 0 (0) 0 (0) 0.06 2 9 (22.5) 0 (0) 0 (0) 0 (0) hyponat remia 1 4 (10) 0 (0) 0 (0) 0 (0) 0.13 2 9 (22.5) 0 (0) 0 (0) 0 (0) hypokal emia 1 4 (10) 0 (0) 0 (0) 0 (0) 1.0 2 2 (5) 2 (5) 0 (0) 0 (0) weight loss 1 13 (32.5) 3 (7.5) 0 (0) 0 (0) 0.37 2 15 (37.5) 7 (17.5) 0 (0) 0 (0) anemia 1 24 (60) 6 (15) 2 (5) 0 (0) 0.61 2 25 (62.5) 11 (27.5) 0 (0) 0 (0) tlc 1 1 (2.5) 11 (27.5) 0 (0) 0 (0) 0.07 2 6 (15) 9 (22.5) 0 (0) 0 (0) anc 1 5 (12.5) 3 (7.5) 0 (0) 0 (0) 0.36 2 1 (2.5) 4 (10) 0 (0) 0 (0) response to treatment group 1 (%) group 2 (%) p value complete response 33 (82.5) 36 (90) 0.33 partial response 7 (17.5) 4 (10) discussion concurrent chemoradiation with the help of cisplatin is a “standard of care” for women with locally advanced carcinoma cervix. this was in response to a national cancer institute alert based results of ve randomized trials stating “strong consideration should be given to the incorporation of chemotherapy and radiotherapy for the treatment of cervical [14] cancer. weekly cisplatin based treatment regimen was recommended by national comprehensive cancer network guidelines, based on the results of 5 randomized trials [4-9]conducted during the 1990s. weekly smaller individual doses of cisplatin may lead to less ct-induced morbidity without compromising efcacy. however, three weekly cisplatin is popular in head-and-neck cancers. it is assumed that high dose three weekly cisplatin may also help in preventing distant metastasis by neutralising occult [15] micrometastasis apart from radiosensitisation. ryu et al in their randomized trial using triweekly single cddp chemotherapy concurrent with rt documented better 5-year survival and lower incidence of hematological toxicity compared with the conventional weekly cddp in patients with [11]lacc. in the present study, 85% and 92.5% in group 1 and group 2 respectively completed the full course of chemotherapy and the most common reason for incomplete treatment was haematologic toxicity. these ndings were similar to study [16]conducted by anusha et al. however in another similar study by ryu et al, the two regimens were tolerated very well, with 86.3% and 92.5% completion of scheduled ct cycles for [11]the weekly and triweekly arms, respectively. the present study observed neutropenia and gi toxicities as the most common acute toxicities, however, no statistically signicant difference was observed for any toxicities between the participants of 2 groups (p>0.05). nauseas was reported by all the patients in both the groups. these ndings were [16,11]supported by anusha et al and ryu et al. however, lee et al documented contrasting results in which tri weekly cisplatin was associated with higher incidence of leucopenia (96%) as [12] compared to weekly cisplatin group (85%). prolonged treatment time had an adverse effect on outcome because of accelerated repopulation of tumor and thus any delays must [16]be avoided. at 6 weeks, following treatment, complete response was observed in 82.5% and 90% patients in group 1 and group 2 respectively in present study. these nding were similar to the ndings reported by anusha et al in which complete response was seen in 17 (85%) patients of arm a, 19 (95%) patients of [16]arm b. the reference study and present study observed no statistically signicant difference in treatment response between two groups. however, ryu et al documented better survival rate in patients in 88.7% cases with tri weekly cisplatin at 5 years versus 66.7% for the weekly cisplatin [11]arm. conclusionthe present study documented similar response and toxicity prole of both the regimens and thus concurrent weekly or 3 weekly cisplatin along with radiotherapy can be used with equal effectiveness in the treatment of cervical cancer. long term follow up of these patients is needed to reach any denite conclusion regarding its effect on overall survival. references 1. who. cancer cervix 2018 [available from: https://www.who.int/ cancer/prevention/ diagnosis-screening/cervical-cancer/en/. accessed on 10 february 2020. 2. arbyn m, weiderpass e, bruni l, de sanjosé s, saraiya m, ferlay j, bray f. estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. the lancet global health. 2020 feb 1;8(2):e191-203. 3. tri-weekly cisplatin based chemoradiation in locally advanced cervical cancer https://www.centerwatch.com/clinical-trials/listings/163716/cervicalcancer-tri-weekly-cisplatin-based-chemoradiation/ accessed on 10 february 2020. 4. whitney, c.w., sause, w., bundy, b.n., malfetano, j.h., hannigan, e.v., fowler, jr, w.c., clarke-pearson, d.l. and liao, s.y., 1999. randomized comparison of uorouracil plus cisplatin versus hydroxyurea as an adjunct to radiation therapy in stage iib-iva carcinoma of the cervix with negative para-aortic lymph nodes: a gynecologic oncology group and southwest oncology group study. journal of clinical oncology, 17(5), pp.1339-1339. 5. rose pg, bundy bn, watkins eb, thigpen jt, deppe g, maiman ma, et al. concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer. n engl j med 1999;340:1144-53. 6. morris m, eifel pj, lu j, grigsby pw, levenback c, stevens re, et al. pelvic radiation with concurrent chemotherapy compared with pelvic and paraaortic radiation for high-risk cervical cancer. n engl j med 1999;340:1137-43. 7. keys hm, bundy bn, stehman fb, muderspach li, chafe we, suggs cl 3rd, et al. cisplatin, radiation, and adjuvant hysterectomy compared with radiation and adjuvant hysterectomy for bulky stage ib cervical carcinoma. n engl j med 1999;340:1154-61. 8. peters wa 3rd, liu py, barrett rj 2nd, stock rj, monk bj, berek js, et al. concurrent chemotherapy and pelvic radiation therapy compared with pelvic radiation therapy alone as adjuvant therapy after radical surgery in high-risk early-stage cancer of the cervix. j clin oncol 2000;18:1606-13. 9. nci clinical announcement. concurrent chemoradiation for cervical cancer (report). u.s. department of public health; 1999. 10. tri-weekly cisplatin based chemoradiation in locally advanced cervical cancer (taco) https://clinicaltrials.gov/ct2/show/nct01561586 accessed on 10 feb 2020. 11. ryu sy, lee wm, kim k, park si, kim bj, kim mh, et al. randomized clinical trial of weekly vs. triweekly cisplatin-based chemotherapy concurrent with radiotherapy in the treatment of locally advanced cervical cancer. int j radiat oncol biol phys 2011;81:e577-81. 12. lee hn, lee kh, lee dw, lee ys, park ek, park js, et al. weekly cisplatin therapy compared with triweekly combination chemotherapy as concurrent adjuvant chemoradiation therapy after radical hysterectomy for cervical cancer. int j gynecol cancer 2011;21:128-36. 13. chumworathayi b, suprasert p, charoenkwan k, srisomboon j, phongnarisorn c, siriaree s, et al. weekly versus three-weekly cisplatin as an adjunct to radiation therapy in high-risk stage i-iia cervical cancer after surgery: a randomized comparison of treatment compliance. j med assoc thai 2005;88:1483-92. 14. akhila vishwanathan c.halperin dew et al p and, by bp and practice of radiation oncology. perez and brady’s principles and practice of radiation oncology 6th edition by edward chapter 69 uterine cervix may 06, 2013. 15. hennequin c, favaudon v. biological basis for chemo-radiotherapy interactions. eur j cancer 2002;38:223-30 16. anusha konakalla v l, das p, swapna j, jena a, radhika k, rao b s, kuna j, jagannathrao naidu k v, subramanian b v. a prospective randomised study on comparison of weekly versus 3 weekly cisplatin chemotherapy as an adjunct to radiotherapy in treatment of carcinoma of the uterine cervix. j clin sci res 2018;7:12-8 x 57gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: mediastinum is the central compartment of the thoracic cavity surrounded by loose connective tissue that contains a group of vital vascular and nonvascular structures and organs viz. heart, great vessels, oesophagus, trachea, thymus, thoracic 1duct, lymph nodes and nerves. diseases of the mediastinum comprise a spectrum of entities ranging from tumors (benign to extremely malignant), cysts, vascular anomalies, lymph node masses and mediastinal brosis and also they can cause life threatening complications by involving these viscera, vessels & nerves that are located in mediastinum. therefore, early detection of mediastinal lesions is essential for appropriate case management. one of the earliest imaging modality to evaluate mediastinal pathologies is plain radiograph (frontal and lateral views) by which we can characterize, localize the lesion. ct scan is the next investigation for further characterization and dening the extent of the lesion. however it requires use of ionizing radiation and also involves the use of intravenous contrast agents which carry a risk of inducement of acute renal dysfunction and idiosyncratic contrast material reactions. magnetic resonance (mr) imaging is a comprehensive modality for assessing the morphology and characteristics of mediastinal lesions. it has high spatial resolution and multiplanar capability, thereby providing better appearance and additional information about the location and extent of the lesion. it uses no ionizing radiation, and can be used even 2in patient with deranged renal function . aims and objectives: the major aim of the present study was to study the spectrum of mri ndings in patients with mediastinal lesions and to characterize and differentiate various mediastinal lesions on mri with histopathological correlation. materials & methods: 62 patients with strong clinical suspicion of mediastinal lesions were evaluated prospectively in the department of radiodiagnosis in mgm medical college & m.y. hospital, indore from april 2018 to august 2019 after ethical & scientic committee clearance.mri evaluation of mediastinum using 3tesla mri scanner was performed after obtaining informed and written consent. t1, t2, dwi, fat sat and contrast images were studied to describe the morphology of lesions. the ndings of mri and histopathology were compared. data was depicted in the form of tables and charts. results &discussion: in our study 33.9% of the patients in our study belonged to age group of 45 to 60 years with the mean age was 52.3 years. out of 62 patients, 41(66.1%) patients were males and 21(33.9%) were females with male to female ratio of 1.9:1.our study is in 3concordance with the study of riti aggarwal etal in 2016.in their study they reported male to female ratio of mediastinal lesions was 1.7:1. majority of patients were symptomatic at presentation which is 4 5in comparison to singh et al in 2013 and dubashi et al in 2009 and the most common presenting complaint was cough seen in 72.6%followed by breathlessness 51.6%, fever and chest pain were less common complaints. similar ndings were 6seen in study of tingting liu et al in 2017 . in our study, most commonly involved compartment was posterior mediastinum 25(40.3%) followed by multicompartmental lesions 16 (25.8%), anterior mediastinum 12(19.4%), middle mediastinum 5(8.1%) and superior mediastinum 4(6.5%)[table1]. posterior mediastinum was more common due to involvement of inammatory lesions in our study. however if we do not consider multi-compartmental lesions separately than the most commonly involved compartment was anterior mediastinum 27(43.5%) followed by posterior mediastinum 25(40.3%), middle mediastinum 17(27.4%) and superior mediastinum 11(17.7%).results are comparable with other studies as well adegboyeet al in role of mri in characterization of mediastinal lesions with its histopathological correlation original research paper dr. saurabh atram professor, department of radiodiagnosis, mgm medical college& m.y. hospital, indore. x 55gjra global journal for research analysis radiodiagnosis aims&objectives:to study the role, assess reliability and compare the ndings of mri & histopathology in mediastinal lesions. methods: total 62 patients of all age group with strong clinical suspicion of mediastinal lesions were included. mri & histopathology was performed in all patients and ndings were analyzed. results: sensitivity of mri in detection of mediastinal lesions was 97.5%, specicity was 83.3%,with positive predictive value of 95.5% and negative predictive value was 90.9%. posterior mediastinum (40.3%) was the most commonly involved compartment in our study. pott's spine was the most common posterior mediastinal lesion in our study 14.5%. in anterior mediastinum, lymphoma was the most common lesion 14.5%. conclusion: mediastinal mri has outstanding results in early detection and characterization of mediastinal lesions especially, the extension and invasion of lesions and provides good preoperative assessment of lesions. abstract keywords : (mri) magnetic resonance imaging,mediastinum, lymphoma, pott's spine volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. jaipal singh third year resident, department of radiodiagnosis, mgm medical college & m.y. hospital, indore. dr. aakanksha verma third year resident, department of radiodiagnosis, mgm medical college & m.y. hospital, indore. dr. vivek yonati* associate professor, department of radiodiagnosis, mgm medical college & m.y. hospital, indore. * corresponding author 56 x gjra global journal for research analysis 72003 and riti aggarwal et al in 2016. in the anterior mediastinum, most common lesions was lymphoma 4(6.5%) followed by thymoma 2(3.2%), thymic cyst 2(3.2%), thymic hyperplasia 2(3.2%), morgagni hernia 1(1.6%) and pericardial cyst 1(1.6%). in middle mediastinum, most common lesion was bronchogenic cyst 3(4.8%) followed by aortic aneurysm 2(3.2%).in posterior mediastinum, the most common was pott's spine 9(14.5%) followed by neurogenic tumors 5(8.0%), spinal metastasis 2(3.2%), ca esophagus 2(3.2%), retropharyngeal abscess 2(3.2%), gct 1(1.6%), neurenteric cyst 1(1.6%), esophageal duplication cyst 1(1.6%) and hiatal hernia 2 (3.2%). our study is in concordance to study by tingting liu et al in 2017. out of 16(25.8%) multi-compartmental lesions in our study, the most common was lymphoma 5(8.1%) followed by ca lung mln 4(6.5%), neuroblastoma 1(1.6%), invasive thymoma 2(3.2%), teratoma 3(4.8%), and thymic carcinoma 1(1.6%). in our study, neoplastic lesions were most common 58.1% (36) mediastinal lesions followed by inammatory lesions 17.7% (11), cystic lesions 12.9% (8) and others 11.3% (7). lymphoma was the most common neoplastic lesion seen in 14.5% cases which in comparison to studies done by adegboye et al in 2003 8and vaziriet al in 2009. bronchogenic cyst was the most common cystic lesion of mediastinum (3/8). pott's spine was the most common inammatory lesion seen in 14.5% cases. similar ndings were seen a study by riti aggarwal et al in 2016. figure1: lymphoma axial t1wi (a) t2wi (b) and coronal t2wi (c) shows heterogeneous hypointense mass on t1 and hyperintense on t2 encasing the mediastinal great vessels extending in anterior and middle mediastinum and dwi (d) demonstrates restriction of diffusion. histopathology of 6 cases was not done which include 2 cases of aortic aneurysm, 2 cases of hiatal hernia and 2 cases of cystic lesions of mediastinum. on histopathology neoplastic lesions were 38 (61.2%), inammatory lesions were 9 (14.5%), cystic lesions were 6 (9.6%) and other lesions were 3 (4.8%).the sensitivity, specicity, ppv and npv of mri along with dwi and contrast in predicting mediastinal lesions was 97.2%, 93.3%, 95.5%, and 90.9% respectively.studies by razek aa et al9 in 2009, youssriah yahia sabri et al10 in 2017 also found similar results. table 2 statistical ananlysis of mri in mediastinal lesions conclusion: mediastinal mri has outstanding results in early detection and characterization of mediastinal lesions especially, the extension and invasion of lesions and provides good preoperative assessment of lesions for better surgical planning and management. mri is also a good modality for lymphoma patients also because, it can evaluate minimal invasion to adjacent structures and mediastinal vessels and can detects the metastatic lymph nodes in these patients. thus it provides the preoperative staging and mri is also helpful in providing post-operative follow up of these patients for monitoring the treatment response.in our study, the diagnostic value of mri turned out to be excellent for almost all mediastinal lesions, especially it was very useful in neurogenic tumors of posterior mediastinum to see the intraspinal extension. hence, mri is a very valuable non-invasive tool for the volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra table 1: distribution of mediastinal lesions lesions superior mediastinum anterior mediastinum middle mediastinum posterior mediastinum multicompartmental total ca thyroid 2 0 0 0 0 2 thymic carcinoma 1 0 0 0 1 2 thymic cyst 0 2 0 0 0 2 thymoma 0 2 0 0 0 2 invasive thymoma 0 0 0 0 2 2 thymic hyperplasia 0 2 0 0 0 2 pericardial cyst 0 1 0 0 0 1 morgagni hernia 0 1 0 0 0 1 lymphoma 0 4 0 0 5 9 teratoma 1 0 0 0 3 4 bronchogenic cyst 0 0 3 0 0 3 aortic aneurysm 0 0 2 0 0 2 ca lung mln 0 0 0 0 4 4 neurogenic tumors 0 0 0 5 1 6 pott's spine 0 0 0 9 0 9 retropharyngeal abscess 0 0 0 2 0 2 eso duplication cyst 0 0 0 1 0 1 ca esophagus 0 0 0 2 0 2 gct 0 0 0 1 0 1 hiatal hernia 0 0 0 2 0 2 neurenteric cyst 0 0 0 1 0 1 spinal metastasis 0 0 0 2 0 2 total 4 12 5 25 16 62 sensitivity 97.2% specicity 83.3% positive predictive value 95.5% negative predictive value 90.9% x 57gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra identication, characterization and differentiation of mediastinal lesions. references: 1. reptis et al mediastinal and pleural mr imaging: practical approach for daily practice radiographics 2018; 38:37–55. 2. ackman jb, gaissert ha, lanuti m, et al. impact of nonvascular thoracic mr imaging on the clinical decision making of thoracic surgeons: a 2-year prospective study. radiology 2016; 280 (2):464–474. 3. riti aggarwal et al, morphological spectrum of mediastinal lesions with special emphasis on evaluation of needle biopsy: an experience from a tertiary care hospital. indian j med res. 2016 oct; 144(4): 544–551. 4. singh g, amin z, wuryantoro, wulani v, shatri h. prole and factors associated with mortality in mediastinal mass during hospitalization at cipto mangunkusumo hospital, jakarta. indonesian journal of internal medicine. 2013;45:3–10. 5. dubashi b, cyriac s, tenal sg. clinicapathological analysis and outcome of primary mediastinal malignancies-a report of 91 cases from a single institute. ann thorac med. 2009;4:140–42. 6. tingting liu et al, mediastinal lesions across the age spectrum: a clinicopathological comparison between pediatric and adult patient. oncotarget, 2017, vol. 8, (no. 35). 7. adegboye vo, ogunseyinde ao, obajimi mo, ogunbiyi o, brimmo ai, adebo oa. presentation of primary mediastinal masses in ibadan. east african medical journal. 2003;80:484–7. 8. vaziri m, pazooki a, zahedi-shoolami l. mediastinal masses: review of 105 cases. acta medica iranica. 2009;47:297–300. 9. razek aa, elmorsy a, elshafey m, elhadedy t, hamza o. assessment of mediastinal tumors with diffusion-weighted single-shot echo-planar mri. j magn reson imaging. 2009; 30 (3):535-540. 10. youssriah yahia sabri et al, mr diffusion imaging in mediastinal masses the differentiation between benign and malignant lesions. european journal of radiology. volume 48, issue 3, september 2017, pages 569-580. introduction acute fungal sinusitis is most commonly found in immunocompromised patients with conditions such as diabetes mellitus, malignancies and acquired immune deciency syndrome. the most common presenting symptoms of patients with invasive fungal sinusitis as documented in a recent study were facial swelling (64.5%), fever (62.9%), and nasal congestion (52.2%) [1]. it may be associated with nasal ulcerations that occur in 38 to 74% of the patients with painful black eschar on the palate or nasal mucosa, which is considered a classical but nonspecic sign. the most frequent sites of involvement are near the middle turbinate, the septum and more rarely the inferior turbinate. they appear to have a marked predilection for vascular invasion; leading on to infarction and necrosis, which is the pathological hallmark of mucormycosis [2]. orbital extension is generally indicated by pain, proptosis, ophthalmoplegia or trigeminal nerve sensory loss. one potential intracranial complication of mucormycosis is the cavernous sinus thrombosis (cst). the rst description of this condition was made by duncan in 1821 [3]. a ct scan, the most commonly used imaging modality, is used to identify invasion but mri is considered superior to ct in delineating the intracranial extension. the accepted mode of treatment is a combination of antifungal therapy, aggressive surgical debridement and reversal of the underlying immunocompromising condition whenever possible [2]. the prognosis is poor. case report case 1: a 21yr old male patient was referred to our ent outpatient department from the neurosurgery department with complaints of swelling over left side of face, decreased vision in the left eye and deviation of mouth towards right side since 5 months. he gave associated history of intermittent fever, nasal discharge, nasal obstruction on the left side and headache. the patient also had a medical history of insulin dependent diabetes mellitus for 10 years for which he was taking regular treatment. he did not give history of smoking, alcohol or drug abuse. on examination the patient was afebrile with a pulse rate of 96 per minute, blood pressure of 134/80mm hg and respiratory rate of 16 breaths/min. systemic examination of the cardiovascular and respiratory systems revealed nothing signicant. an examination of his nose and paranasal sinuses showed a deviation of the nasal septum to the right, hypertrophied middle turbinate and mucopurulent discharge in the left middle meatus and tenderness of left frontal and maxillary sinuses. a nasal endoscopy was done which revealed black eschar formation and exposed bone in the roof of the left nasal cavity. the biopsy report indicated chronic sinusitis with areas of necrosis and fungal elements in the form of clusters of broad aseptate hyphae consistent with mucorales. ophthalmological examination revealed left sided periorbital edema, ptosis with chemosis, xed pupil not responding to light (direct and consensual light reexes were absent), no perception of light on vision testing and restricted extraocular movements that revealed affection of iii, iv & vi cranial nerves. on fundoscopic examination, there was a pale disc and central retinal artery occlusion was suspected. a detailed neurological examination showed the patient's higher mental functions and level of consciousness to be normal with no meningeal signs, hypoesthesia in the distribution of ophthalmic and maxillary divisions of trigeminal nerve and no other localizing signs or other cranial nerve involvement. the patient was admitted and started on broad spectrum antibiotics covering gram positive, gram negative and anaerobic organisms while he was further evaluated. a complete hemogram was done which showed all parameters to be within normal limit. his blood sugars and renal functions were signicantly deranged. chest x-ray was normal. a ct scan of the nose and paranasal sinuses that had already been done before the patient was referred to our department showed polypoidal mucosal thickening involving all the sinuses on the left side. mr angiography of the brain showed an abscess involving the left medial aspect of temporal bone, left middle cerebellar peduncle with adjacent leptomeninges thrombosis along with left ica thrombosis (fig 1). patient was already on injection amphotericin b which was continued along with i.v. antibiotics and xed insulin infusion. fig 1. axial cut mri t2 weighed image showing involvement of left cavernous sinus septic thrombosis of cavernous sinus secondary to rhinoorbital mucormycosis original research paper dr anshika harit* ms dnb ent, senior resident, dept of ent, maulana azad medical college & lok nayak hospital, new delhi, india. *corresponding author x 147gjra global journal for research analysis ent mucormycosis is characterized by mycotic inltration of the mucous membrane of the nasal cavity and/or the paranasal sinuses. it occurs commonly in immunocompromised patients with a fatal outcome if not treated. one possible intracranial complication of mucormycosis is the cavernous sinus thrombosis which is a rare and fatal infective disease. herein, we share our experience with four cases of acute fulminant invasive fungal sinusitis with cavernous sinus syndrome to show that cst is not that uncommon and the management of such cases. cavernous sinus thrombosis is a medical emergency and the treatment consists of aggressive debridement of the disease and simultaneous use of antifungal therapy. abstract keywords : cavernous sinus thrombosis, magnetic resonance imaging, fungal sinusitis dr ishwar singh ms ent, director professor & head, dept of ent, maulana azad medical college & lok nayak hospital, new delhi, india. dr karandeep singh nd2 year junior resident, dept of ent, maulana azad medical college & lok nayak hospital, new delhi, india. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 148 x gjra global journal for research analysis patient was planned for total maxillectomy. intraoperatively the fungal debris was seen involving all the sinuses. pus was seen coming out of the oor of the orbit and necrosed tissue was found involving till the infratemporal fossa. postop period was uneventful. patient's amphotericin b dose was completed and the patient was discharged and referred for orbital exentration to ophthalmology department. case 2: 63 year old male presented to ent opd with complaints of nasal obstruction on the right side since 4 months. it was associated with decreased vision on the right side. patient reported of having endoscopic debridement done from some private hospital 6 months back. he did not have any supporting documents. patient had past history of stroke 5 years back and was on tab ecosprin and atorvas. patient was a known case type 2 diabetes mellitus. anterior rhinoscopy revealed crusts in bilateral nasal cavity. diagnostic nasal endoscopy was performed for a detailed assessment. greenish color thick crusts were seen in right nasal cavity which were sent for fungal smear and culture. mucormycosis was conrmed on histopathology report. mri brain with contrast was ordered to see intraorbital extension of the disease and to rule out cavernous sinus involvement. sphenoidal sinusitis with involvement of the meningeal margin of right temporal lobe including involvement of right cavernous sinus was seen (fig 2). patient was planned for debridement under general anaesthesia and was started on injection amphotericin. patient unfortunately expired due to sudden cardiorespiratory arrest having completed 4000mg of amphotericin. fig 2. axial cuts show hyperintense signal at right sphenoid sinus and involvement of right cavernous sinus case 3: 50 year old female, known case of hypertension and type 2 diabetes, was admitted in ent emergency with blackish discoloration of left side of cheek since 1 month. it was associated with high grade fever. the swelling according to the patient had rapidly progressed to involve the eye and nasal framework on the left side. on examination foul smelling discharge could be seen coming out of the necrotic area that was involving the left maxillary, zygomatic region along with left naso maxillary groove and left eye. the eschar was immediately debrided in the emergency. tissue was sent for histopathology which revealed broad septate hyphe with acute angle branching suggestive of mucormycosis. ophthalmological examination was done. the mass seemed to be involving the upper and lower eyelid. perception of light was negative. patient was started on liposomal amphotericin. cect nose and para nasal sinus showed left ethmoid sinusitis with destruction of its lateral wall with displacement of left eyeball laterally and involvement of left medial rectus. left total maxillectomy and orbital exentration was done under general anaesthesia (fig 3). patient suffered from stroke 4 days postoperatively and developed left hemiparesis. ncct head showed ill dened hypodense areas in left centrum semiovale and corona radiate in left cerebral parenchyma. neurosurgery referral was taken in view of hemiparesis. ct angiography revealed non opacication of intracranial left ica. mri brain showed multiple ring enhancing lesions in left basi frontal region & anterior temporal lobe along with left cavernous sinus thrombosis. patient was started on tab ecosprin and atorvas. she will continue with conservative management of hemiparesis and physio therapy. pat ient ' s wound has healed wel l postoperatively and dose of amphotericin has been completed. fig 3. axial cut mri shows septic thrombosis of left cavernous sinus and involvement of left ica. discussion fungal sinusitis is an inammation of the sinuses that is caused by many fungi. it can be divided into invasive and noninvasive. invasive fungal sinusitis can be further categorized as acute fulminant, chronic and granulomatous invasive fungal sinusitis based on the clinical manifestation of the infection. acute fulminant invasive fungal sinusitis occurs most frequently in immunocompromised patients; such as those with diabetes mellitus, malignancies, neutropenia, and acquired immune deciency syndrome. mucoraceae and aspergillus are the most common organisms found in acute fulminant invasive fungal sinusitis [4]. the incidence of morbidity and mortality among patients with complications arising from rhinosinusitis has been reported to range from 5 to 40 percent. the incidence was signicantly higher when fungal invasion was detected, ranging from 20 to 80 percent [5]. the early clinical symptoms of acute fulminant invasive fungal sinusitis include: nasal obstruction, rhinorrhea, facial pain, headache, proptosis, and diplopia. however, these symptoms are not specic and are also observed in acute bacterial sinusitis. this may lead to misdiagnosis or delayed treatment. fungal invasion often occurs within the nasal cavity, most commonly at the middle turbinate. it manifests by sequentially involving the nasal cavity, sinuses, orbit and eventually the brain [6]. this makes our patients atypical subjects as they rst manifested with ophthalmological symptoms with no symptoms indicative of nose or paranasal sinus involvement by the fungi such as fever or rhinorrhoea which are some of the most common presenting symptoms. loss of vision as an initial symptom is an atypical manifestation of this condition. chopra et al have reported this feature in 22% of the patients reviewed in their study [7]. the diagnosis of invasive fungal rhinosinusitis requires histopathological evidence of fungi invading nasal tissue; hyphal formations within the mucosa, the submucosa, the blood vessels or the bones present around the sinus area [5]. nasal mucosal ndings are considered to be the most consistent ndings and endoscopic examination is recommended in all high risk patients [6]. the poorly controlled diabetes of the patient could be a signicant contributing factor in the rapid and fulminant progression of the disease with the atypical manifestations. poorly controlled diabetes with acidosis impairs cellular immunity. this predisposes patients to develop mucormycosis as their neutrophils have reduced ability to phagocytose and adhere to the endothelial lining. the acidosis and hyperglycemia provide an ideal environment for fungal growth [2]. as delay in diagnosis is one of the causes for high mortality, a high index of suspicion is needed and appropriate use of imaging and histopathological examination with prompt treatment can be life saving in these patients. radiography can be used to help with the differential volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra diagnosis. a unilateral nidus, severe nasal mucosal edema, or extrasinus invasion such as bony erosion may be noted on the computed tomography of the sinuses. in the pre-antibiotic era, the mortality rate of acute fulminant invasive fungal sinusitis was 50 80% [8]. however, the prognosis has improved because of greater recognition and improved treatment. sinusitis resulting in orbital, bony, or intracranial complications is uncommon. the orbital complications include preseptal cellulitis, orbital cellulitis, subperiosteal abscess, and orbital abscess. intracranial complications include epidural or subdural abscess, brain abscess, meningitis, encephalitis, and cavernous sinus thrombosis. most of these complications are a result of acute exacerbation of chronic sinusitis. however, fungal sinusitis complicated by inammation of the cavernous sinus is unusual. the cavernous sinuses are complex structure of the venous plexus that are located on either side of the sphenoid bone, posterior to the superior orbital ssure and anterior to the apex of petrous temporal bone. the internal carotid artery with its periarterial sympathetic plexus passes through the sinus. the oculomotor nerve, trochlear nerve, ophthalmic division, and maxillary division of the trigeminal nerve are located in the lateral wall of the sinus from above to below. the abducens nerve is located inferolateral to the internal carotid artery. when the cavernous sinus is involved in a neoplasm, vascular lesion, non infectious inammation, or infection, multiple neuropathies occur that are referred to as the cavernous sinus syndrome. the early ocular involvement with periorbital edema, chemosis, loss of vision and restriction of movements of extraocular muscles commonly occurs in cavernous sinus thrombosis as was seen in our patients. if fungal sinusitis results in intracranial extension, the mortality rate increases. in one study the overall survival rate was 49.7%, poor prognosis being associated with renal or liver failure and intracranial extension[1]. magnetic resonance imaging of the brain is an important instrument used to evaluate intracranial lesions. in our patient, hyper-signal intensity over the right cavernous sinus on t2-weighted images of the brain on mri was observed in both cases. this allowed for early detection of the intracranial lesion caused by fungal sinusitis. the treatment of acute fulminant invasive fungal sinusitis with cavernous sinus syndrome should include antifungal medications and drainage of the infected sinus by surgery[4]. surgical management of the cavernous sinus may not be necessary. the principal antifungal medication used is amphotericin b. in addition, debridement of the infected sinus by functional endoscopic sinus surgery is also essential. necrotic soft tissue should be removed until a bleeding border is noted. control of the underlying condition is important in the immunocompromised patient. conclusion cavernous sinus thrombosis secondary to fungal sinusitis should be treated as a medical emergency, as the outcome is fatal in majority of cases. the treatment is essentially a combination of medical and surgical procedure. with the evolution of endoscopes and emergence of newer and better drugs, the treatment aspects have improved, however one has to be extremely cautious and careful while dealing with such cases as the prognosis remains guarded, despite the progress in medical technology. references 1. turner, j.h., soudry, e., nayak, j.v., & hwang, p.h. (2013). survival outcomes in acute invasive fungal sinusitis: a systematic review and quantitative synthesis of published evidence. laryngoscope, 123(5):1112-8. 2. viswanatha, b., vijayashree, m.s., harsha, m.b., prabhakar, s.k., d’souza, g.e., & krishna, n. (2014). a unique case of invasive fungal sinusitis mimicking cavernous sinus thrombosis. research in otolaryngology, 3(2): 16-9.doi:10.5923/j.otolaryn.20140302.02 3. haber, d.m., fernandes, a.m., neto, d.d.s., & schiavetto, r.r. (2008). rhinoorbitocerebral mucormycosis associated with cavernous sinus thrombosis: case report. international archives of otorhinolaryngology;12(4):574-8 4. chi, t.h., chen, h.s., yuan, c.h., & su, f.m. (2014). acute fulminant invasive fungal sinusitis with cavernous sinus syndrome. journal of college of physicians and surgeons pakistan, 24 (special supplement 3): s240-s242. 5. piromchai,p., & thanaviratananich, s. (2013). invasive fungal rhinosinusitis versus bacterial rhinosinusitis with orbital complications: a case-control study. scientic world journal. doi:10.1155/2013/453297. 6. gillespie, m.b., huchton, d.m., & o'malley, b.w. (2000). role of middle turbinate biopsy in the diagnosis of fulminant invasive fungal rhinosinusitis. laryngoscope, 110: 1832–6. 7. chopra, h., dua, k., chopra, n., puri, s., & mittal, v. (2009). invasive fungal sinusitis: our experience. an international journal of otorhinolaryngology clinics,2(3): 21-5. 8. ingley, a.p., parikh, s.l., & delgaudio, j.m. (2008). orbital and cranial nerve presentations and sequelae are hallmarks of invasive fungal sinusitis caused by mucor in contrast to aspergillus. american journal of rhinology & allergy, 22:155-8. x 149gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction : the prevalence of childhood overweight and obesity has more than doubled in the past 25 year gender discrepancy may be explained by the fact that female have a higher percentage of body weight that female fat content lower proportion mass that may increase the rate of quadriceps obesity alter the process in case of tibia vara. most of these problems have considerable impacts on quality of life and some may reduce life expectancy. osteoarthritis (oa) is a chronic degenerative disorder of multiple causes associated with the loss of articular cartilage, hypertrophy of bone at the ends, subchondral sclerosis, and biochemical and morphological alterations in synovial (1)membrane and joint capsule. prevalence of osteoarthritis knee: marked joint space reduction, osteophyte formation & (12)deformity. change in the gait pattern due to fatigue will lead to altered knee kinematics at heel strike and consequently decreased shock absorption. obesity is associated with musculoskeletal pain and osteoarthritis .the principal risk factors of osteoarthritis of the knee are: age, obesity and gender. on the hand ,change in body conguration that may affects the physical activity may a role in the orthopedic disorder such as genu valgum and genu varum and caloric consumption and led to the development of obesity. genu valgum is commonly referred to as “knock knees angle in and touch when the legs are straightened. if the condition persist or worsens into late childhood and adulthood, corrective osteomy may be recommended to straighten the legs. in addition to cosmetic concern, adult with uncorrected genu velgum are typically prone to injury and chronic knee problem such as chondromalacia and osteoarthritis. whereas obesity increase overall loading of the knee limb misalignment concentrates that loading on focal area, to the level at which cartilage damage may occur. consequently, while it is widely speculated that obesity cause increased loads on the knee leading to joint degeneration. the quadriceps pulls the patella upward laterally and generates high power through a mechanical advantage from the patella. the vastus medialis and lateralis provide both functional mobility and stability of knee joint and maintain balance between the two muscles, so the degree of activation and temporal coordination of these two muscles are key to providing safe movement of the knee joint imbalance between the vastus medialis and lateralis of the quadriceps leads pain, as patella glide abnormally. genu velgum and genu varum are common knee malalignment problem that affect the cross-sectional area, onset, time and activation of the vastus medialis and lateralis. obesity is the risk factor for both the development (1-14) and progression (15-19) of knee osteoarthritis. hypotheses to explain the obesity-oa relationship fall into 2 categories, metabolic and mechanical the mechanical hypothesis has received less attention in epidemiologic investigation. varus mal-alignment intensies the effects of excess body weight on the medial tibiofemoral compartment. the direction of mal-alignment medial compartment load; valgus mal-alignment increase load lateral compartment load. in the normally aligned, ambulating knee, load is transmitted to the medial compartment load is disproportionately transmitted to the medial compartment varus mal-alignment further increase the total load passing medially during gait. effect of quadriceps muscle strengthening in individual with osteoarthritis of knee joint in various grades of obesity original research paper premsagar l. dhane intren, faculty of physiotherapy, krishna institute of medical sciences deemed to be university, karad, maharashtra, india. x 23gjra global journal for research analysis neuro science background: in oa knee joint lower extremity muscle weakness is important factor in knee pathology .strengthen exercise improve clinical nding in knee oa patient, such as pain and quality of life. although obese people have great absolute legs strength than there non obese counterpart, the opposite actually it's true when normalizing body mass. muscle strength in obese people is off special patho mechanical interest because obesity independent affects the knee mechanically. objectives: objectives of the study were to nd out effect of quadriceps strengthing in grade ii oa of knee joint in grade i, ii and iii obese individuals material and methods: pre and post test assessment was done with 1rm and mmt results: statistical analysis of quadriceps strengthening was found extremely signicant in grade i obese individual with knee joint oa conclusion: the study concluded that there is marked increase in strength in grade 1 obesity as compared to grade ii, and grade iii obesity. abstract keywords : graded obesity, oa knee joint, quadriceps strengthening volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. g. varadhrajhulu* dean/hod, department of neuro sciences, faculty of physiotherapy, krishna institute of medical sciences deemed to be university, karad, maharashtra, india. *corresponding author 24 x gjra global journal for research analysis the difference in the impacts of versus valgus mal-alignment on load distribution is well established. the direction of malalignment is likely to affect the potency of obesity as factor leading to progressive knee oa. knee alignment determines load distribution across the knee. during gait~70% of knee joint loading passes reaction through the medial compartment due to the ground reaction force passing medial to the knee joint. quadriceps strengthen exercise are commonly prescribed for patient with knee oa because they can reduce pain and improve function. however, little is known about their effects on knee loading and disease progression, and it is unclear whether these effects are inuence by the presence of mal-alignment. it is also possible that greater quadriceps strength increases compressive forces across the knee joint, and that these effects may be accentuated with knee mal-alignment. increased knee joint loading has been associated with an increased risk of disease. it is known that knee joint loads are increase by modiable factors such as varus mal-alignment and obesity. this notion is important because lower extremity muscle weakness is important factor in knee pathology .strengthen exercise improve clinical nding in knee oa patient, such as pain and quality of life. although obese people have great absolute legs strength than there non obese counterpart, the opposite actually it's true when normalizing body mass. muscle strength in obese people is off special patho mechanical interest because obesity independent affects the knee mechanically. material and methodology ÿ type of study: experimental study ÿ study design: randomized clinical trail ÿ sampling method: simple random sampling ÿ sample size: 38 ÿ place of study: physiotherapy opd, krishna college of physiotherapy, karad. materials: ÿ towel ÿ resistance band ÿ plinth ÿ weight cuffs inclusion criteria: ÿ both male and female participants willing to participate in the study. ÿ age group between 35-55 years ÿ individuals with grade i, ii and iii obesity . ÿ subjects diagnosed with grade oa by certied physiotherapist according to (kellgren and lawrence scale) exclusion criteria: ÿ history of trauma to knee ÿ systemic illnesss ÿ malignancy ÿ polyarthritis ,spondylo arthropathies, rheumatic arthritis. outcome measures ÿ manual muscle testing (mmt) ÿ 1 repetition maximum (1rm) procedure ethical clearance was taken from institutional ethical committee. study was carried out in krishna institute of medical sciences, in this according to inclusive and exclusive criteria subjects was taken. they was told thoroughly about the project and intervention. they was also be told about its benecial and side effects and consent will be taken. they were divided into 3 groups according to the grades of obesity. group a were containing type 1 obesity subjects. group b were containing type ii obesity subjects. group c were containing type iii obesity subjects. and they were trained for the quadriceps strengthening for 7 days and pre and post assessment was taken for the muscle including mmt, 1 rm. and ndings was noted down. quadriceps strengthening exercises: 1. quadriceps isometric exercises. 2. straight leg raise. 3. knee extension in high sitting. 4. quadriceps isometrics with plantar exion and dorsiexion 5. quadriceps table 6. static cycling. data presentation, analysis and interpretation 1) gender distribution: table 7.1 : gender distribution. 45 subjects having oa age group above 35 years were taken. out of 45 subjects, 23 included male and 22 included female. fig : gender distribution 2) age distribution: table 7.2 : mean age of participants age group of all participants was above 35 years. the mean age of the participants is given above, outcome measures 1 rm table 7.3: comparison of 0 week and 7 days of 1 rm the table also shows the comparison of mean and standard deviation at 0 week and 7 days between the grade wise obesity. the table also shows the comparison of mean and standard volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra male female total 23 22 45 study group ( n= 45) mean + sd grade i 37.8+ 2.11 grade ii 38.33+ 2.225 grade iii 39.8 + 1.935 groups 0 weeks interventional mean ± sd 1 week interventional mean ± sd p value t value inference grade i 43.33+5.876 58.33+5.563 <0.0001 7.685 extremely signicant grade ii 39+9.10 46.33+5.16 0.0006 4.0363 extremely signicant grade iii 43+8.61 43.33+6.98 0.670 0.4350 not signicant deviation at 0 weeks and 1week values of grade i. ii and iii obesity. in the grade i, the mean of rm score at 0 week intervention was43.33+ 5.876 and at 1 week was 58.33+ 5.563 . the t value was 7.685 . the p value was found to be 0.0001 which is extremely signicant. in the grade ii, the mean of rm score at 0 week intervention was 39+ 9.10 and at 1 week was 46.33+ 5.16 . the t value was 4.06 . the p value was found to be 0.0001 which is extremely signicant in the grade iii, the mean of rm score at 0 week intervention was43+ 8.61 and at 1 week was 43.33+6.98 . the t value was 0.4350 . the p value was found to be 0.678which is extremely signicant mmt table 7.4: comparison of 0 week and 1 week of mmt within group the table also shows the comparison of mean and standard deviation of mmt at 0 week and 7 days between the grade wise obesity. the table also shows the comparison of mean and standard deviation at 0 weeks and 1week values of grade i. ii and iii obesity. in the grade i, the mean of mmt score at 0 week intervention was3+ 0.00 and at 1 week was 4.33+ 0.4880 . the t value was 10.583 . the p value was found to be 0.0001 which is extremely signicant. in the grade ii, the mean of mmt score at 0 week intervention was 3+ 4.14 and at 1 week was 4+ 0.845 . the t value was 4.583 . the p value was found to be 0.0004 which is extremely signicant in the grade iii, the mean of mmt score at 0 week intervention wastwo.66+ 0.488 and at 1 week was 3.33+0.488 . the t value was 3.16 . the p value was found to be 0.69 which is very signicant discussion oa of knee is one of the most common causes in older population and that leads to activity limitations and work. prevalence of oa is highest in third decade of life. thus, preventing and avoiding oa of knee joint progression is necessary to decrease the associated morbidities. oa of the knee joint is one of the most common causes of activity and work limitations in older population. prevalence of oa is highest in the third decade of life and thus, preventing and avoiding progression of oa of the knee joint is necessary to decrease the associated morbidities basically, osteoarthritis can be described as degenerative changes , accompanied by painful limitation of movement and inuenced by physical activities and posture . obesity is main disposing factor for the degenerative changes in weight bearing joint i.e, knee joint. previous study 24conducted by r lee, w kean on obesity and knee osteoarthritis showed the relation between obesity and knee osteoarthritis. this study concluded that obesity is a primary risk factor for incidence of knee osteoarthritis due to biomedical and metabolic conditions. therefore it was important to see the changes in various grades and to check the impact of exercises on various grades of obesity in this study, 45 subjects who were clinically diagnosed with oa were taken and their obesity was classied according to the international classication of bmi. of which, 23 (51.1%) were male and 22(48.9%) were females. 45 subjects of the age between 35 to 55 years were included in this study. treatment in this study consists of 1 week protocol in which outcome assessment was done before the treatment started and 1 week after commencement of the treatment. in this study, 1 rm and mmt, was taken as the outcome measures. the present study showed that after 1week, considerable changes were seen in the strength of the quadriceps muscle. using the outcome assessment of 1 rm, it was seen that subjects with grade i and grade ii obesity showed more improvement after 1 week with a p value of 0.0001 (extremely signicant) compared to subjects with grade iii obesity which had a p value of 0.678 (not signicant) using the outcome assessment of mmt, it was seen that subjects with grade i obesity showed the most improvement after 1 week with a p value of 0.0001 (extremely signicant), followed by subjects with grade ii obesity with a p value of 0.0004 (extremely signicant). subjects with grade iii obesity had comparatively less improvement with a p value of 0.069 (very signicant) thus, there was a signicant increase in the subjects' quadriceps strength following the treatment administered in this study. a study conducted by (citation) showed results similar to our study with signicant changes in 1 rm and mmt of subjects after incorporating quadriceps strengthening exercises for 1 week. they were more signicant in grade i obesity followed by grade ii and grade iii obesity. there are many studies which proved that there is effect of quadriceps strengthening on oa knee joint and there is benecial effect of vmo strengthening. a study conducted by 2 6 c slemenda etal l on quadriceps weakness and osteoarthritis of knee concluded that quadriceps weakness may be present in patients who have osteoarthritis but do not have knee pain or muscle atrophy ; this suggested that weakness may be due to muscle dysfunction. many studies showed that osteoarthritis of knee joint decreases quadriceps muscle strength, endurance as well as dynamic balance, hence the aim of rehabilitation of this study was to increase quadriceps muscle strength, endurance and dynamic balance with exercises. 25a previous study conducted by a imoto,m peccin,v trivisani on quadricep strengthening exercises are effective in improving pain, function ,and quality of life in patients with osteoarthritis of the knee. this study concluded that quadriceps strengthening exercises applied in randomized clinical trail was effective in improving pain, function and quality of life of patients with knee osteoarthritis. this present study showed that after 1week, there were considerable changes in the outcome measures specially x 25gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra groups 0 weeks interventional mean ± sd 1 week interventional mean ± sd p value t value inference grade i 3+ 0.00 4.33+0.4880 <0.000110.583 extremely signicant grade ii 3+0.414 4+0.845 0.0004 4.583 extremely signicant grade iii 2.66+0.4880 3.33+0.4880 0.069 3.16 very signicant which was more seen in grade i obesity which was followed be grade ii and grade iii. in this study, 1 rm and mmt, was taken as an outcome measure. a study showed the changes in 1 rm and mmt after incorporating quadriceps strengthening exercises for 1 week was found to be signicant more in grade i obesity followed by ii and iii grade obesity. this study showed that there was extremely signicant difference within 0 weeks and 1 weeks and within 0 week and 1 weeks of mmt had more signicant changes . this study showed that there is a very signicant difference in mmt that is exercises are more effective in grade i obesity with compared to grade ii and iii this study supported the result of the previous research within group, but there was signicant difference in grade i, ii and iii obesity. in this study the 1 rm was also taken as the one of the outcome measures and the their was signicant effect seen in the grade i and ii obesity and their was no signicant effect seen in the grade iii obesity which concluded that their was effect seen in improving power by strengthening protocol for quadriceps for 7 days in grade 1 and ii but no effect is seen in the grade iii in improving strength of the muscle but where as there is signicant effect seen in improving power of the muscle by strengthening of the 7 days in individual. 26study conducted by d sanghi etall on the association of anthropometric measurement and osteoarthritis knee: a cross sectional study concluded that bmi and anthropometric measurement have signicant association with knee osteoarthritis. so there was extremely signicant change in strength in grade 1 and grade 2 obesity as compared to grade 3 in current study. according to the statistical analysis this study concluded that grade i obese individuals with grade ii oa were showing more recovery and also had improved mmt grade and 1 rm which was followed by grade ii obesity and grade iii. thus more emphasis needs to be given on research in this area. improvements such as an increase in the sample size, equal distribution of genders in the population can be made. more advanced treatment protocols as well as improved outcome assessment measures can be used. also, an increase in the study duration would prove to be benecial. this study will help the further researchers in nding out the to nd out an advancement in treatment strategy for knee osteoarthritis and improving the quality of life of obese subjects having osteoarthritis. this study will also help in nding out the stratergies in preventing osteoarthritis in obese subjects who are at risk of getting osteoarthritis of knee due to biomedical and metabolic conditions. conclusion results show extremely signicant improvement in all three grades (p<0.0001) but grade i which showed the maximum improvement by reduced mean values of 1 rm and mmt grade in subjects with knee osteoarthritis. on the basis of this study, it was concluded that grade i obese individuals with grade ii oa were showing more recovery and also had improved mmt grade and 1 rm which was followed by grade ii obesity and grade iii. thus, the alternative hypothesis is proved references 1. onis m and m blossner,2000.prevalence and trends of overweight among preschool children in developing countries ajcn,72 (4):1032 1039 2. patterson .r.l. frank, a.kristal,e.a white comprehensive examination of health condition associated with obesity in older adults. american j preventive med.,27(5):385-390 3. salenius p.vankka e the development of the tibiofemoral angle in children j bone joint surg am1975;57;259-261 4. peltonen ,m.,a.k lindroos and j.s torgerson 2003.musculoskeletal pain in the obese; a comparison with general population and longterm change after conventional and surgical obesity treatment ,pain 104(3):549-557 5. felson dt, anderson jj naimark a walker am , meenan rf ovesity and knee osteoarithritis, the framinggham study, ann intern med 1988;109-24 6. davis ma, ettinger wh neuhaus jm . the role of metabolic factor and blood pressure in the association of obesity with osteoarithritis of the knee joint j rheumatol 1988;15:1827-32 7. vaan bar me assendelft wj,dekker j , oostendrop ra bijlsma jw.effectiveness of exercise therapy in patients with osteoarithritis of hip or knee: a systematic scoscopy and 8. bischoff ha roos em effctiveness and safety of strengthing,aerobic and coordination exercise for patient with osteoarithritis, curr opin rheumatol 2003;15:141-4 9. kettunen ja harilaninen a,sandelin j, et al; knee arthroscopy and exercise varus exercise only for chronic patellofemoral paon syndrome; a randomized controlled trail. bmc med 2007;5:38 dio 10.1186/ 1741-7015-5-38 10. wong ym chan st, tang kw et al :two modes of weight training programs and patellar stabilization j a thl train 2009;44:264-71 11. k.r. baker,m.e. nelson, d.t.felson,j.e. layne,r.sarno,and rroubenoff, “ the efcacy of hone based progressive strength training in older adults with knee osteoarithritis; randomized controlled trail,’’ journal of rheunatology, vol 28 no.7 pp.1655-1665,2001. 12. e roddy,w zhng,and m . doherty,effectiveness of home exercise for osteoarithritis of knee?a systmatric review ,’’ annals of the rheumatic diseases,vol.64 no. 4 pp.544-548,2005 13. guccione aa, felson dt, anderson jj, anthony jm, zhang y, wilson pw, et al. the effects of specic medical conditions on the functional limitations of elders in the framingham study. am j public health 1994;84(3):351-8. 14. lawrence rc, helmick cg, arnett fc, deyo ra, felson dt, giannini eh, et al. estimates of the prevalence of arthritis and selected musculoskeletal disorders in the united states. arthritis rheum 1998;41(5):778-99. 15. carvalho na, bittar st, pinto fr, ferreira m, sitta rr. manual for guided home exercises for osteoarthritis of the knee. clinics (sao paulo) 2010;65(8):775-80. 16. buckwalter ja, lappin dr, the disproportionate impact of chronic arthralgia and arthritis among women, clinorthop. 2000 mar:159-168. 17. deyle gd, henderson ne, matekel rl, ryder mg, garber mb, allison sc. effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: a randomized, controlled trial. ann intern med. 2000; 132:173-181. 18. felson dt, zhang y, hannan mt, naimark a, weissman b, aliabadi p, levy d. risk factors for incident radiographic knee osteoarthritis in the elderly: the framingham study. arthritis rheum. 1997; 40:728 -733. 19. lachance l, sowers mf, jamadar d, hochberg m. the natural history of emergent osteoarthritis of the knee in women. osteoarthritis cartilage. 2002; 10:849-854. 20. mcconnell s, kolopack p, davis am. the western ontario and mcmaster universities osteoarthritis index (womac): a review of its utility and measurement properties. arthritis rheum 2001; 45:453-61. 21. dr a c a marijnissen -joint distraction in the treatment of knee osteoarthritis: efcacy and underlying mechanisms.2012 july. 22. liikavainio t, lyytinen t, tyrvainen e, sipila s, arokoski jp, physical function and properties of quadriceps femoris muscle in men with knee osteoarthtitis. arch phys med rehabil. 2008;89(11):2185-2194. 23. maly mr, costigan pa, olney sj, contribution of psychosocial and mechanical variables to physical performance measures in knee osteoarthritis.phys ther.2005;85(12):1318-1328.9 24. r lee, w kean.obesity and knee osteoarthritis.inammopharmacol (2012) 20:53-58 25. imoto, m peccin, v trivisani, quadricep strengthening exercises are effective in improving pain, function ,and quality of life in patients with osteoarthritis of the knee. acta ortop bras. 2012; 20(3):174-179 26. d sanghi etall .the association of anthropometric measurement and osteoarthritis knee in non-obese subjects: a cross sectional study,clinics 2011;66(2):275-279 26 x gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction the habitual use of stimulants, sedative and euphoric drugs were prevalent in india long before any other country of the modern world. earlier, society was self-regulating and did not need precise rules for effective drug control. drug consumption was carried out openly, legitimized by cultural norms and restricted by traditional demand. with international intervention however, indigenous controls have been displaced by a single model, developed primarily for the west. in the indian context, the imposition of this model has resulted in the replacement of culturally sanctioned use by secular use and of traditional suppliers by criminal networks. furthermore, adherence to the united nations drug control conventions ensures that most nation states adopt a similar prohibition-oriented approach when formulating their national drug control legislation. with india's position between the golden triangle and the golden crescent, it was becoming a transit country for routing drugs to different countries through india. new drugs were also being manufactured synthetically in other countries which were falling off on the indian soil during transit. the government thereby brought in the narcotic drugs and psychotropic substances (ndps) act in 1985 with more stringency and concrete prohibition over usage of drugs. the ndps act 1985 was the only drug law for dealing with the drug problem in india. it came into force due to the pressure of international conventions which india was a signatory. cannabis and opium lost its traditional and indigenous value and became drugs of abuse. the act did not in any way bring down the rate of drug trafcking but was only causing the drug maas to improve and update their technology for safe and highly networked trafcking. it was only the small-scale drug peddlers and drug users who were falling prey to the extremely rigorousprovisions of the ndps act. according to a un report (1999), one million heroin dependents were registered in india, and unofcially there were as many as ve million .according to a report titled, “the extent, pattern and trends of drug abuse in india: national survey” by the ministry of social justice and empowerment and the united nations ofce on drugs and crime (unodc) published in 2004, states that apart from alcohol (62.46 million users), cannabis (8.75 million users), opiates such as heroin, opium, buprenorphine and propoxyphene (2.04 million users) and sedatives (0.29 million users) were the drugs most abused. for the welfare of drug using population, the national demand reduction programme which has its root from section 71 of the narcotic drugs and psychotropic substances act, 1985 was formulated. section 71 has stated that the government can establish as many de-addiction centres as possible for the treatment and rehabilitation of drug dependents. accordingly, from section 71, the national scheme of assistance for prevention of alcoholism and substance abuse was emerged. as the ndps act deals with drug use both from the enforcement and treatment angles, the responsibility of treating drug dependents in the country did not wholly fall in the hands of ministry of health. thereby ministry of social justice and empowerment approached it as a correctional issue and envisaged a wide range of services for treating addiction. however, the ministry of social justice did not become a direct provider for services, it limited its responsibility by training and providing nancial assistance for the ngos in the eld of de-addiction. legalization of specic drugs could pave a way for decrease in users involved in drug crimes as they are usually the soft targets of drug maas. the funds which government spends for enforcement activities for dealing with drug offences may also decrease. therefore, the funds could be effectively utilized for treatment, rehabilitation, preventive education and awareness generation. india should soon be adapting the decr imina l i za t ion approach s imul taneous ly strengthening harm reduction mechanisms and promote preventive education. methodological approaches the aim of this research was to draw up a situational analysis of the current drug policies and rehabilitation practices existing in india, its rationale, formulation, implementation and its relevance to the current reality of new drug use/abuse problem. it further aimed at strengthening and consolidating understandings of such policies and practices concerning the co-operation mechanisms between the non-governmental organizations and the governments. this study was primarily formulated keeping in line the initiative of the united nations drug demand reduction programme in india – a qualitative research analysis original research paper dr. sandra joseph x 27gjra global journal for research analysis social science india is a welfare-based nation; therefore, it has an embedded responsibility to protect the marginalized communities. however, drug dependency has always been a hidden phenomenon. focusing on indian scenario, this research critically analysed the implementation of the demand reduction programme, i.e. the national scheme of assistance for prevention of alcoholism and substance abuse which emerged from section 71 of narcotic drugs and psychotropic substances (ndps) act. this research has consolidated an in-depth analysis of the rationale of treatment and rehabilitation components of the scheme, its implementation mechanisms from the centre to grassroots, its intervention processes at community level and the efciency of monitoring systems. the study was carried through participatory approach by including drug dependents, policy makers, lobbyists, government bodies and de-addiction centres. the study brought out a national perspective by covering chennai, mumbai, new delhi and mizoram representing southern, western, northern and north east regions of the country respectively. this approach was deployed to obtain a holistic understanding of the country. keeping intact the human rights aspect of drug dependents, careful analysis was made by including reections and critics of all political and social actors in this eld. the treatment and rehabilitation services were analyzed categorically and thematically by posing specic standards such as availability, accessibility, quality and protection of human rights. it is hoped that the ndings of this study will throw more light into the hidden realities of the drug demand reduction programme in india. abstract keywords : volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 28 x gjra global journal for research analysis of the world forum on “beyond 2008” on drugs use/abuse and its policies. objectives 1. study policy implementation mechanisms ranging from the central to the community levels with reference to the national demand reduction programme. 2. analyse strengths and gaps in the demand reduction programmeits rationale, planning, implementation mechanisms, intervention processes, monitoring systems and outcomes. 3. suggest a knowledge framework so as to enhance the qual i ty o f po l icy formulat ion and i t s overal l implementation using the inclusive/participatory approach. study design: the study design used for the research was qualitative study design. the study design involved observing and describing the behavior of social and political actors in the eld of drug use. it researches and analyzes complexity, sensitive areas, and areas in need of exploration, to discover associations and relations with regard to drug issue. interviews, focus group discussions, content analysis were the qualitative techniques used in the research. sample design: the study having been qualitative in nature, in-depth interviews with key informants, focus group discussion were used. nonprobability sampling design was the broader design used for the study. multistage sampling design was used to identify the geographical regions and for further selection of units of data collection in each region. multi-stage sampling is a kind of complex sample design in which two or more levels of units are imbedded one in the other. heterogeneity sampling design complemented with purposive sampling was used to identify the units of data collection. heterogeneity sampling design is a design which is used to include all opinions or views, and not concerned about representing these views proportionately. another term for this is sampling for diversity. this design helped in identifying differentstakeholders in the eld of drug abuse from outreach workers, recovering drug dependents, teenagers, practitioners, professionals, policy makers, government ofcials, and experts in the eld. however, heterogeneity sampling combined with purposive sampling design enabled the researcher to identify the units of information with maintaining both diversity and as well as sustaining an underlying purpose of seeking specic predened groups. in effect, sampling was not people, but opinions, perceptions, and ideas in order to obtain the crux of the working of the scheme at the local level. secondary sources included policies acts, schemes, brochures, manuals, journals, books, reports etc from various agencies namely narcotics control bureau, unodc, directorate of social defense, ministry of health and family welfare, ministry of social justice and empowerment, academic institutions, rrtcs, ngos, govt. de-addiction centres and private de-addiction centres etc. content analysis was done to study all forms of documents the policies, laws and legislations which are available in connection to demand reduction. major findings the ndps act was enacted by parliament in 1985 in keeping with international drug conventions, namely the single convention on narcotic drugs, 1961; the protocol amending the single convention on narcotic drugs, 1972 and the convention on psychotropic substances, 1971. the ndps bill, 1985 was passed hastily over four days, without much legislative debate. it received the president's assent on 16 september 1985 and came into force on 14 november 1985. the ndps act, 1985 replaced the opium act, 1857, the opium act, 1878 and the dangerous drugs act, 1930. according to the statement of objects and reasons of the ndps act, 1985, india was becoming a transit for drug trafcking and the then legislation was ineffective in countering the problem. the following deciencies were noted in the law prevailing at the time – (i) absence of stringent penalties against drug trafcking, ii) weak enforcement powers, iii) development of a vast bodyof international law, which india was a signatory to, and, iv) lack of regulations over psychotropic substances. like other international treaties, the drug conventions to which india was a signatory, were not self-executing. their provisions were supposed to be incorporated into domestic law by legislative acts, in accordance with constitutional principles and the basic concepts of the legal system of that state. the ndps act , 1985 was introduced as a comprehensive legislation to tighten control over abuse on narcotic drugs and psychotropic substances, enhance penalties, especially for trafcking in drugs, strengthen regulations over psychotropic substances and provide for the implementation of international conventions. although the ndps act was prohibitionist in its approach and has criminalized the use of drugs, it has still inculcated a provision in the act for treatment and rehabilitation of drug dependents. section 71 of the ndps act has stated that the government can establish as many de-addiction centres as possible for the treatment and rehabilitation of drug dependents. accordingly, from section 71, the national scheme of assistance for prevention of alcoholism and substance abuse emerged which catered to provide nancial assistance for ngos to provide preventive, treatment and rehabilitation services to the drug using population. the ministry of social justice and empowerment was the nodal agency for demand reduction in the country. key findings on treatment and rehabilitation gaps in accessibility ÿ integrated rehabilitation centre for addicts registered with the ministry are non-existent in reality within interior districts of a state ÿ transport constraints faced by family members to travel to the centre ÿ restricted admission for severely dependent patients on hard drugs like heroin, cocaine and synthetic drugs ÿ restricted admission for hiv positive and tb patients ÿ cost of food was high although treatment is free ÿ stigmatization of use – hesitance of family members to visit a de-addiction centre ÿ in-treatment duration is minimum one month which results in economical burden for the family as the dependent volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra becomes unemployable gaps in quality of services ÿ the norms as specied in the minimum standards of services were not followed in the centres properly ÿ professional counselors and social workers were not appointed in the centres, which resulted in ÿ compromised outcome out of the counseling sessions. ÿ awareness generation programmes were organized mostly for the motive of publicizing their centres. lack of emphasis on preventive education and awareness in society. ÿ space allotted for counseling, group therapy and family classes was not very spacious to accommodate all patients. ÿ sixty percent of patients relapsed after undergoing treatment ÿ simple replication of other centres' treatment model without any research and innovations ÿ female counselors and male patients face difculty in counseling sessions when sharing and dealing with sensitive issues during counseling sessions gaps in protection of human rights ÿ involuntary admission: patients were forcefully admitted only with the consent of family members with rescue vans from their homes to the centres ÿ certain centres jailed the patients and disallowed them to visit their family members. the staff at the centres assumed that only if they were disallowed to meet their family members, the patients will realize their presence and importance. ÿ the patients were forced to do all the odd chores at the centre and if they disobeyed, they were assaulted and physically abused ÿ lack of space: 30 – 35 patients were lodged in the space which was t only for 1520 patients. ÿ there were reports of escapism of patients and incidences of mysterious murder which had taken place in few centres. ÿ certain centres believed in negative reinforcement as a technique for recovery of patients. they believed that through punishment and insult the patients will change for the better. dignity of the individual was not upheld at all. ÿ discrimination of hiv patients led to restricted admission and referral to other hospitals ÿ certain patients underwent in-treatment for more than 2 months by paying expensive fees as the family members did not want them back home but were willing to pay. in such cases the patient without his will was jailed in the centre unwillingly. ÿ misappropriate use of anti-abuse tablets (disulram) by patients after discharge resulted in emergencies and sometimes even proved fatal. ÿ lack of expertise among staff resulted in restricted admission of narcotic drug dependent patients ÿ lack of care & management of withdrawals resulted in chaining the patients to their beds and assaulting them if they showed aggressive withdrawal symptoms instead of proper medications and timely care ÿ drug dependents who were referred through police custody faced the most violations in the centres. ÿ lack of provision of legal assistance for patients who needed it. policy recommendations a) anti death penalty law section 31a was incorporated in 1989 after the parliament passed the ndps (amendment) bill, 1988. the issue of mandatory death penalty for drug offences is excessive, unscientic and inhumane. poor drug users are soft targets for law enforcement and they are unable to afford legal representation and plead guilty for crimes they have not committed. this section has to be removed from the act through an amendment and it is in the hands of the judiciaries and parliamentarians of the country to take this giant leap and stand up for the right to life for drug dependents. b)need for convergence between ministries the role of ministry of health and family welfare in the area of drug de-addiction is demand reduction by way of providing treatment services alone. the de-addiction programmes in india developed by the two ministries, ministry of social justice and empowerment and ministry of health and family welfare appear to run in parallel lines to each other with little or no cooperation between the two agencies. while addiction is considered as a disease, it is not seen from the purview of health department but treated as a moral issue or a correctional disorder. demand reduction by way of treatment alone is the concern of ministry of health and family welfare. it does not provide after care and rehabilitation services. however, the activities of boththe govt. agencies overlap considerably in several ways. it is recommended that both the ministries' resources and expertise should be converged for the betterment of services provision to drug dependents. at the policy level amendments has to be made for coalition of ministries to work together. d) replacement of imprisonment with rehabilitation the funds exhausted for maintaining the drug dependents in prisons can be utilized sensibly by the government to set up more human resources and establish an independent commission for executing the demand reduction programme. instead of receiving medical assistance, drug dependents are prosecuted and jailed, which worsens their condition. those prisons are not conducive to treatment and rehabilitation, which the ndps act itself aims to secure. therefore those persons who are under police custody and are proven to be drug dependents should strictly be referred to de-addiction centres and not jailed. e) differentiation of alcoholism and substance addiction the government of india conveniently included treatment for alcoholic patients along with treatment of patients dependent on hard drugs. the dynamics and needs of the drug dependents are way different from the dynamics of alcoholic dependents. the withdrawal symptom of substance dependents is very intense when compared to that of withdrawal symptoms of alcohol addiction. treating different proles of drug dependents in the same centre may not be advisable as low prole dependents may be exposed to different kinds of drugs from other patients. group sessions and lectures can also not be given in a similar manner. section 71 of the ndps act, states that de-addiction centres be established for voluntary treatment & rehabilitation of drug dependents. such voluntary treatment was meant for persons who were dependents of narcotic drugs and psychotropic substances as per the ndps act. the main reason for the emergence of the section was to provide treatment instead of prosecution. thereby, the scheme of assistance for prevention of alcoholism and substance abuse emerged from the spirit of section 71 of the ndps act. but inclusion of treatment for alcoholic patients in the de-addiction centres cannot be justied as alcohol was not mentioned in the list of narcotic drugs or psychotropic substances in the ndps act. f) diverse spread of voluntary organizations the presence of voluntary organizations is not uniform throughout the nation. similarly, there are certain spheres of activities that attract more voluntary organizations just as their concentration in some regions. this twin situation often x 29gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra results in disparate development of regions as well as of sectors. it is the intention of the ministry to encourage the horizontal spread of development alongside sectoral growth in spheres that have received comparatively less attention or may need more attention. for example, the north eastern part of india needs more concentrated and even spread of voluntary organizations than the other regions as it has high rate of addiction. recommendations for social integration a) at school level there has not been any concrete effort taken by the department of education in inculcating modules in the curriculum for awareness on ill effects of drug use among school children. the new national policy on narcotic drugs and psychotropic substances which came about in 2012 has suggested inclusion of mandatory chapters of drug use and effects in the curriculum for higher secondary students. education on drug dependency should become a part of the curriculum. more focus should be given to the age group of 13 to 18 years who are more susceptible to drug abuse. b) medical management of addiction to hard core drugs drug dependents addicted to hard core drugs like heroin, cocaine and other opiates do not get admitted easily in deaddiction centres/voluntary organizations because of lack of expertise to manage the withdrawal symptoms posed by the patients. training and capacity building of service providers is a must at the grass root level for treating and rehabilitating persons who are dependent on hard core drugs. c) women and children the present demand reduction programme studied under the research project does not provide exclusive services to women or children drug dependents. the de-addiction centres are not equipped with enough resources to cater to women or child drug dependents.therefore, the ministry should undertake a study and look into the concentration of are women and children drug dependents region wise. for example, the population of street children who are dependent on drugs are majority in mumbai and the ratio of women drug dependents are relatively high in the north eastern regions. accordingly, de-addiction centres should be established through ngos exclusively in such regions. d) inclusion of harm reduction measures harm reduction model helps in reducing the harms inicted to and by the dependents. when drug dependents associated with criminal behaviour are introduced to abstinence model of treatment, it is not very effective in the rehabilitation process. further, injecting drug users are high risk groups for contracting hiv, aids. they face many other health ailments and as a result they die at a very early age. therefore, in order to reduce the impact of addictive behaviour, harm reduction strategy acts as a very good alternative and effective process. patients who are dependent on opiates can be given substitution therapy with buprenorphine and methadone under the demand reduction programme. injecting users should be given needle exchange programme which will reduce the risk of contracting hiv and aids. e) indigenous models of treatment in very few ngos of the country, yoga techniques are profoundly inculcated in the de-addiction services. ayurvedha, siddha and unani medicines are also used for deaddiction but in very few centres. the effectiveness of these services in no way can be underestimated when compared to the allopathic medicine. however allopathic medicine is widely used for medical management of addiction across the country. the concerned ministry dealing with drug abuse in the nation should deploy more resources to research into the effect of indigenous medicines on addiction. conclusion drug policies around the world have proven to be largely ineffective in controlling the production of illegal narcotics. with very few exceptions, national drug laws and policies seek primarily to punish illicit drug production, possession, use and even dependence. in the worst cases, drug users are made to be scapegoats for a wide range of social problems, and sanctions are vastly disproportionate to the supposed offenses. according to the 2010 world drug report there is currently more opium, more coca and more cannabis on the market than ever before. designer drugs are also on the rise, and amphetamines are being produced on an alarming scale.not only have these policies been unsuccessful, they have had a broad range of destructive consequences for both individuals and society. around the world, drug policy is characterized by heavy-handed and punit ive law enforcement strategies absent of a public health or human rights framework. these policies have failed to reduce drug use and have exacerbated the spread of hiv and hepatitis c. legalization of drugs could pave a way for decrease in users involved in drug crimes as they are usually soft targets of drug maas. the funds which government spends for enforcement activities for dealing with drug offences will also decrease. instead the funds can be used for treatment and rehabilitation of drug users and for preventive education and awareness for curbing initiation of new drug users. the government of india should be able to curtail the criminalization approach towards drug users at the earliest. the parliament is presently reviewing amendments to the ndps bill. will the rhetoric of 'tough on drugs' prevail once again? or will india be able to act as a mature and responsible society which limits the offences and spend more on rehabilitation of the drug dependents and on preventive education. it is an acid test for drug policy reformers as well as human rights advocates, both of whom would like to see india move in the latter direction. references: 1. government of india, the narcotic drugs and psychotropic substances act 1985 2. kar n, sengupta s, sharma p, rao g.; predictors of outcome following deaddiction treatment: prospective longitudinal study for one year; indian journal of psychiatry. 2003. 3. malhotra a, mohan a. national policies to meet the challenge of substance abuse: programmes and implementation. indian j psychiatry. 2000 4. sharma ak, sahai m.; pattern of drug use in indian heroin addicts; indian journal of psychiatry; 1990 . 5. tripathi bm, lal r. substance abuse in children and adolescents; indian journal of pediatrics; 1999. 30 x gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction it is very common to come across lacrimal sac infections in one's day to day practice as an ophthalmologist. among the entire lacrimal system , infection of the lacrimal sac is the most common and is known as dacryocystitis. it is of two types acute and chronic. acute dacryocystitis often presents with pain, fever, and periocular swelling and shows signs of inammation. whereas in chronic dacryocystitis the patient complains of constant watering from the eye associated with or without regurgitation of mucoid or mucopureulent discharge. the patency of the lacrimal duct can be tested by applying pressure over the lacrimal sac area or by irrigating the lacrimal drainage system. the discharge that we obtain from the lacrimal puncta is then taken for microbial analysis. multiple studies have been done in various parts of the world to get a better understanding of the bacteriological spectrum after taking swab culture from the conjunctiva and the lacrimal sac. materials and methods a meta analysis and review of literature on various studies which were previously done regarding the microbial analysis and the drug sensitivity and resistance was performed. various search engines and thesis were also evaluated in detail to get a better understanding of the current status. anatomy lacrimal sac the lacrimal sac is situated in the lacrimal fossa. the lacrimal fossa is bonded in front by the frontal process of the maxillary bone and behind by the lacrimal bone. the thickness of the lacrimal bone can vary from one individual to another but in most cases the lacrimal bone is thinner than the maxillary 2bone. the lacrimal bone can be visualized intranasally as it lies anterior to the uncinate process of the ethmoid bone. the lacrimal sac is lined by a double layered epithelium and it is divided into two parts –a fundus superiorly and a body inferiorly. the fundus starts 3 to 5 mm above the superior part of the medial canthal tendon while the body starts around 8 10 mm below the fundus to the osseous opening of the nasolacrimal canal. near the posterior lacrimal crest ,the orbital periostum splits and encloses the lacrimal sac and forms the lacrimal fascia. the larimal fascia is surrounded by the bres of the orbicularis oculi muscle .between the lacrimal sac and the lacrimal fascia lies a rich venous plexus. the mucosa which lines the lacrimal sac helps to prevent colonization of microorganisms and thereby infections. the epithelial cells bind tightly to one and another and protect the underlying tissues from the invading organisms .these epithelial cells also protect the sac by secreting immunoglobulin a, anti-infection peptides and mucins. apart from these primary defense mechanism ,the lacrimal 3drainage associated lymphoid tissue (ldalt) also protects the sac and forms the second line of defense. nasolacrimal duct. the lacrimal sac continues downwards into a duct called the nasoclarimal duct. the nld has a intraosseous part which lies superiorly and is about 12 mm and an inferiors 5 mm membranous portion. the diameter of the bony canal is 1 mm. the bony part travels posterolaterally within the maxillary bone while the membranous part runs through the nasal mucosa. the nasolacrimal duct nally opens into the inferior meatus under the inferior nasal turbinate. at the opening of the nld lies the valve called the valve of hasner. similar to the double layer epithelium of the lacrimal sac, the nld also has two layer lining. the mucin of the epithelial lining inuences the tear uid seceretion and also acts as an antimicrobial protective agent apart from helping in the transport of the tear uid. microbiology a study of the patients having chronic dacryocystitis among adults was done to understand the bacterial growth. it was seen that gram positive organism were the most common ones. among the gram positive organisms, staphylococcus aureus (42%) was most common followed by staphylococcus epidermis (10%) and then staphylococcus pneumoniea(10%). with regards to gram negative organisms pseudomonas aeruginosa( 18%) was very common. it was seen that chronic dacryocystitis was more prevalent among females compared to males and it was more common in the left eye. it was also more commonly seen among lower socioeconomic strata with poor hygienic condit ions. nasal pathologies l ike hypertrophied inferior turbinates, deviated nasal septum, nasal polyp and allergic rhinitis were also attributing factors. in a study done by das et al, among the 500 samples that he took 93% were positive for bacteria and most of them were gram positive organisms(77%) with a predominance of staphylococcus species and a 23% showing gram negative species with predominance of pseudomonas aeruginosa. another study conducted in southern india showed that coagulase negative staphylococci and staphylococcus aureus to be most common isolates(73% and 12% bacteriological profile of the lacrimal sac in dacryocystiti original research paper mridula v amarnath chinmaya mission hospital,bangalore,karnataka x 153gjra global journal for research analysis ophthalmology in our routine ophthalmology practice it is very common to come across lacrimal sac infections. lacrimal sac infections most commonly presents with watering from the eye either associated with or without discharge, which can be assessed by applying pressure over the lacrimal sac.1 it is important to analyse the microbial spectrum in cases of lacrimal duct obstruction along with sac infection. it was noted that gram positive organisms are the most common source of infection. among the gram positive organisms it is the staphylococcal species mainly the staphylococcus aureus which is responsible. other gram positive organisms include staphylococcus epidermis and streptococcus pneumonia. among the gram negative organisms the most common ones are the pseudomonas aeruginosa, hemophillus inuenza, and klebsiella. anaerobic organism like propionibacterium and fungi like candida are very rare. it is equally important to assess the sensitivity of the organism to various drugs. a better understanding of the drug sensitivity is important in the management of lacrimal sac infections. it was found out that gram positive organisms are sensitive to vancomycin,ooxacin, gatioxacin and chloramphenicol while gram negative organisms showed sensitivity to mainly tobramycin. abstract keywords : lacrimal sac, dacryocystitis, microbial analysis. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 154 x gjra global journal for research analysis respectively) . a study done by bharathi et al in tamil nadu showed that coagulase negative staphylococci (44%%), s aureus (11.2%) and s pneumonia(7%%) as the most common causative organism for chronic dacryocystitis. in a study done among the population in nepal having chronic dacryocystitis, it was seen that there was an equal proportion among both gram positive and negative organisms. however a study done by badhu et al from northern india showed that s pneumonia was the most frequently isolated organism. an egyptian study showed that coagulase negative staphylococci (53%%) and klebsiella pneumonia (18%5) were the common isolates. sun et al study which was done in china reported that staphylococcus species contributed majorly to the bacterial prole in chronic dacryocystitis (76%).an iranian study showed that the prevalence of gram positive, gram negative and culture negative samples were 77%, 19.2% and 3.5 % respectively and staphylococcus epidermis was the most common one. in the lacrimal duct the oxygen supply was mainly consumed for the growth of aerobic and facultative bacteria. this in fact led to an anaerobic condition for the anaerobic bacteria like propionibacterium. in the previous studies it was seen that anaerobic bacteria accounted for 8 % of the entire growth. a multicentered prospective study was done in the us in order to assess the microbial growth and it was performed in 17 centers and the acute and chronic groups of dacryocystitis were compared. there was a total of 90 culture isolates with 67% gram positive isolates,27% gram negative isolates and 3% mycobacterium isolates. in the acute group, 77% were gram positive, 22% were gram negative whereas in the chronic group 66% were gram positive and 32% were gram negative and 3% were mycobacterium isolates. the proportions between gram positive and negative among the groups revealed no statistically signicant difference. in a study done by kuchar et al in congenital nld obstruction, the spectrum of microorganisms mainly included s pneumonia having a 36% of the isolates followed by haemophillus inuenza with 21%. in a study done by usgha et al 250 samples were evaluated with congenital nld obstruction among which 83% had a gram positive culture with s pneumonia being the most prevalent and haemphilus inuenza being the most frequent among gram negative organism. they also reported a single case of fungal isolate of candid species. congenital nld obstruction usually starts in the neonatal period and is more common among female. the clinical manifestation ranges from pediatric acute dacryocystitis to 4meningitis . it is seen that s aureus is the most common isolate. some of the rare organisms that are seen pantoea species, epstein barr virus and sporothrix. for the microbiological analysis the samples are usually taken from the conjunctival sac, lacrimal sac and in some cases from the intraoperative lacrimal sac uid. the discharge can be obtained by either applying pressure over the lacrimal sac and allowing the purulent discharge to regurgitate through the lacrimal puncta or it can also be collected by irrigating the lacrimal drainage system with sterile saline and collecting the sample from the reux material. the samples are collected with the help of a sterile cotton swab ensuring that the lid margins or the conjunctiva are not touched. the specimen which is collected is then inoculated on a solid media like sheep's blood agar, chocolate agar, sabouraud's dextrose agar or liquid media like brain heart infusion agar or thioglycolate media. the sample which is collected is also smeared onto a clean sterile glass slide for 10% potassium hydroxide wet mount, gram stain, zeihlneelson acid fast stain. all the inoculated media are incubated aerobically. 0the sabouraud' s dextrose agar is incubated at 27 c, and is examined on a day to day basis and is nally discarded after 3 weeks if no growth is noticed. similarly the blood agar, chocolate agar, thioglycolate broth, brain heart infusion agar 0is incubated at 37 c, examined daily and then is discarded if no growth is noticed after a period of 7 days. the cultures that 5have been inoculated should be considered signicant if 1) the growth of the same particular organism is seen on more than one solid phase medium. 2) if there is a presence of conuent growth at the site of inoculation on one solid medium 3) the growth on one of the medium is consistent with the microscopic ndings like appropriate staining and morphology with gram stain. 4) if the same organism is seen in more than one specimen. the identication of the species should be made based on the microscopic morphological ndings, staining properties and the biochemical properties according to the standard laboratory criteria. for each inoculation the susceptibility testing has to be done according to the standardized methods. as in case for blood agar, the susceptibility is measured by measuring the area of where hemolysis had not occurred. for each antimicrobial agent the zone diameter is measured and it is then converted into the sensitivity and resistant categories by referring an interpretation chart according to the national committees for clinical laboratory standards, usa. in a study done by mandal et al, it was seen that chloramphenicol is effective against most of the gram positive organisms while for s epidermis drugs like aminoglycosides and tobramycin were effective. for p aeriginosa and klebsiella pneumonia, uoroquinolones mainly the ciprooxacin and ooxacin are found to be benecial. a study conducted by chaudhary et al reported that a very high rate of microorganisms were seen in the lacrimal sac and hence it is mandatory to treat them before any intraocular surgery is conducted to rule the potential risk of postoperative infection. a study conducted by amin et al to evaluate the sensitivity and resistance of the microorganism to the various drugs showed that majority of the bacterial isolates were susceptible to vancomycin (96%), gatioxacin(92%) cefotaxime(89%) amikacin (93%) tobramycin(89%) and ooxacin(83%). and they were mainly resistant to macrolides (43%) and amoxicillin (38%).it was seen that among all the drugs gatioxacin and ooxacin showed the least resistance to the bacterial isolates in both acute and chronic infections of the lacrimal sac (8% and 11.3 % respectively). a study done by ponpanich et al showed that ciprooxacin was the most effective drug against all gram positive and gram negative organisms. mills et al showed that the frequency of methicilin resistant s aureus in the acute group was certainly more when compared to the chronic group and they also revealed that ooxacin and tetracycline is the most effective drug as monotherapy. they also proved that when acitracin and neomycin was used as the initial mode of therapy, it was successful in curing dacryocystitis in nearly 85 % of the patients. when compared to other developing countries, india is labeled as one of those counties that has a rampant usage of antibiotics. inappropriate use of topical drugs can increase the resistance to the bacterial ora and eventually be less effective in the further management. the usage of broad spectrum antibiotics is also considered as a risk factor for developing resistance and hence it needs to be used with at most care and 6concern . the diagnosis of dacryocystitis is further conrmed with the laboratory ndings. unlike previously where s pnemoniae was more common currently s aureus has become the prominent organism in lacrimal sac infections. the emergence of new rare species, resistant microbes may also be seen in the future causing lacrimal sac infections. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra conclusion obstruction of the nld leads to colonization of the bacteria and thereby leading to infection in majority of the patients. gram positive organisms are more commonly seen compared to gram negative organisms. the infections needs to be treated based on the sensitivity of the organism. it is very crucial for the early diagnosis and immediate treatment of the infection as sometimes it can be a threaten to the vision due to its untoward complications and sequel. however in the past few decades, accurate diagnosis along with medical management and surgical management if required has provided a good outcome in the management of lacrimal sac infections. references 1. perra m, serra a. an immunochemical study of the defense mechanism in the human lacrimal sac. arch histo cytol. 1995;(58): 517-526 2. mauriello j,de luca j. clinicopathological study of the lacrimal sac with nasolacrimal duct obstruction. ophthal plast reconstr surg. 2002;(8): 13-21 3. knope. lacrimal drainage associated lymphoid tissue. invest ophthalmol vis sci. 2001;( 42): 566-574 4. paulsen f, coreld a .impact of mucins and tff peptides. ophthalmologe. 2006;( 101): 12-20 5. mandal ar, banerjee tt.clinicobacteriological study of chronic dacryocystitis in adults. j indian med assoc .2008;(106):296-312 6. das jk,deka ac.bacteriology of chronic dacryocystitis .india j clin diagn res. 2014 ;(24) 322-345 x 155gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction : medical students build their clinical knowledge on the grounds of previously obtained knowledge in basic medical sciences. biochemistry is considered to be a difcult subject by medical students. as far as the biochemistry component in the medical curriculum is concerned, there seems a general consensus that medical students understand enough about biochemistry to know how it can elucidate their investigations of a clinical problem or how it can enlighten to medical advance. unlike other pre-clinical subjects where the students can correlate topics with specimens, dissections or real life examples, conceptualization in biochemistry is often a challenge. since didactic lecturing has been the main teaching learning method in biochemistry, the dynamic concepts with complex mechanisms are difcult to explain during lecturing even with the use of still power point slides. the applications of communication technology provide new possibilities for improving the effectiveness of teaching 1,2 learning process. over the past few years, there has been a steep increase in the use of animation to communicate dynamic molecular processes to a large group of audience. since animated videos have the potential to explain the dynamic and changing process at the molecular level which are not observable, these can be used to deliver better representation of the concepts in biochemistry.the molecular processes taking place inside the living system can be clearly presented in animation than in static illustrations. the moving graphics can attract the viewers and attain audience motivation. when students have more visual experiences, they would have better learning outcomes than just imagining the processes in their mind. by giving them visualized information in a right way, animated videos help in clear and deep understanding of the processes easier and can remember all the information better. moreover, animations directly guide the learner's attention to the specic parts of the content those are difcult to conceptualize the students through static pictures. review of literature: studies reported the inuence of animated videos in creating students motivation and interest in learning complex dynamic 3,4 mechanisms in premedical subjects . balsley et al. remarked that animated videos can be used to illustrate microscopic and sub microscopic processes taking place at the cellular 5and molecular level . according to bradley stith, lectures using animated videos lead to more complete understanding of the cell biology concepts than lectures alone that used only 6static illustrations . animated videos have the potential to 7serve both affective function and cognitive function . the best feature of animated videos is that they could deliver complicated information in detail with high accuracy even 8though that can not be seen by naked eyes . three dimensional animations can describe the medical processes with high accuracy even those that can not be seen by naked eyes. animated visualizations showing both structure and molecular processes convey important scientic concepts in biochemistry and molecular biology. animations visually help students to understand difcult concepts related to the dynamics of complex chemical systems including molecules 9and reactions . research question whether the use of animated videos during lecturing in biochemistry class for medical students improve student's perception, motivation and thereby academic performance. objectives: 1. to study the effectiveness of animated videos during lecture on the academic performance of rst year mbbs students in biochemistry in comparison with didactic lecture 2. to analyse whether the use of animated videos during lecturing create an effective learning environment resulting in the motivation in learning materials and methods: study design : educational interventional study study setting : dept of biochemistry, sree gokulam medical college and research foundation, trivandrum study period : th th 24 may to 20 aug 2018 sampling method : systematic sampling inclusion criteria : first year mbbs students who were willing to participate after getting informed consent study on the effectiveness of animated videos as a supplementary learning tool in biochemistry original research paper dr. manju. k. s assistant professor dept. of biochemistry, sree gokulam medical college and research foundation thiruvananthapuram, kerala biochemistry background: lectures emphasize learning by listening alone and often students may not be receptive. to overcome this, one can use innovative teaching-learning methods to impart interest and attention and for this animated videos can be used as a supplementary teaching learning tool. objectives: to study the effectiveness of animated videos during lecture on the academic performance and to analyse whether the use of animated videos during lecturing create an effective learning environment. materials and methods: this educational interventional study was conducted at sree gokulam medical college and research foundation, trivandrum. about 134 undergraduate students admitted to rst year mbbs course were participated after giving informed consent and were divided in to two groups based on systematic sampling method. study tools included ppt slides, animated videos and structured questionnaire. the score of post test of the two groups was compared by unpaired 't' test. feedback obtained from students used for assessing the student's perceptions about the subject and attitude towards the teaching learning methods used. results: students exposed to animated videos during lecture showed a signicantly better performance in post test along with a positive change in the attitude towards learning in comparison with students attending lecturing only, while the perception about the subject was same in both groups. abstract keywords : biochemistry, animated videos, student's performance, assessment volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 60 x gjra global journal for research analysis exclusion criteria : students who were absent in any one session of the module and those who were not willing to participate in the study. sample size : 134 rst year mbbs students methodology: about 150 undergraduate students admitted to rst year mbbs course during the academic year 2017-18 were willing to participate the study by giving informed consent. students were grouped in to two based on systematic random sampling after getting the ethical clearance certicate from institutional ethical committee. about 16 students who were absent either in any one session or post test excluded from the study. there were 70 students in the control group in which the topic was presented by conventional didactic lecture. the experimental group consisted of 64 students to whom the topic was presented by using animated videos as a supplementary teaching learning tool along with didactic lecture. the topic of 'electron transport chain and biological oxidation 'was presented separately in six sessions. one group was taught by conventional didactic lecturing. other group was taught by using animated videos along with lecturing. at the end of all sessions a post test was conducted by using peer reviewed question paper consisting of both mcqs and saqs. marks obtained was entered in microsoft excel and analysed by spss version 16. the feedback regarding the students perceptions and attitude was collected by using peer reviewed structured questionnaire for which the reliability test for internal consistency was analysed. then control group were exposed to animated videos. statistical analysis: data analysis will be done using spss version 16. the score of post test of the two groups will be compared by unpaired 't' test. questionnaire used to collect the feedback about the perceptions and attitudes of students was analysed by reliability statistics. internal consistency of the 10 items questionnaire is 0.72. feedback obtained from students using the structured questionnaire with a 5-point likert scale, ranging from 1(strongly disagree) to 5 (strongly agree) for assessing the students perception and attitude about the subject and teaching learning methods used. descriptive statistics was done and difference in perception and attitude of students in both groups was analysed based on mannwhitney u test. a p value <0.05 considered to be statistically signicant. results: a statistically signicant increase in the mark of post test observed in experimental group (18.94±4.31, mean±sd) in comparison with control group (16.34±3.54, mean±sd) (p<0.001) (table 1). the animated videos exposed group scored higher marks in both mcqs and saqs in comparison with control group (graph 1). table 1: comparison of marks in post test between the groups analysis done by unpaired 't' test. data expressed as mean ± sd graph 1 : comparison of marks (mean ± sd) obtained in mcqs and saqs between the groups no statistically signicant difference was observed between the two groups regarding the perception of students about the subject. about 57% of students in the control group (graph 2) and 50% of students in the experimental group (graph 3) commented that biochemistry is an interesting subject. about 57% of control group and 66% of experimental group agreed that biochemistry is more difcult to understand than other preclinical subjects. graph 2: perception of students attending didactic lecture (control group) graph 3: perception of students attending lecture with animated videos (experimental group) a signicant difference in the attitude and interest towards the teaching learning method observed between the two groups (p=0.000) (table 2). the students in the experimental group commented that the sessions of lecturing with animated videos was very effective for maintaining attention of students and this method of teaching is ideal for generating interest in subject and motivation for active learning. table 2: comparison of perception and attitude of students between the two groups volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra group marks of post test t-value p-value control 16.34 ± 3.54 3.83 <0.001 experimental 18.94 ± 4.31 questions median ± iqr u z p control experimental q1.biochemistry is an interesting subject 4 ±1 4±1 1.89e3 -1.71 0.087 q2. biochemistry is more difcult to understand than other subjects 4±0 4±0 2.13e3 -0.52 0.603 q3. knowledge in biochemistry helps to better understanding of disease concepts 4±1 4±1 2.21e3 -0.14 0.89 q4.do you feel that didactic lecture is a very effective teaching method in biochemistry 3±2 3±1 1.73e3 -2.34 0.019 q5.do you feel that power point presentation during lecture is an ideal teaching learning method in biochemistry 4±1 4±0 1.91e3 -1.61 0.106 x 61gjra global journal for research analysis analysis done by mann-whitney u test. p<0.05 considered statistically signicant regarding the attention span of students, 38% of students in control group commented 50% attention span while 29% of students in the experimental group had 50% attention span. but 47% of the students attending the lecturing with animated videos reported more than 75% of attention span while only 14% of students attending the conventional didactic lecturing reported an attention span more than 75%. (graph 4). these observations indicate an impact of animated videos along with lecturing in generating interest in subject, maintaining attention throughout the class and motivating the learning process. graph 4 : comparison of attention span of students in the session attended discussion the objective of this study was to analyse the effectiveness of animated videos during lecturing in generating interest in subject, maintaining the attention span, improving the motivation for active learning thereby enhancing the academic performance of students. the results showed a statistically signicant difference in the marks obtained in post test between the two groups of students. group of students to whom the animated videos were shown scored a statistically signicant higher marks in comparison with the group of students attending the traditional lecturing only. this result indicates the usefulness of animated videos as a supplementary teaching learning tool in biochemistry. this view is in concordance with recent 10 studies of hoyenk et al. who studied the effectiveness of three dimensional digital animation in teaching human musculoskeletal system. in their study, comparison was made between the two groups of students from different academic years and the results reect the effectiveness of digital animation in recalling anatomical knowledge requiring spatial ability. the present study observed a signicant impact of animated videos in enhancing the attention span of students during lecturing, generating interest in the topic and imparting an increased motivation in learning which are ultimately reecting in the academic performance. a critical literature 11 review conducted by ruiz et al. reported that the benets of animation vary according to learner characteristics such as prior knowledge and spatial ability. the features of animation that appear to facilitate learning include permitting learner control over the animation pace that allows the learner to interact with animations and splitting the animation activity in 12 13 to segments. pollock et al. and tversky and morrison argued that animations are more effective than static sequential images for teaching dynamic events. stith conducted a study to analyse the value of animations over static illustrations in science teaching and reported that the students who viewed the animations scored signicantly higher on the test than 6those who had not viewed the animation . mc clean et 14al. conducted a more comprehensive study on the effect of animation based educational modules and reported that student's retention and content material became signicantly better when the student received a lecture coupled with the 15 animation. o'day dh conducted the effect of animated videos on signal transduction pathways and reported that animations provide students with insight in to biological processes in a way that traditional lecturing and static graphics do not. several previous studies showed a tendancy of effectiveness of animation based learning on problem-solving transfer 16when compared with text-based learning . studies reported that the psychological educational dimensions of teaching and learning with animations lead to construction of knowledge transfer ability which is one of the most important 17thinking skills. conclusion: present results showed a signicant impact of animated videos during lecturing on student's perception and attitude towards the subject as well as learning process resulting a signicant improvement in the academic performance . limitations of the study: the present study focussed on the effect of animated videos during lecturing on the change in perception and attitude towards learning and thereby on the academic performance. a remaining question is whether teaching with animated videos affects additional aspects of knowledge, abilities and skills. sample size: this study was conducted in a small group of students in a single medical college, and the duration of the study was limited. this study is recommended to be conducted in a large group of students in more number of medical colleges. topic for teaching : only a single topic was selected for the study. this study is recommended to be conducted in different topics in different medical colleges. acknowledgement: author acknowledges dr.sajithkumar.r and other faculty members,nodal centre for faculty development,medical council of india, department of medical education, govt medical college,kottayam,kerala for the valuable guidance of this educational project; dr.manju.l, associate professor, dept of statistics,sree gokulam medical college and volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra q7.the method of teaching you have attended is effective for maintaining attention of students throughout the class 3±2 4±1 918.0 -6.23 0.000 q8.this method of teaching is ideal for generating interest and motivation in the subject 3±1 4±1 1.13e3 -5.32 0.000 q9.this method of teaching is effective in understanding the concept of selected topic in biochemistry 4±1 4±1 1.23e3 -4.86 0.000 q10.do you recommend this method for teaching other subjects also 4±1 4±1 1.16e3 -5.13 0.000 q11.overall how do you assess this teaching method 4±0 4±1 1.41 -4.62 0.000 62 x gjra global journal for research analysis research foundation for her help and support in analysing the data; 1mbbs students of 2017-18batch, sree gokulam medical college for their co-operation and support for the successful completion of this study. references: 1. bransford jd and schwartz dl. rethinking transfer : a simple proposal with multiple implications. review resear edu 1999;24:61-100. 2. salomon, g. (2002). technology and pedagogy: why don’t we see the promised revolution? educational technology, 42(2), 71-75. 3. kesner m h, linzey av. “can computer based visual-spatial lead to increased student performance in anatomy and physiology?”. the american biology teacher. 2005;67(4):206-216. 4. holsanova j, holmberg n and holmquist k. reading information graphics : the role of spatial contiguity and dual attentional guidance”. applied cognitive psychology.2009;23(9):1215-1226. 5. balsley t, de grave w s, muijtiens a m and scherpbier a j. “comparison of text and video cases in a post graduate problem based learning format medical education. 2005;39:1086-1092. 6. bradley.j.stith. use of animation in teaching cell biology. cell biology education.2004;3(3):181-188. 7. martin t and schwartz d l. physically distributed learning: adapting and reinterpreting physical environments in the development of fraction concepts. cognitive science.2005;29(4):587-625. 8. mayer r e. “multimedia learning”. the psychology of learning and motivation. 2002;41:85-139. 9. kozma r and russel j. students becoming chemists: developing representational competence. int j gilbert(ed.), visualization in science education 2005;7:121-45. 10. hoyek n, di rienzo f, de almeida m, guillot a. effectiveness of three dimensional digital animation in teaching human anatomy in an authentic classroom context. anat sci educ 2014;10:1446. 11. ruiz jg, cook da, levinson a j. computer animations in medical education : a critical literature review. med educ 2009;43(9):838-46. 12. pollocke, chandler p and sweller j. assimilating complex information. learning and instructions 2002;12:61-86. 13. tversky b and morrison jb. animation: can it facilitate? int j hum com stu 2002;57:247-262. 14. mc clean p, johnson c, rogers r, daniels l, reber j, slator bm, terpstra j and white a. molecular and cellular biology animations development and impact on student learning. cell biol edu 2005;4(2):169-179. 15. o’day dh. animated cell biology : a quick and easy method for making effective high-qualiy teaching animations. cbe life sci educ.2006;5:255-263. 16. maayer re and sims vk. ‘for whom is a picture worth a thousand words? extensions of a dual-coding theory of multimedia learning. j of edu psych 1994;86:389-401. 17. bransford jd and schwartz dl. rethinking transfer :a simple proposal with multiple implications. review resear edu 1999;24:61-100. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 63gjra global journal for research analysis introduction the biodiesel is used as an alternative energy substitute for fuel oilfor diesel fuel (solar) types. biodiesel can be applied in the 100% form (b100) or a mixture with diesel fuel at a certain concentration level [12]. one of the methods of the indonesian government in the use of biodiesel is the b20 program, the b20 program is a government program to require the mixing of 20% biodiesel with 80% diesel fuel [4]. in this study, trying to mix the diesel fuel with biodiesel made from coconut oil with a stirring process at the level 10% and 20% concentrations are then applied to the diesel engine to be analyzed its effect on the performance of the diesel engine consisting of power, torque, and specic fuel consumption. [6][7][8][9][10]the comparison of the effects of diesel and biodiesel temperatures to the performance of direct injection diesel enginesfor biodiesel fuel showed that the best thermal oefciency was 21.3% at 70 c with 11% bsfc, and in this condition there was a decrease in specic fuel consumption by 8% [11]. [2] the comparative experimental investigation of combu stion,performance and emission in a single cylinder diesel engine using diesel fuel and biodiesel. it is shows when at maximum load the specic fuel consumption of lhr engine fueled with biodiesel is higher by about 5.24% than diesel fuel. the high fuel consumption is due to the low heating value and high density of biodiesel fuels. [3] showsthe performance characteristics and analysis of multi cylinder turbocharged engines using diesel fuel mixed with biodiesel from jatropha plants at a percentage of 20%, 30%, and 40% showed power, torque, and thermal efciency using biodiesel fuel is higher than that produced by diesel fuel. fuel with 20% biodiesel percentage shows better performance than other types of fuel. [5] the diesel engine performancesfueledwith oxidized biodiesel shows that the use of b20 fuel had 16.2% higher power and specic fuel consumption was 11.2% lower than diesel fuel. materials the materials used in this study are diesel fuel with the numbers of cetane 48 (pure diesel fuel), 51 (dexlite) and biodiesel (b100). biodiesel fuel (b100) used in this studyfrom coconut oil. this study uses a variation of the fuel mixture which is then applied to the diesel engine to nd out how much inuence on engine performance. the composition of the fuel mixture used in this study includes: a. b10 solar = 10% biodiesel (b100) + 90% solar (cetane 48) b. b20 solar = 20% biodiesel (b100) + 80% solar (cetane 48) c. b10 dexlite = 10% biodiesel (b100) + 90% dexlite (cetane 51) d. b20 dexlite = 20% biodiesel (b100) + 80% dexlite (cetane 51) after all the fuels have been mixed, the next step is to test the characteristics of the fuel mixture which includes testing the density of the fuel. [1] there is a difference between pure coconut oil (pco) and jathropa oil methyl ester (jome) and diesel fuel. the difference is due to differences in the structure of the fuel. the higher the viscosity and density of pco and jome the results will affect the difculty of fuel injection in the combustion chamber, fuel atomization, and the mixture of fuel with air so that it will affect the performance of diesel engines. thetest used in this study include dynamometer type chassis dynamometer (single-axle dynamometer) to measure the power and torque produced by a diesel engine, a fuel consumption measuring gauge consisting of owmeter and stopwatch, owmeter to measure fuel ow speed, stopwatch to measure the duration of fuel consumption of a diesel motor (s), measuring glass1 liter and burette to determine fuel percentage, tachometer to measure engine speed (rpm), fan to cool the engine used for testing and placed in front of the engine, and the diesel engine for test. the specications of the diesel engine used in this study can be seen in table 1. table 1. spesication of diesel engine the performance analysis of a diesel engine fueled with blends of biodiesel from coconut oil and diesel fuel original research paper yuniarto agus winoko thmechanical department state polyteknic of malang, soekarno-hatta 9 street of malang x 23gjra global journal for research analysis engineering the article discusses the diesel fuel mixed with biodiesel. diesel fuel mixed with 10% biodiesel is called b10 and diesel fuel mixed with 20% biodiesel is called b20. the purpose of this study is to determine the performance of the engine which consists of optimum power, optimum torque and minimum fuel consumption, when using b10 and b20 fuels that have been mixed with diesel fuel. it also determines the optimum power, optimum torque and minimum fuel consumption, when using b10 and b20 fuels that have been mixed with dexlite. the engine performance test method uses an experimental laboratory based on iso 1585 standards when engine speed is 1500 4500 rpm with multiples of every 500 rpm.then the data is presented in graphical form to be analyzed. based on the results of the analysis, the power increases 1.68% when using b10 dexlite fuel, torque increases 1.68% when using b10 dexlite fuel, and fuel consumption decreases up to 5% when using b10 dexlite fuel. abstract keywords : biodiesel mixture, dexlite, engine performance, solar. febrio hendroyono* thmechanical department state polyteknic of malang, soekarno-hatta 9 street of malang *corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra engine type 4-stroke, direct injection number of cylinder 4 diameter x stroke 93 mm x 92 mm displacement 2499 cm3 compression ratio 18,4 : 1 maximum power 85 hp / 3900 rpm maximum torque 17.5 kg.m / 2000 rpm 24 x gjra global journal for research analysis methods in this study there are 2 tests, namely density testing of fuel and diesel engine performance testing. diesel engine performance test ing use dynamometers (chassis dynamometers: single-axle dynamometer). the diesel engine performance testing method uses p-max method. the diesel engine are operated in the range of 1250 rpm to 4500 rpm. then record every change in power and torque in the specied engine speed range. in fuel consumption testing, the diesel engine is operated in the range of 1500 rpm to 4000 rpm. fuel consumption testing is measured using a owmeter and stopwatch. measure the amount of time (s) the diesel engine needs to consume 10 grams of fuel using a stopwatch. make a data records of the variables needed, namely the time of fuel consumption per engine speed at each variation of the fuel mixture. for testing the density using a pycnometer. fig. 1 shows set up engine performance testing. fig. 1 set up engine performance testing result and discussion the result of fuel characteristics testing the results of fuel density tests show that diesel fuel with the same type of cetane number, when mixed with biodiesel can increase the density of the fuel, for example diesel fuel (solar) with a concentration of biodiesel mixture of 20% has a greater density compared to diesel fuel (solar) with a concentration of biodiesel mixture of 10%. the changes of the density cause differences in the structure (chain) of the fuel is longer, so that a higher density indicates the density between molecules in the fuel is solid and fused, resulting in higher fuel viscosity. this condition affects the difculty of fuel injection, fuel atomization, and the mixture of fuel with air so that it will affect the performance of diesel engines. in the fuel density test results, show in the table 2. table 2. the density of all variant of fuel engine performance testing results fig. 2 power measured engine speed fig.2shows, the power measured by using b20 diesel fuel producing power measured is lower than that produced in standard conditions (b10 diesel fuel). at 1279 rpm the power produced is 1,19% lower than that producedin standard conditions. when 1503 rpm there was andecrease in power of 0,22%, in 2014 rpm was 0,31%, when 2494 rpm was 0,92%, when 3005 rpm was 1,93%, and when 3517 rpm was 0,08%. when averaged, for the signicant effect there was an increase in power measured of 1,68% by using b10 dexlite fuel compared to using standard fuel and the power measured of b10 dexlite fuelis higher than that produced in standard conditions, b20 diesel fuel, and b20 dexlite.it is because the density of b10 dexlite fuel has the lowest value than the density of other fuels, which indicates the intermolecular density of b10 dexlite fuel is more subdued. the causes the viscosity of the b10 dexlite fuel is lower than the viscosity of other fuels , so that it can simplify the process of injection (extraction) of fuel. injected fuel is more easily integrated with air (homogeneous) so that more fuel is burned and more combustion energy produced. the power produced will also be far greater than that produced by other types of fuel, including standards. the amount of power produced also depends on engine speed and fuel temperature. when the engine speed is low, the piston motion is slow so that the amount of mixture of air and fuel entering is low. conversely, when the engine rotation is high, the piston movement is fast and the amount of air entering will be large. however, at certain rotation limits if the motor rotation is too high, it is possible the intake valve closes before the air has not entered the cylinder. during beginning engine speed (1279 rpm) the fuel temperature is lower than the temperature at 3996 rpm. so that the viscosity of fuel at the beginning of the engine speed is higher than at 3996 rpm, which causes the power that produced at the beginningof engine speed smaller than the power at 3996 rpm.. the results of engine performance testing (power measured) can be shifted or different compared to the standard specications of the vehicle, due to various factors including errors due to the testing process, setting or reading data as well as or power reading errors due to the dynamometers. fig. 3torque -engine speed fig. 3 shows, the torque by using b10dexlite fuel is higher than that produced in standard conditions, b20 diesel fuel, and b20 dexlite. at 1279 rpm the torqueproduced is 4,66% higher than that producedin standard conditions. when 1503 rpm there was an increase in torque of 4,07%, in 2014 rpm was 1,71%, when 2494 rpm was 0,08%, when 3517 rpm was 0,79%, when 3996 rpm was 0,56%, and when 4508 rpm of 2.31%. during high rotation, b20 dexlite produces the lowest torque compared to other fuel mixture when averaged, for the signicant effect there was an increase in torque of 1,68% by using b10 dexlite fuel compared to using standard fuel. it is because the torque value produced depends on the engine speed and power measured (ne) produced by the diesel engine. this refers to the torque formula which is directly proportional to the power produced, but inversely proportional to the engine speed. the higher the speed of the engine and if not accompanied by a large increase in power, the resulting torque will be smaller. fig. 3, volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra no fuel fuel composition density (kg/m3) 1 biodiesel 100% biodiesel 860 2 b10 solar (standart) 10% biodiesel (b100) + 90% solar (cetane 48) 849 3 b20 solar 20% biodiesel (b100) + 80% solar (cetane 48) 887 4 b10 dexlite 10% biodiesel (b100) + 90% dexlite (cetane 51) 839 5 b20 dexlite 20% biodiesel (b100) + 80% dexlite (cetane 51) 845 which tends to decrease with increasing engine speed. at engine speed of 3517 rpm, the torque produced by all types of fuel is in a position that coincide with each other, this indicates that at the engine speed the mixture of air fuel for all types of fuel approaches the stociometry so that it produces the same torque value. the results of torque can be shifted or different compared to the standard specications of the vehicle, due to various factors including errors due to the testing process, setting or reading data as well as or power reading errors due to thedynamometers. fig. 4 specic fuel consumption (sfc) engine speed fig. 4shows the specic fuel consumption (sfc) using b20 dieselfuel is lower (economical) than produced in standard conditions. at 1500 rpm the sfc produced 2,85% lower than that produced in standard conditions. when 2000 rpm there was a decrease of 3% sfc, while 2500 rpm was 1,35 %, and while 3500 rpm was 14,6%. based on testing, b10 diesel produces the highest sfc than any other fuel mixture. when averaged, for the signicant effect there was a 5% decrease in sfc fuel consumption by using b10 dexlite compared to using standard fuels. it is because the value of the specic fuel consumption depends on the power measured (ne), the density of the fuel, fuel temperature, and engine speed. increased engine speed will be accompanied by an increase in fuel temperature which will affect the viscosity of the fuel, as well as an increase in temperature will increase the measured power (ne). it also refers to the formula of specic fuel consumption (sfc) which is inversely proportional to the power measured (ne) that produced (sfc = mf / ne). so that with the same engine speed on all types of fuel, the higher the power measured (ne), the specic fuel consumption produced will be smaller. we can see that the value of power measured (ne) at 3500 rpm with b10 dexlite fuel is 0.79% higher than that produced by the standard, which results in the fuel consumption value of b10 dexlite being smaller than the standard fuel consumption. the specic fuel consumption can be shifted or different compared to the standard specications of the vehicle, due to various factors including errors due to the testing process, setting or reading data as well as or power reading errors due tothe dynamometers. conclusion the main purpose of this study is to analyze the performance of diesel engines, when using diesel fuel mixed with biodiesel from coconut oil at a concentration level of 10% and 20%. based on the results of diesel engine performance testing, it shows that the b10 dexlite fuel produces optimum power and torque than other fuel mixtures namely b10 diesel (sandard), b20 diesel, and b20 dexlite. for the specic fuel consumption test, it shows that b10 dexlite produces the minimum fuel consumption than other fuel mixes, namely b10 diesel (sandard), b20 diesel, and b20 dexlite. engine performance testing is carried out on a diesel engine by using various variations of biodiesel blends from coconut oil in the range 1500 rpm 4500 rpm. from the test results, biodiesel from coconut oil can be used as an alternative fuel for diesel engines and b10 dexlite is suitable blend of biodiesel from coconut oil. references 1. hoang, t.a., and le, v.v. 2017. the performance of a diesel engine fueled with diesel oil, biodiesel and preheated coconut oil.international journal of renewable energy development. 2. navindgi, m. c., dutta, m., & kumar, s. p. 2012. comparative experimental investigation of combustion,performance and emission in a single cylinder thermal barriercoated diesel engine using diesel and neem biodiesel. international journal of engineering research and development. 3. patil, d., &arakerimath, r. 2012. performance characteristics and analysis of jatropha oil in multicylinder turbocharge compression ignition engine. international journal of engineering research and development. 4. winoko, y. a. &santosa, s. 2016. the improvement of after burning system by utilize zeolitecatalyst to reduce the engine exhaust emissions. international journal of engineering research and development. 5. ekrem, b. (2010) effects of biodiesel on a di diesel engine performance, emission and combustion characteristics. science direct, 89, 3099–3105. 6. fathima, j., selva, i.p., lima, r.m. (2011) fatty esters from vegetable oils for use as a diesel fuel. ieee conference on clean energy and technology (cet). 7. hossain, a.k., davies, p.a. (2012) performance, emission and combustion characteristics of an indirect injection (idi) multi-cylinder compression ignition (ci) engine operating on neat jatropha and karanj oils preheated by jacket water. biomass and bioenergy, 46, 332-342. 8. kadu, s.p., sarda, r.h. (2010) experimental investigations on the use of preheated neat karanja oil as fuel in a compression ignition engine, engineering and technology, 540-544. 9. marcelo, j.da.s, samuel, n.m.s., luizina´, c., helton, a.r., deonir, s., reginaldo, f.s., reinaldo, a.b., carlos, e.c.n. (2013) comparative analysis of engine generator performance using diesel oil and biodiesels available in parana´ state, brazil. renewable and sustainable energy reviews, 17, 278–282. 10. misra, r.d., murthy, m.s. (2010) straight vegetable oils usage in a compression ignition engine a review. renewable and sustainable energy reviews, 14, 3005-3013. 11. murugesan, a., umarani, c., subramanian, r., nedunchezhian, n. (2009) biodiesel as an alternative fuel for diesel engines a review. renewable and sustainable energy reviews, 13, 653-662. 12. volpato, c.e.s., conde, a.p., barbosaj, a., salvador, n. (2009) desempenho de motor diesel quatro tempos alimentado com biodiesel de o´leo de soja (b100).cienciaagrotecnolo´gica, 33(4), 1125–1130. x 25gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction word “hemangioma” is commonly used in generic sense to describe a variety of vascular lesions both congenital and acquired of differing etiologies and natural histories. this confusing nomenclature has been largely responsible for illogical treatment of cutaneous vascular lesions. on basis of clinical and cellular studies the vascular anomalies of infancy and childhood divided in two major categories hemangioma and malformations by muiliken & glowacki in 1982. vascular tumours of childhood are typically benign. most common type are – ÿ infantile hemangiomas ÿ congenital hemangiomas ÿ kaposiform hemangioendothelioma and ÿ pyogenic granuloma infantile hemangiomas are most common tumor of infancy, 90% of ih are diagnosed by history and examination. deeper lesions, may be difcult to diagnosed as they noted later than supercial lesions and may not have signicant over lying skin changes. the eld of vascular anomalies has been impeded by imprecise terminology. non uniform terminology has created diagnostic confusion, blocked communication between doctors, inhibited research and caused incorrect treatment. biological classication claried the eld of vascular anomalies by categorizing lesions based on their clinical behavior and cellular characteristics. biological classification: mulikan and glowacki (1982): investigated vascular anomalies on the basis of cellular features and cell kinetics. . they classied vascular anomalies in two major groups namely hemangioma demonstrating endothelial hyperplasia & malformation lesions with normal endothelial turnover. they proposed biological classication for vascular ano malies: biological classification of vascular in infants and children (1982): using this classication 90% of vascular anomalies could be correctly diagnosed by history & physical examination. this classication was accepted by international society for the study of vascular anomalies (issva) in 1996. classication of vascular anomalies continues to expand and has become more precise as knowledge of these lesion evolves. in present study we followed biological classication of issva classification of hemangioma: there are two recognized subsets of hemangioma that demonstrate pattern of histological and biological behavior. 1. infantile hemangoima (typical): benign tumor composed of endothelial cells, follow a predictable clinical course of proliferation in infancy followed by involution, usually with in rst 5 to7 years of life 2. congenital hemangioma: they develop during prenatal life and present fully developed at birth. a) rapidly involuting congenital hemangioma (involute rapidly during rst few week or month of life) b) non involuting congenital hemangioma (persists in to late childhood) infantile hemangioma (typical) clinical features: 1. most common benign tumor of infancy 2. affect caucasian infants (4% to5%)more than dark skinned 3. 23% of infants less than 1200gm developed infantile hema study of incidence and presentation of hemangioma in bundelkhand region original research paper dr. sudhir kumar professor plastic surgery, m.l.b. medical college, jhansi general surgery background and objective: there are variety of vascular lesions which are mostly present in childhood. due to different etiologies and management these are divided in to two groups (a/c to biolo gical classication) tumor or swelling –include infantile hemangioma, congenital hemangioma, kaposiform endothelioma, pyogenic granuloma and malformation –include arterial venous lymphatic..among these lesion infantile hemangioma (typical) is most common tumor of infancy. this study was taken up to estimate the incidence and presentation of hemangioma (typical) in children of bundelkhand region. material and method: our study include 1066 children of age group up to 5 yrs..each and every child was examined in detail and record were measured meticulously. result and conclusion: actual incidence is not known. overall reported incidence is 4-5%.in our study incidence is 3.1%,presented more in male, associated with prematurity, mostly present as single lesion & distributed more on head (60%),neck(25%) than trunk & extremity(15%) abstract keywords : infantile hemangioma, congenital hemangioma, kaposiform endothelioma. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. kirti katiyar* junior resident, department of surgery, m.l.b. medical college, jhansi *corresponding author dr. ashok kumar junior resident, department of surgery, m.l.b. medical college, jhansi hemangiomas malformations proliferating phase capillary involuting phase venous arterial lymphatic fistulae 32 x gjra global journal for research analysis ngioma 4. female infants are more frequently affected ,male to female ratio ranges from 1:3 to 1:5 in different studies 5. head and neck is most common site (80%) followed by trunk (25%) and extremity (15%) 6. in 80%cases there is single lesion median age of presentation2 weeks biological behaviour of hemangioma (typical) hemangiomas are endothelial tumor with a unique biologic behavior ÿ grow rapidly ÿ regress slowly ÿ never recur stages in life cycle of hemangioma: 1. proliferating phase (0-1 yr of age) : hemangioma is composed of plump,rapidly dividing endothelial cells that form tightly packed sinusoidal channels. 2. involuting phase(1-5 yr of age) : there is decreasing endothelial proliferation ,increasing apoptosis,and beginning of brofatty replacement of hemangioma 3. involuted phase(>5 yrs of age): after complete regression,all that remains are few tiny capillary like feeding vessel and draining veins.the endothelium lining of these vessels is at and mature. pathogenesis of hemangioma still remains a mystery different hypothesis 1. human papilloma virus -8 infection 2. abnormal hormonal inuence 3. chorionic villous sampling 4. local hypoxia bischoff and co-workers reported that hemangioma endo thelial cell (hemecs) and hemangioma endothelial proginator cells, both present in hemangiomas, are immature and share features with cord blood ecs hemecs express genes that are expressed by placenta ,umbilical cord and bone marrow stem cells. one of them,the glucose transporter protein glut-1,has become a marker for histopathological diagnosis of hemangioma. clinical considerations: infantile hemangiomas may be subdivided in accordance to the depth of soft tissue involvement ; supercial ,deep, and mixed. additionally they may be divided by whether they are spatially conned (localised),or cover a territory (segmental). segmental infantile hemangiomas are more often associated with the so-called phaces and lumbar syndromes. complications of hemangioma: 1. in proliferative phase a. ulceration b. bleeding c. congestive heart failure d. skeletal distortion e. hypothyroidism 2. in involution phase a. stigma –in form of skin atrophy b. wrinkling c. pallor d. talengiecatic vessels 3. diagnosis a. most cases donot require imaging. if clinical features are atypical or the anatomic extent of lesion not apparent than usg and mri can be used. aims and objectives ÿ to nd out incidence of hemangioma in bundelkhand region. ÿ to nd out sex ratio among children of bundelkhand region. ÿ to nd out incidence of hemangioma at the time of birth and after birth ÿ to nd out whether prematurity associated with hemangioma ÿ to nd out incidence of multiple or single lesion and their distribution according site material and method our study include children of age group from 0 up to 5 yrs., who visited vaccination counter of mlb medical college hospital stbetween 1 january 2012 to 30th october 2013. 1066 children in that age group visited vaccination counter. each and every child was examined for hemangioma. children with hemangioma was examined in detail and their record were measured meticulously. these children managed accordingly for the hemangioma. in 1066 children screened by us, hemangiomas were detected in 34 children. in our study we managed these children by these four modalities wait & watch, oral steroids, intralesional steroids and surgical treatment. most of patients kept under close observation, and regular 2 months follow up. at every visit lesion examined for increase or decrease in size by measurement and for any complication. every patient advised for compulsory ultrasonography (usg) to nd out any association with visceral hemangiomatosis and advised for proper care of lesion to prevent bleeding & ulceration. result: our study include children of age group from 0 up to 5 yrs. who visited vaccination counter of m.l.b. medical college hospital st th between 1 january 2012 to 30 october 2013. table 1: incidence of hemangioma (in our study) table 2: incidence of hemangioma in female in our study) table 3: incidence of hemangioma in male (in our study) volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra incidence number of patients percentage (%) patients without hemangioma 1032 96.9% patients with hemangioma 34 3.1% total 1066 100% heamagioma in female number of patients percentage (%) total female without hemangioma 440 94.8% total female with hemangioma 24 5.2% total 464 100% hemangioma in male number of patients percentage (%) tatal male without hemangioma 592 98.33% tatal male with hemangioma 10 1.67% total 602 100% x 33gjra global journal for research analysis table 4: distribution of patients according to sex table 5: distribution of cases with respect to age group (age at the time of entry into the study) table 6: distribution of cases according to time of pre sentation table 7: distribution of case according to pre-maturity table 8: distribution of case according to number of lesions. table 9: distribution of case according to site of lesions discussion incidence in our study group 1066 children from vaccination counter of pediatric department, we found hemangioma in 34 children. so incidence in our study group is 3.1%. actual incidence of hemangioma is not known. according to holmdam; (1955), jacobs (1957) it is approx 10%-12% in children at age of 1 yrs and according to pratt (1969), jacobs & walton(1976), approx 1:1 to 2.6% in rst few days of life. they reported overall incidence is 4% to 5% (approximately). our gure is different from these studies. possible reason for this may be erroneous nomenclature followed in past. we have followed the biological classication for diagnosis. other reasons can be our small samples size. sex ratio: female predominance was also reported by bones, graham tonilnson (1950) and conrmed by finn, glowacki & mulliken (1983). in their studies they reported females to male ratio of 3 to 5:1. our female to male ratio is less than these authors. reason may be that girls are paid less attention in bundelkhand region. illiteracy, poverty, and females feticide may be other reasons. previously in early studies, according to greenhouse 1955 hoimdat! 1955. preterm infants showed equal frequency compared with full term infants. but in newer studies hemangioma more common in preterm as frequently as 22.9%.in our study 14.7% associated with prematurity (5 of 34 patient associated with prematurity). approximately 80% hemangioma present as single lesion. in our study 94.11% (32 out of 34 patients) hemangioma present as single lesion. according to distribution hemangioma involve 60% head & neck, 29% trunk & 15% extremity. in our study hemangioma involve 50% head & neck, 35.2% trunk, 26.4% extremity. according to malgileth & mureles 1965 less than 5% hemangioma ulcerate. in our study 3 patients out of 34 ulcerate — 8.8%. according to study 2.3% patients as with other congenital anomalies but according in our study none of patients associate with any congenital anomalies & not associates with visceral hemangioma. so in our study 24 out of 34 patients kept under observation & their natural history followed, most of them follow natural history according to lister but clear conrmation could not be given in short period of follow up of patients. conclusion 1. in total study sample size of 1066 having 602 (56.66%) males and 464 (43.5%) females. in our study m:f = 1.3:1 2. in total 1066 children in our study, presenting with hemangioma only in 34 children. 3. incidence of hemangioma according to our study population of bundelkhand region is 3.1% 4. in our study hemangioma in more common in female out of 34 children with hemangioma 24 (70.6%) are females and 10 (29.4%) are males. female to male ratio is 2.4:1. 5. majority of cases 23 (67.6%) were of less than 1 yr of age (at the time of entry into study) 6. hemangiomatous lesion were present at the time of birth in 3 (8.8%) cases. 7. hemangiomatous lesion were appeared after birth in 31 (79.5%) cases. 8. prematurity associated with 5 (14.7%) cases. 9. among pre-mature babies 3 were female (8.82%) and 2 were males (5.88%) 10. among 34 patients, single lesion was present in 32 patients (94.11%) & multiple in 2 patients (5.88%), so hemangioma present mostly as single lesion. 11. among lesion (42), distribution according to site 21 in ( 50%) in head & most, 12 in (35.2) in trunk, 9 in (26.4) in extremities 12. among total 42 lesion 5 lesions complicate(11.9%) 13. among our study group no patient had associated any congenital anomaly 14. in our study group no patient had visceral hemang io matosis 15. among study group no associated with any syndrome references 1. mulliken jb, glowacki j. hemangiomas and vascular malformations in infsnta) and children a_ classication based on endothelial characteristics. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra sex number of patients percentage (%) male 10 29.4% female 24 70.6% total 34 100% age grope number of patients percentage (%) <1yr 23 67.6% 1-5 yr 11 32.4% total 34 100% time of presentation number of patients percentage (%) lesions present at birth 3 8.8% lesions appear after birth 31 79.4% total 34 100% pew-maturity number of patients percentage (%) h/o prematurity present 5 14.71% no h/o prematurity 29 70.5% total 34 100% number of lesions number of patients percentage (%) single lesion 32 94.117% multiple lesion 2 5.88% total 34 site of lesions number of patients percentage (%) lesion on head & neck 21 50% lesion on trunk 12 35.2% lesion on extremities 9 26.4% total 42 100 34 x gjra global journal for research analysis plant reconsts surg. 1982: 69:412-33. 2. firn m.c., giowacki j, mulliken jb. congenital vascular lesions: clinical application of a new classication. j pediatr surg. 1983: 18: 894-900. 3. bouillard p. vikkuia m. vascular malformation: localized defects in vascular morphogenesis. clin genet. 2003. 63: 340. 4. loela m. bry m. tammela t. et al., vegfs and receptors involved in | angiogenesis versus lymphangiogenesis. curr opin cell biol. 2009: 21-154. 5. brouillard p. vikkula m. genetic causes of vascular malformation hum mol genet. 2007. 16 (spec no. 2) r140. 6. holmes lb. chorionic villus sampling and hemangiomas. j. craniofac surg 2009; 1 (20 suppl): 675. 7. pocock b. boon lm, vikkula m. molecular basis of vascular birthmarks. sem plant surg 2006:20:149. 8. paltiel hj. burrows pe. kozakewich hp et al., softtissue vascular anomalies utility of us for diagnosis. radiology. 2002: 214(3): 747-54. 9. meyer js, hoffer fa. barnes pd. et al., biological classication ajr am j. roentgenol 1991; 157 (3); 559-64. 10. moukaddam h. pollar k. haims ah. mri characteristics and classication of peripheral vascular malformation and tumors. skeletal radiol. 2009:38(6): 535-47. 11. gorincour g, kokta v. rypens. f. et al., imaging characteristics of to subtypes of congenital hemoangiomas rapidly involuting congenital hemangiomas and non-involuting congenital hemangiomas. pediatrradiol. 2005;35 (12) 1178-85. 12. dubois j. alison m. vascular anomalies; what a radiologist needs to know. pediatr radiol. 2010: 40(6). 895-905. 13. chen y.j. wang ck. tien yc. et al., mri of multifocal kaposiform haemangioendothelioma without kasabach-merritt phenomenon br j. radioll 2009: 82(975): e51-4. 14. tamai n, hashii y, osuga k et al, kasposiform hemangioendothelioma arising in the deltoid muscle without the kasabach-merritt phenomenon. skeletal radiolol 2010, 39(10): 1043-6. 15. north pe, waner m. mizeracki a, et al., glut1: a newly discovered immunohistochemical marker for juvenile hemangiomas. hum pathol 2000;3: 11-22. 16. north pe, waner m. james ca. et al., congenital non-progressive entity unlike infantile hemangioma. arch dermatol. 2001, 137; 1607-20. 17. enjolras o, mulliken jb, boon lm. et al., noninvoluting congenital hemangioma; a rare cutaneous vascular anomaly. plat reconstr surg. 2001; 107: 1647-54. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 35gjra global journal for research analysis 26.maninder pal singh pardal.cdr introduction in september 2019 , the workers came across a large number of fever cases in a mid sized city of india. detailed epidemiological investigations revealed that there was an outbreak of 28 cases of enteric fever and 17 cases of dengue fever. in this paper, we describe ve cases in these two outbreaks who had dengue fever and enteric fever coinfection. material and methods the study design used was a cross sectional descriptive study. period of the study was sep 2019 in a mid sized city of india. detailed information pertaining to date of onset of symptoms, date of admission, movement history during the known incubation period, history of having worked as food handler in the cook house, personal hygiene and other relevant data was obtained from each case. besides, active case nding by way surveys during the period of the outbreak was also carried out. the study team reviewed thoroughly all the cases which occurred during the period of study. a detailed clinical and epidemiological history was elicited. case denition used for conrmed case of enteric fever by the workers has already 1been validated by pardal mps et al. case denition for conrmed case of dengue fever has also been validated by 2kunwar r et al. results all the ve cases which occurred during the period of study were conrmed by blood culture for salmonella typhi and ns1 antigen for dengue fever. all the cases had clinical features of enteric fever viz, moderate to high grade fever, relative bradycardia, pain abdomen, loose motions, headache and cough. however, rose spots were observed only in 2 (40%) cases. all the cases also displayed clinical features of dengue fever, viz muscle and joint pain; and 3 (60%) of them had vomiting in addition to the above features of enteric fever. there was no leucopenia or relative lymphocytosis in any case. the organism was conrmed on blood culture as s enterica serovar typhi (s typhi) in all the ve cases. the antibiotic sensitivity test revealed resistance against ampicillin, chloramphenicol, and cotrimoxazole. the patients did not show good clinical response to ciprooxacin, while the best clinical response was obtained with ceftazidime. there were no complications or fatalities in any of these cases. discussion enteric fever and dengue fever have been major cause of morbidity and mortality all over the world. is a major cause of 3,4,5,6morbidity and mortality in tropical areas worldwide. sudjana p et al reported a case of dengue and typhoid fever 7co-infection in an adult in indonesia. bansal r et al reported 8two cases of dengue fever and typhoid co-infection in 2015. sharma y et al reported eleven cases of typhoid co-infection out of 141 cases of dengue, giving a coinfection rate of 7.8% in 9north delhi. srinivasaraghavan r et al reported a case of culture positive salmonella typhi in a ten year old child with 10dengue fever. in our study we have reported ve cases of culture positive salmonella typhi out of seventeen cases of dengue fever, thereby giving a co-infection rate of 29.41% 9which is much higher than that carried out by sharma y et al. besides, this is one of the rare instances wherein, ve cases of dengue and typhoid fever are being reported, as against other 7,8,10workers who have reported one or two such cases. recommendations in day to day clinical practice, while dealing with cases of dengue either typical or atypical, co-infection with enteric fever should always be kept in mind. besides improvement of sanitation and personal hygiene, emphasis should be given on vaccination against typhoid. in order to reduce the burden of dengue fever, all strictest possible preventive measures to control the breeding of aedes mosquito must be implemented. conclusion: the workers wish to emphasize that the risk factors predicting the presence of such co-infections, if identied, will certainly go a long way in controlling the incidence of dengue and typhoid co-infection. conflicts of interest none identied references 1. pardal mps, minhas s. outbreak of enteric fever: a fact nding mission. int j community med public health 2020;7:998-1002 2. kunwar r, prakash r. dengue outbreak in a large military station : have we learnt any lesson? medical journal armed forces india 2015 (71),11-14. 3. divyashree s, nabarro le, veeraraghavan b, rupali p. enteric fever in india: current scenario and future directions. trop med int health. 2016 oct;21(10):1255-1262. doi: 10.1111/tmi.12762. epub 2016 sep 8. 4. vanderslott s, phillips mt, pitzer ve, kirchhelle c. water and filth: reevaluating the first era of sanitary typhoid intervention (1840-1940). clin infect dis. 2019 oct 15;69(supplement_5):s377-s384. doi: 10.1093/cid/ciz610. 5. mustafa ms, rastogi v, jain s, gupta v. discovery of fth serotype of dengue virus (denv-5): a new public health dilemma in dengue control. medical jou dengue and enteric fever co-infection : a known entity? original research paper dr pmp singh dadh, hq 41 artillery division, c/0 56 apo x 15gjra global journal for research analysis community medicine introduction : in this paper, we describe ve cases of dengue fever and enteric fever co-infection. material and methods : the study design used was a cross sectional descriptive study. results : all the ve cases which occurred during the period of study were conrmed by blood culture for salmonella typhi and ns1 antigen for dengue fever. there were no complications or fatalities. discussion : co-infection with dengue and enteric fever has been reported by several workers in india as well as abroad. in our study we have reported ve cases of culture positive salmonella typhi out of eleven cases of dengue fever. recommendations : while dealing with cases of dengue, co-infection with enteric fever should always be kept in mind. conclusion: the workers emphasize that the risk factors predicting the presence of such co-infections, if identied, will certainly go a long way in controlling the incidence of dengue and typhoid co-infection. abstract keywords : volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr sukhmeet minhas* ofcer commanding, station health organisation, kirkee *corresponding author 16 x gjra global journal for research analysis rnal armed forces india 2015 (71),67-70. 6. chumpu r, khamsemanan n, nattee c. the association between dengue incidences and provincial-level weather variables in thailand from 2001 to 2014. plos one. 2019 dec 26;14(12):e0226945. doi: 10.1371/journa l.pon e.02 26945. ecollection 2019. 7. sudjana p, jusuf h. concurrent dengue hemorrhagic fever and typhoid fever infection in adult: case report. southeast asian j trop med public health. 1998 jun;29(2):370-2. 8. bansal r, bansal p, tomar lr. typhoid and dengue coinfection: case reports. trop doct. 2015 jan;45(1):52-3. doi: 10.1177/0049475514552835. epub 2014 oct 14. 9. sharma y, arya v, jain s, kumar m, deka l, mathur a. dengue and typhoid coinfectionstudy from a government hospital in north delhi. j clin diagn res. 2014 dec;8(12):dc09-11. doi: 10.7860/jcdr/2014/9936.5270. epub 2014 dec 5. 10. srinivasaraghavan r, narayanan p, kanimozhi t. culture proven salmonella typhi co-infection in a child with dengue fever: a case report. j infect dev ctries. 2015 sep 27;9(9):1033-5. doi: 10.3855/jidc.5230. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction the total burden of cancer across the globe is estimated to be 1 around 22 million. cancer has become one of the ten leading causes of death in india. cancers especially those of oral cavity and lungs among men and cervix and breast among 2women account for over 50% of all cancer deaths in india. radiotherapy either by itself or in combination with surgery or chemotherapy plays an essential role in the treatment of head 3and neck cancer. the common side effects of head and neck radiation therapy include skin reactions, fatigue, nutritional 4 effects and alterations in mouth and pharynx. it is estimated that oral mucositis affects 40% of the patients undergoing chemotherapy, 75% of the patients undergoing high dose chemotherapy and bone marrow transplantation and more than 90% of the patients undergoing radiotherapy for head 5and neck cancer. honey is a source of carbohydrates, containing 80% natural sugar mostly fructose and glucose, 18% water, 2% minerals, vitamins, and protein. laboratory studies and clinical trials have shown that honey is an effective broad spectrum antibacterial agent. the data shows that the wound healing properties of honey include stimulation of tissue growth, enhanced epithelialisation, and minimized scar formation. these effects are ascribed to honey's acidity, hydrogen peroxide content, osmotic effect, nutritional and antioxidant contents, stimulation of immunity, and to unidentied compounds. prostaglandins and nitric oxide play a major role in inammation, microbial killing, and the healing process. honey was found to lower prostaglandin levels and elevate nitric oxide end products. these properties help to explain some biological and therapeutic properties of honey, 6particularly as an antibacterial agent or wound healer. the investigator after reviewing related literatures came to know that the interventions like regular oral cavity assessment, proper oral care and application of honey have good effect in reducing oral complications among head and neck cancer patients undergoing radiation methodology a true experimental pre test post test control group design with quantitative research approach was used for this study. the study was conducted in radiotherapy department at govt. medical college hospital, kottayam. population of the study consisted of patients with head and neck malignancies, undergoing radiation therapy. sample include sixty patients undergoing radiation therapy for head and neck malignancies at govt. medical college hospital, kottayam; thirty in experimental group and thirty in control group. the tools used to collect the data were socio personal data sheet, clinical data sheet and oral assessment tool. the data collection process extended over a period of 8 weeks. samples were selected from their rst day of radiation therapy using simple random sampling technique. after obtaining informed consent from the patients, socio personal data and clinical data were collected. assessment of oral cavity is done by using oral assessment tool. subjects in the experimental group received one to one teaching program of 15 minutes duration and are provided the information booklet describing self care practices to be followed by the patients including daily oral examination, dental care, mouth washing, lip care, hydration and diet. patients in the experimental group received oral application of 10 ml of ag mark honey before and after 15 minutes of radiation therapy and 6 hours thereafter in every days of radiation therapy, and instructed them to rinse the honey in the mouth, swish it around for one minute duration, and slowly swallow. post test was performed at the end of rst, second and third week of radiation therapy (day 5, day 10 and day 15 respectively). results socio personal and clinical data of patients undergoing radiation therapy for head and neck malignancies ÿ among the 60 samples 46.7% of patients in the control group and 50% of patients in the experimental group were belonged to the age group of 6175 years. ÿ majority of the patients in the control (73.3%) and experimental group (83.3%) were males. ÿ while considering the education 46.7% of patients in the control group and 70% of patients in the experimental group had secondary education. ÿ with regards to occupation 53.3% of the patients in the control group and 46.7% of patients in the experimental group were daily wages. ÿ among the 60 samples 36.7% of the patients in the control group and 53.3% of patients in the experimental group had history of both smoking and alcoholism. ÿ majority of the patients in the control group (96.7%) and the experimental group (96.7%) were taking non vegetarian diet. ÿ majority of the patients in the control group (53.3%) and the experimental group (70%) had no family history of cancer. effectiveness of an intervention package on reduction of oral complications among patients undergoing radiation therapy for head and neck malignancies original research paper melvi k benny lecturer, little lourdes college of nursing, kidangoor. x 41gjra global journal for research analysis nursing the present study investigated the effectiveness of an intervention package on reduction of oral complications among patients undergoing radiation therapy for head and neck malignancies. a true experimental pre test post test control group design with quantitative research approach was used for this study. the objectives of the study were to assess the levels of oral complications, determine the effectiveness of an intervention package on reduction of oral complications. a total of 60 patients undergoing radiation therapy for head and neck malignancies at govt. medical college hospital, kottayam, were assigned to control (n=30) and experimental (n=30) group using simple random sampling technique. socio personal data sheet, clinical data sheet and oral assessment tool were used for collecting data. the data was analyzed using descriptive and inferential statistics. the result of analysis revealed that the intervention package was effective in reducing oral complications (p<0.001) among patients undergoing radiation therapy for head and neck malignancies. abstract keywords : head and neck malignancies; radiation therapy; oral complications; intervention package; information booklet. sr. rose abraham* associate professor, government college of nursing kottayam. *corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 42 x gjra global journal for research analysis ÿ among the group majority of the patients in the control group (53.3%) and 43.3% of patients in the experimental group had malignancy in the oral cavity. ÿ majority of patients in the control group (56.8%) and the experimental group (46.7%) received a dose per fraction of 176-200 cgy. ÿ majority of patients in the control group (70%) and experimental group (73.3%) had normal weight (bmi 18.5 24.9). chi square value shows that there was no statistically signicant difference between control and experimental group in terms of age, gender, education, occupation, adverse health habits, diet and family history of cancer, site of malignancy, dose per fraction of radiation and bmi and hence groups were homogenous in nature. oral complication of patients undergoing radiation therapy for head and neck malignancies table 1: frequency distribution and percentage of levels of oral complications in patients undergoing radiation therapy for head and neck malignancies based on rst, second and third post test score (n = 60) from the table, it is evident that after completion of one week radiation therapy (on d5), 100% of patients in control group and 66.7% of patients in the experimental group developed mild oral complication. remaining 33.3% of patients in experimental group had no oral complications. after completion of second week radiation therapy (on d10), 66.7% of patients in the control group had mild oral complications and 33.3% of patients developed moderate oral complication but in experimental group 100% of patients developed only mild oral complications. after completion of third week radiation therapy (on d15), 100% of patients in control group and 30% of patients in the experimental group developed moderate oral complications and remaining 70% of patients in experimental group had only mild oral complications. effectiveness of intervention package on oral complications among patients undergoing radiation therapy for head and neck malignancies table 2: mean and standard deviation of pre test and post test oral complications scores of patients undergoing radiation therapy for head and neck malignancie (n =60) table 2 shows that mean pre intervention oral complications assessment score of patients undergoing radiation therapy for head and neck malignancies were 7.2 for control group and 7.13 for experimental group. the mean rst post test oral complication assessment score in the control group was 9.1 and in the experimental group were 7.9. the mean second post test oral complication assessment score in the control group were 13.63 and in the experimental group were 10.3. the mean third post test oral complication assessment score in the control group were 17.53 and in the experimental group were 13.9. table 3: summary of ancova of oral complications in patients undergoing radiation therapy for head and neck malignancies in the control and experimental group (n=60) ***signicant at 0.001 level. table 3 shows that f value of ancova is signicant at 0.001 levels in post test 1, post test 2 and post test 3. hence the null hypothesis is rejected and it is inferred that there is a signicant difference in the post assessment scores of oral complications among patients undergoing radiation therapy for head and neck malignancies in control and experimental group in post test 1, post test 2 and post test 3. discussion the study nding revealed that there was a signicant difference in the post assessment scores of oral complications among patients undergoing radiation therapy for head and neck malignancies in the control and experimental group in post test 1, post test 2 and post test 3. it can be concluded that the intervention package was effective in reducing severity of radiation induced oral complications in patients undergoing radiation therapy for head and neck malignancies. the result of the present study also comparable to a study done on topical application of honey in the management of radiation mucositis in malaysia. fourty patients diagnosed with head and neck cancer undergoing radiation therapy were selected. honey application was given to the experimental group and no interventions were given to the control group. the study result showed that topical application of honey was effective in reducing severity of 7radiation induced oral mucositis (p<0.001). conclusion adequate knowledge regarding self care practices to be followed by the patients including daily oral examination, dental care, mouth washing, lip care, hydration, diet and application of honey helps to reduce the oral complications. thus the morbidity and mortality due to oral complications can be reduced in patients receiving radiation therapy for head and neck malignancies. references 1. who. world cancer report 2014 [internet].2015 feb [cited 2015 feb 15]. available from: http://www.who.int/mediacentre/factsheets/fs297/en/cancer 2. mishra a, meherotra r. head and neck cancer: global burden and regional trends in india. asian pacic journal of cancer prevention [internet]. 2014 [cited 2014 dec 15];15 (2): 537-50. available from: http://dx.doi.org/10.7314/ apjcp.2014.15.2.537 3. yeh s. radiotherapy for head and neck cancer. semin plast surg [internet]. 2010 may [cited 2015 sep19]; 24(2):127–36. available from:http:// www. ncbi.nlm.nih.gov/pmc/articles/pmc3324252/ 4. bowman vb. head and neck cancers. in: langhorne me, fulton js, otto sc, editors. oncology nursing. us: mosby elsvier; 2007. p. 213-31. 5. herrstedt j. prevention and management of mucositis in patients with cancer. int j antimicrob agents [internet]. 2000 [cited 2015 nov 2];16(2):161-3. available from: http://www.ncbi.nlm.nih.gov/ pubmed/ 11053801? dopt=abstract 6. al-waili n, salom k, al-ghamdi aa. honey for wound healing, ulcers, and volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra levels of oral complicati ons post test 1 (day5) post test (day10) post test 3 (day15) control n=30 experi mental n=30 control n=30 experi mental n=30 control n=30 e x p e r i mental n=30 f % f % f % f % f % f % normal (17) 0 0 10 33.3 0 0 0 0 0 0 0 0 mild (8-14) 30 100 20 66.7 20 66.7 30 100 0 0 21 70 moderate (15-21) 0 0 0 0 10 33.3 0 0 30 100 09 30 control group (n=30) experimental group (n=30) oral complications mean sd mean sd pre test 7.2 0.41 7.13 0.35 post test 1 9.1 1.52 7.9 0.92 post test 2 13.63 2.09 10.3 1.45 post test 3 17.53 2.01 13.9 1.27 group sum of squares df mean square f post test 1 22.36 1 22.36 14.14*** post test 2 170.98 1 170.98 56.45*** post test 3 205.07 1 205.07 76.63*** burns; data supporting its use in clinical practice. scienticworldjournal [internet]. 2011 apr [cited 2015 sep 21]; 11:766-87. available from: http://www.ncbi.nlm.nih.gov/pubmed/21479349 7. biswal bm, zakaria a, ahmad nm. topical application of honey in the management of radiation mucositis: a preliminary study. supportive care in cancer [internet]. 2003 feb [cited 2015 apr 18]; 11(4):242-248. available from: link.springer.com/article/ 10.1007/500520-003-0443-y. x 43gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: today modern hospitals which possess the super specialization medical and surgical facilities largely rely and take support of biomedical equipment to provide evidencebased treatment and care to their patients, right from the diagnosis stage of the patient condition, the selection of best available plan of care for their treatment to improve their health condition, bring them back to normal from their suffering and to enhance their quality of life. medical gadgets or biomedical equipment took a vital role in health care; they started to play a major role in the practice of medicine in recent times. by understanding the importance for management and maintenance of the biomedical equipment in delivery of care to the patients at the public healthcare institutions, the ministry of health and family welfare, government of india has launched the program for their upkeep and minimization of downtime and has provided the standard guidelines named as biomedical equipment management and maintenance program (bmmp) in the year 2015. this program is presently being successfully implemented in 28 states/ union territories of india to reduce healthcare delivery cost through an understanding with private partner expert in this domain and by entrusting the asset management and systematic upkeep of the biomedical equipment inventory presently available in the public healthcare institutions across [1]the state through a single vendor contracting system . national health systems resource centre (nhsrc) was established in the year 2006 with a clear objective to assist the state governments for the development of the standard policy and strategy through the provision of support by mobilization [2]of technical assistance and capacity building . their aim for this program is to prepare a master database of all the biomedical equipment available in the public healthcare institutions, to tag each one of the equipment with the unique identication number for smart tracking. comprehensive equipment history and their operational performance both in terms of downtime and maintenance cost can be monitored through real-time by using a software module which is developed for monitoring the entire biomedical equipment at state government hospitals, through the smart governance system. a centralized call center is established at the state headquarters to receive equipment related complaints from across the spectrum of healthcare institutions and log their complaint in the central server, which prompts the service engineer stationed at the eld level to attend the call and x the problem at the earliest. the core objective of this program is to increase the efciency of available equipment by reducing their downtime and to ensure optimal operational efciency for the care of the patients visiting these facilities. reliability about the information provided by these biomedical equipment attached to the patient can be assured by embracing a biomedical equipment management and maintenance, a process evaluation at a government hospital – telangana, india original research paper y v s ramana general manager, department of hospital administration, gandhi hospital, secunderabad, telangana, india x 37gjra global journal for research analysis hospital administration modern hospitals with a super-specialty level of care facilities rely largely on medical gadgets, the biomedical equipment to offer precision care to their patients both for medical and surgical treatment options. this highly specialized equipment requires proper maintenance and care in terms of calibration to provide accurate information about the patient vital signs that are crucial for their diagnosis and line of care. it becomes necessary for a systematic procedure for their management and maintenance – here comes the importance of biomedical equipment management and maintenance program devised by government of india to enhance the public healthcare facilities through proper preventive and breakdown maintenance of their biomedical equipment, thereby to enable doctors to get reliable information for their patient care. the present study aims at the evaluation of this prime program implementation results from the end-users of a tertiary care teaching healthcare facility in telangana state. end users expressed their opinion that 16.6% felt the services are excellent after the introduction of bmmp services, 33.7% said good after (22.0% before), 9.6% said satisfied after (18.9% before), 3.1% said poor after (7.9% before) the introduction of biomedical equipment management and maintenance program bmmp services.this is our original work, done by us and is not presented or published previously. we have no conict of interest 1. general manager, department of hospital administration, gandhi hospital, secunderabad, telangana, india 2. assistant manager biomedical engineer, department of hospital administration, gandhi hospital, secunderabad 3. professor and head, department of hospital administration, gandhi medical college &hospital, secunderabadend users opined that 30% of equipment was being repaired in≤1 month, 70% of the equipment take about ≤ 1 month for the repair of biomedical equipment before bmmp. they opined that 40% of equipment is being repaired ≥ 15 days, 30% of the equipment is repaired ≤ 15 days, about 20% of biomedical equipment is repaired within weekdays and about 10% of biomedical equipment is repaired within one day after the introduction of the bmmp program. these values are indicative and for study purpose only, there are instances of equipment being in the state of breakdown beyond one month also – which were with the instance of annual maintenance contract / comprehensive maintenance contract termination and no clear instructions were available with bmmp contractor for their renewal and maintenance of continual contracts and upkeep of these machines, which were otherwise looked after by original equipment manufacturers oems through memorandum of understanding with the hospital. abstract keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra jyothi guduri* assistant manager biomedical engineer, department of hospital administration, gandhi hospital, secunderabad *corresponding author k t reddy professor and head, department of hospital administration, gandhi medical college &hospital, secunderabad 38 x gjra global journal for research analysis scientic management system of preventive maintenance and calibration for precession accuracy of diagnostic information, [3]which presently needs to be improved at these facilitates . context and aim: healthcare in india is provided by hospitals managed by government sector and private players, the majority of rural healthcare facilities are in the control of state government and majorities of private hospitals are concentrated in the urban conglomerate. the estimated bed distribution for pan [4]india hospitals is shown in the table below . telangana is the 11th largest state in terms of land area and 12th largely populated state situated in the south-central region of the country. hyderabad is the capital city of telangana state; it is 4th largest metropolis in the country in terms of population density. 19% of the state population lives in hyderabad making it one of the prime destinations of the country. hyderabad is a cosmopolitan city with a representation of people from pan india and students from pan asia who study at the universities situated here. healthcare in hyderabad is at the tertiary level in government institutions comprising of postgraduate level teaching medical college hospitals and quaternary at the corporate hospitals which offer the care of treatment comparable at par with the developed nations. biomedical equipment ranging from the simple vital sign monitoring to the sophisticated organ functioning systems to enable organ transplantations are available in the healthcare industry and are now used for swift diagnosis, impeccable surgery, and therapeutics, etc. the use of a malfunctioning biomedical equipment may result in faulty diagnosis and wrong treatment and can lead to damaging or even devastating aftermath. there is a need for an enduring mechanism that can maintain and repair the biomedical equipment routinely before use and this can be done only with the help of qualied biomedical engineers. thus there is a sincere need for a well-organized cadre of biomedical engineers with specialization in medical instrumentation. the organized system of bmmp should be made responsible for the maintenance and proper functioning of biomedical equipment at the public healthcare provider institutions which are effortlessly striving for the healthcare services of the bpl populations relying on these facilities for their healthcare needs. the bmmp program is aimed at the development of the system to: ÿ design and development of a comprehensive computerized database for biomedical equipment at public healthcare institutions ÿ professional monitoring by the biomedical engineers ÿ online ui tag and maintenance module ÿ farsighted managerial skill to maximize accuracy, functioning, and cost-effectiveness for maintenance and [5]management . end user perception: following table shows the information received from the enduser of biomedical equipment at the tertiary care level government teaching medical college hospital at telangana, hyderabad with their level of satisfaction before and after the implementation of bmmp program using a likert scale 1 being not satised and 10 being highly satised for a range of operational and maintenance issues. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra sr. no hospitals type bed count (in million) bed count percentage 1 government 8.6 59.7 2 private 5.8 40.3 3 total 14.4 100.0 end user perception before and after bmmp program figures in percentage value sr. no work request remark 10 point likert scale (1 not satised 10 highly satised) 1 2 3 4 5 6 7 8 9 10 1 response to breakdown call before 6.12 24.49 40.82 12.24 16.33 after 36.36 40.91 22.73 2 upkeep in desired time before 10.71 7.14 8.93 32.14 12.50 28.57 after 5.26 6.58 7.89 21.05 59.21 3 arrangement of spareparts before 4.23 7.04 8.45 19.72 22.54 38.03 after 3.13 6.25 7.81 18.75 21.88 12.50 14.06 15.63 4 professional knowledge before 10.71 14.29 17.86 12.50 28.57 16.07 after 36.78 51.72 11.49 5 quality of work before 15.63 37.50 21.88 25.00 after 6.33 17.72 30.38 45.57 6 downtime before ≥ 1 month 70.00 ≥ 15 days 30.00 7 days 1 day after ≥ 1 month 30.00 ≥ 15 days 40.00 7 days 20.00 1 day 10.00 findings: biomedical equipment management and maintenance program biomedical equipment management and maintenance program biomedical equipment maintenance program at the public health institutions is evaluated using a structured questionnaire to collect the information about the response to breakdown calls, upkeep of machine under breakdown within the desired period, time taken by service agent for arrangement of required spare parts in the biomedical equipment, professional knowledge and inspection by the service agent to nd out the root cause for the repair, quality practice by the service agent, overall downtime of biomedical equipment, using a standard tool with 10 pints likert scale – 1 is not satised and 10 is highly satised from the end-users both after implementation of bmmp program and the practice followed before bmmp program. it is learned from the study that the end-users at the public healthcare institution expressed their opinion that 16.6% felt the services are excellent after the introduction of bmmp services, 33.7% felt the services are good after the introduction of bmmp services, 22.0% felt the services were good before the introduction of bmmp services, 9.6% felt the services are satisfied after the introduction of bmmp services, 18.9% felt the services were satisfied before the introduction of bmmp services, 3.1% felt the services are poor after the introduction of bmmp services, 7.9% felt the services were poor before the introduction of bmmp services. x 39gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra end users opined that 30% of equipment was being repaired less than or equal to one month after the introduction of the bmmp program whereas there were 70% of the equipment that use to take about less than or one month for the repair of biomedical equipment. they opined that 40% of equipment was being repaired less than or equal to 15 days after the introduction of the bmmp program whereas there were 30% of the equipment that use to take about less than or equal to 15 days for repair of biomedical equipment. about 20% of biomedical equipment is repaired within weekdays after the introduction of the bmmp program. about 10% of biomedical equipment is repaired within one day after the introduction of the bmmp program. categorical opinion for minor equipment repair, major equipment repair and equipment repair with the help of service agent from original equipment manufacturer is shown in the graph both after implementation of the bmmp program and before in the terms of end-user experience. these values are indicative and for study purpose only, there are instances of equipment being in the state of breakdown beyond one month also – which were with the instance of annual maintenance contract / comprehensive maintenance contract termination and no clear instructions were available with bmmp contractor for their renewal and maintenance of continual contracts and upkeep of these machines, which were otherwise looked after by original equipment manufacturers oems through memorandum of understanding with the hospital. references:1. biomedical equipment management and maintenance program (bmmp): technical guidance document for in-house supporting of public-private partnerships (2019), ministry of health & family welfare, government of india, new delhi. 2. national health systems resource centre – nhsrc (2019), introduction to the organization. 3. biomedical equipment management and maintenance program (2005), national health mission, ministry of health & family welfare, government of india, new delhi. 4. jitendar sharma(2019), presentation on biomedical equipment management model for india, world health organization. 5. sahay bk, saxena rk (1996 jul-1997 jan), biomedical equipment and medical services in india, administration. page: 7-9. introduction: the relief of pain during surgery is the raison d'etre of anesthesia. effective post operative analgesia reduces post operative morbidity, allows early ambulation and discharge. post operative analgesia is achieved by various techniques using various drugs among which neuraxial blockade plays an important role. the spinal cord has taken the centre stage in analgesia practice following the demonstration of analgesia with intrathecal morphine by yaksh & rudy (1977). deposition of drugs in the subarachnoid space and epidural space paved a new era for pain relief. opioids are powerful centrally acting analgesic agents, which however also have peripheral effects. morphine, butorphanol and tramadol when given epiduraly provides good post operative analgesia. aim of the study: to compare the efcacy of epidural morphine, butorphanol and tramadol for post operative analgesia for lower abdominal surgeries particularly herniorraphies, to compare the duration and quality of post operative analgesia of morphine, butorphanol and tramadol and to study the side effects associated with epidural morphine, butorphanol and tramadol. materials and methods: this study was double blind randomised controlled study carried out on 75 patients in three groups of 25 each. patients who are coming for herniorraphies were selected for the study. all the patients belonged to asa risk i and ii with age distribution between 20 to 70 are selected. patients who are opioid addict, emotionally unstable and asthmatics were excluded. after getting, informed consent the patients were randomly allocated into three groups. group 'm' was taken as morphine study group, group 'b' as butorphanol study group and group 't' as tramadol study group. patients were assessed under the 10 point visual analogue pain scale. all the patients were premeditated with inj. glycopyrollate 4 mcg/ kg intramuscularly 45 minutes prior to anaesthesia. baseline measurements of pulse rate, respiratory rate, blood pressure and spo2 were done. technique: an intravenous infusion line with dextrose normal saline was started. after strict aseptic precautions l2-l3 interspace was identied and using a 18 gauge combined spinal and epidural needle, epidural space was identied after which a long spinal needle (27g) is inserted into sub arachnoid space, about 0.5% hyperbaric bupivacaine 15mg was injected. then comparative evaluation of epidural morphine, butorphanol & tramadol for post operative pain relief in lower abdominal surgeries original research paper dr. sankaran chockalingam m.d, senior assistant professor, thirunalveli medical college and hospital, tamilnadu. anaesthesiology background: neuraxial blockade is the preferred technique over general anesthesia for most of the lower abdominal surgeries. effective post operative analgesia can be achieved by epidural anesthesia. depositing opiods in the epidural space helps in extending the postoperative analgesic duration. we want to evaluate the effectiveness of morphine, butorphanol and tramadol for the post operative period in combined spinal & epidural anesthesia. study design: this study was double blind randomised controlled study carried out on 75 patients undergoing herniorrhaphy, in three groups of 25 each . the patients were randomly allocated into three groups. group 'm' was taken as morphine study group, group 'b' as butorphanol study group and group 't' as tramadol study group. l2-l3 interspace was identied and using a 18 gauge combined spinal and epidural needle, epidural space was identied after which a long spinal needle (27g) is inserted into sub arachnoid space, about 0.5% hyperbaric bupivacaine 15mg was injected. then the epidural catheter is inserted in the usual manner and kept 3 to 4 cms into the epidural space. at the end of surgery in group 'm' (morphine group) 50 mcg / kg of morphine in 10ml saline was injected through the epidural catheter. in the group 'b' (butorphanol group) 40 mcg/ kg of butorphanol in 10 ml saline was injected through the epidural catheter. in group 't' (tramadol group), 1.5mg / kg of tramadol in 10 mg saline was injected through the epidural catheter and the catheter was removed in all the three groups. time of epidural opioid injection was noted. the level of consciousness was assessed every hour and graded according to the sedation score. the pain relief is graded as vaps and was assessed every hour and the total duration of post operative analgesia was taken as the period from the time of giving epidural drugs till the patients rst requirement of rescue analgesic. patients were observed for any side effects like respiratory depression, nausea, vomiting, urinary retention, hypotension, pruritus, headache for 24 hours. kruskal – wallis 'one way analysis of variance test” was performed to nd out the level of signicance in the duration of analgesia, quality of analgesia, sedation between the three study groups. results: morphine produces excellent post operative analgesia for a duration of 14-16 hours compared to butorphanol with a duration of 7-9 hours, and tramadol with a duration of 4-6 hours. the onset of action of morphine was delayed by 60-90 minutes while butorphanol and tramadol had an earlier onset of pain relief with in 5-10 minutes. there was no correlation between sedation score and quality of analgesia. morphine in these doses epidurally does not produce respiratory depression and butorphanol which had ceiling effect does not produce the same while no such respiratory depression occurred in tramadol. the incidence of vomiting is high with tramadol group 40% while 20% 20% each in butorphanol and morphine. hence routine use of antiemetics is advisable after epidural opioids. the incidence of urinary retention is 28% with morphine while no such events occurred in other two groups. conclusion: it has been found out by this study that morphine epidurally provides excellent long lasting pain relief compared to butrophanol and tramadol. morphine, the queen of opioids with respect to quality and duration of pain relief cannot be compared with any other opioids. hence it remains the gold standard opioid for pot operative analgesia epidurally. abstract keywords : epidural analgessia, combined epidural analgesia, morphine, butorphanol, tramadol, postoperative pain relief, lower abdominal surgeries volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. muthu vijayasankar* m.d, associate professor, tamilnadu government multi super speciality hospital, chennai, tamilnadu. *corresponding author 62 x gjra global journal for research analysis the epidural catheter is inserted in the usual manner and kept 3 to 4 cms into the epidural space. the pulse rate and blood pressure were monitored every 5 minutes and continuous spo2 monitoring was done. a fall of systolic pressure by 20% from the base line value was considered as hypotension and managed with intravenous uids, oxygen and inj. ephedrine in titrated incremental doses. at the end of surgery in group 'm' (morphine group) 50 mcg / kg of morphine in 10ml saline was injected through the epidural catheter. in the group 'b' (butorphanol group) 40 mcg/ kg of butorphanol in 10 ml saline was injected through the epidural catheter. in group 't' (tramadol group), 1.5mg / kg of tramadol in 10 mg saline was injected through the epidural catheter and the catheter was removed in all the three groups. time of epidural opioid injection was noted. the level of consciousness was assessed every hour and graded according to the sedation score. the pain relief is graded as vaps and was assessed every hour and the total duration of post operative analgesia was taken as the period from the time of giving epidural drugs till the patients rst requirement of rescue analgesic. patients were observed for any side effects like respiratory depression, nausea, vomiting, urinary retention, hypotension, pruritus, headache for 24 hours. data analysis: descriptive statistical analysis of all the data collected in the present study was performed. kruskal – wallis 'one way analysis of variance test” was performed to nd out the level of signicance in the duration of analgesia, quality of analgesia, sedation between the three study groups. observation and results: patients in all the three groups were comparable in age, weight distribution and the site and type of surgery. age distribution: patients in the age group between 20 and 70 were selected for the study.(table 1 & 2). the lowest age of a patient in the group 'm' was 25 and the highest age was 60 years. in group 'b' the lowest age of a patient was 28 and the highest age was 65. in group 't' the lowest age of a patient was 20 and the highest age was 64. table 1. age comparison (in years) among three groups table 2. hence the age between the three groups are comparable as there is not a statistically signicant difference p=0.259. weight distribution: in group 'm' the minimum weight of a patient was 40kgs and maximum of 60 kgs. in group 'b' the minimum weight of a patient was 45kgs and maximum of 62 kgs. in group 't' the minimum weight of a patient was 45kgs and maximum of 64 kgs ( table 3 ). table 3. hence the weight in between the groups are comparable as there is no statistically signicant difference with 'p' value >0.286. duration of postoperative analgesia in group 'm' the minimum duration of post operative analgesia was 840 minutes and the maximum duration was 975 minutes with a mean of 919.2 minutes and standard deviation of 38.36 minutes. in group 'b' the minimum duration of post operative analgesia was 420 minutes and the maximum duration was 570 minutes with a mean of 505.6 min and standard deviation of 49.08. in group 't' the minimum duration of post operative analgesia was 240 minutes and the maximum duration was 330 minutes with a mean of 272.4 min and standard deviation of 28.61( figure 1 ). applying kruskal – walis one way analysis of variance the duration of post operative analgesia showed the signicant statistical difference between the three groups with p value <0.001. figure 1. quality of analgesia: vaps score ( table 4 & 5 ) judged the quality of analgesia(10). in group 'm' the quality of analgesic was good with a score of 24 in rst hour in 20 patients, but the analgesic quality increases after 1 hour to excellent pain relief with score of 0-1 in 17 patients. in group 'b' the quality of analgesia at rst hour was excellent with pain score of 0-1 in 6 patients and good in 19 patients with pain score of 2-4. at fourth hour all the 25 patients were with good pain relief with score of 2-4. in group 't' the quality of analgesic at rst hour was good with pain score of 0-2 in 22 patients but the analgesic quality does not last longer. at fourth hour the analgesic quality was fair with pain score of 5-6 in 18 patients and good with a score of 2-4 in 7 patients( figure 2 & 3 ). patients were given the rst dose of parentral analgesic when the pain score was 6 and above. sttable 4. vaps score (1 hour) figure 2. thtable 5. vaps score (4 hour) volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra age in years 20-29 30-39 40-49 50-70 group 'm' 6 5 8 6 group 'b' 2 5 8 10 group 't' 2 12 5 6 mean s.d standard group 'm' 39.960 11.275 2.255 group 'b' 44.560 10.755 2.151 group 't' 39.680 12.906 2.581 weight (kgs) mean +/standard deviation group m 51.4 +/5.537 group b 52.56 +/6.014 group t 52.44 +/-5.233 pain score group 'm' group 'b' group 't' no.of patients % no.of patients % no.of patients % 0-1 0 0 6 24 0 0 2-4 20 80 19 76 22 88 5-6 5 20 0 0 3 12 >7 0 0 0 0 0 0 pain score group 'm' group 'b' group 't' no.of patients % no.of patients % no.of patients % 0-1 8 32 0 0 0 0 x 63gjra global journal for research analysis figure 3 applying kruskal – walis one way analysis of variance the quality of analgesia showed the signicant statistical difference between the three groups with p value < 0.001. sedation score: at the rst hour( table 6 & figure 4 ) in group 'm' out of 25 patients 17 patients were fully awake but as the time progress sedation scale increases. it took around 60 to 75 minutes to reach a sedation score of 2-3 in group 'm'. at fourth hour 18 patients were with a sedation score of 3. in group 'b' at the rst hour 2 patients were with a sedation score of1, 17 patients with score of 2 and 6 patients with score of 3. at fourth hour ( table 7& figure 5) 7 patients were with score of 1 and 18 patients with score of 2. in group 't' at the rst hour 19 patients were with score of 1,6 patients with score of 2 but at the fourth hour all the patients were fully awake. sttable 6. sedation score (1 hour) figure 4. thtable 7. sedation score (4 hour) figure 5. applying kruskal – walis 'one way analysis of variance” the sedation score showed the signicant statistical difference between the three groups with p value < 0.001. respiration: respiration was not depressed in any patients(10). even patients who had a sedation score of 2 or 3 had no airway obstruction due to falling back of tongue. no signicant change in respiratory rate and tidal volume were observed. complications: in group 'm' 5 patients had vomiting 1 patient had pruritus and 7 patients had urinary retention ( table 8 & figure 6 ). in group 'b' 5 patients had vomiting while in group 't' vomiting occurred in 10 patients. table 8. complications figure 6. discussion : the demonstration of opiate receptors(3) in the spinal cord and the role played by the spinal cord in the nociception and its modulation has helped managing the post operative pain effectively. a single dose of an opioid(7) given epidurally provides excellent pain relief for a reasonable period came as a blessing for the anaesthesiologist to extend his services well into the post operative period. duration of post operative analgesia: the mean duration of post operative analgesia in group 'm' was 919.20 minutes(1,9), in group b was 505.6 minutes(2), and in group 't' was 272.4 minutes(8) when given epidurally for post operative analgesia at the end of surgery. applying kruskal – wallis 'one way analysis of variance” the differences in the duration of post operative analgesia between the three groups was statistically signicant with 'p' value <0.001. quality of analgesia: the quality of analgesia(4) in group 'm' was excellent in 20% and good in 80% which increased after rst hour to excellent pain relief. at fourth hour 68% of patients had excellent pain relief. this showed the hydrophilic nature of epidural morphine which had delayed onset time. in group 'b' at rst hour 24% had excellent pain relief and 76% good, which at fourth hour all the patient were with good pain relief. the result correlated with lipophilic nature of butorphanol with an early onset. in group 't' at rst hour 88% of patients had good pain relief(12) but it does not last longer. at the fourth hour 72% were in fair pain relief 24% patients had vas score of 6 and they need resource postoperative pain relief. applying kruskal wallis “one way analysis of variance” there was a statistically signicant difference between the three group with respect ot quality of analgesia with p value <0.001. sedation scale: in group 'm' sedation scale increased from 1 to 3 after rst hour volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 2-4 17 68 25 100 7 28 5-6 0 0 0 0 18 72 >7 0 0 0 0 0 0 sedation score group 'm' group 'b' group 't' no.of patients % no.of patients % no.of patients % 1 17 68 2 8 19 76 2 8 32 17 68 6 24 3 0 0 6 24 0 0 4 0 0 0 0 0 0 sedation score group 'm' group 'b' group 't' no.of patients % no.of patients % no.of patients % 1 0 0 7 28 25 100 2 7 28 18 72 0 0 3 18 72 0 0 0 0 4 0 0 0 0 0 0 group vomiting urinary retention pruritus respiratory depression group 'm' 5 7 1 0 group 'b' 5 0 0 0 group 't' 10 0 0 0 64 x gjra global journal for research analysis explaining the delayed onset. in group 'b' the initial sedation score was 2 which sustained after fourth hour and it gradually thwaned to score of 1 after 6 hour. in group 'i' at rst and fourth hour all the patients were fully awake with a sedation score of 1 as tramadol inhibits nor adrenaline uptake and stimulates serotonin release responsible for their wakefulness. applying kruskal wallis “one way analysis of variance” there was a statistically signicant difference between the group with respect to sedation with p value < 0.001. hemodynamic status: there was no signicant change in heart rate or fall in blood pressure in any of these patients. respiration: respiration was not depressed in any of the patients in all the groups. there was no signicant change in respiratory rate and tidal volume. even patients with a sedation score of 2 or 3 had no airway obstruction due to fall back of tongue. all the patients maintained apo2 > 95% without any oxygen supplementation(6). complications: vomiting occurred in 20% of patients in group 'm', 20% in group 'b' and 40% of patients in group 'i' and hence routine use of antiemetics is recommended when opioids are administered epidurally. urinary retention occurred in 28% patients in group 'm' while no such complications reported in group 'b' or group 'i'. pruritus occurred in one patient in group 'm' while no such complications occurred in other groups. there was no respiratory depression observed in all the three groups. summary: this study done to comparatively evaluate the efcacy of epidural morphine, butorphanol and tramadol for post operative analgesia bears the following results. morphine produces excellent post operative analgesia for a duration of 14-16 hours compared to butorphanol with a duration of 7-9 hours, and tramadol with a duration of 4-6 hours. the onset of action of morphine was delayed by 60-90 minutes while butorphanol and tramadol had an earlier onset of pain relief with in 5-10 minutes. there was no correlation between sedation score and quality of analgesia. morphine in these doses epidurally does not produce respiratory depression and butorphanol which had ceiling effect does not produce the same while no such respiratory depression occurred in tramadol. the incidence of vomiting is high with tramadol group 40% while 20% 20% each in butorphanol and morphine. hence routine use of antiemetics is advisable after epidural opioids. the incidence of urinary retention is 28% with morphine while no such events occurred in other two groups. conclusion: morphine epidurally provides excellent long lasting pain relief compared to butrophanol and tramadol. the delayed onset of action of morphine epidurally compared to butorphanol and tramadol can be nullied by its administration epidurally within the two segment regression time. morphine, the queen of opioids with respect to quality and duration of pain relief cannot be compared with any other opioids. hence it remains the gold standard opioid for pot operative analgesia epidurally. references 1. palacios qt, jones mm, hawkins jc et al; post caesarean analgesia : a comparison of epidural morphine and butorphanol canad j. anaesth 1991; 38:24-30. 2. abound tk et al, epidural morphine or butorphanol for the relief of post caesarean section pain: ventilator responses to carbondioxide, anaesth analg 1987;66:887-93. 3. atcheson r, lambert dg. update on opioid receptors. brit j. anaes. 1994;73:132-34. 4. sung et al ; balanced anaesthesia : a comparison of morphine an d butorphanol south med j 1987 feb ; 77(2) : 180-2. 5. rawal n et al; comparison of intramuscular and epidural morphine for post operative analgesia in the grossly obese: inuence on the post operative ambulation and pulmonary function, anaesth analg 63:583, 1984. 6. celleno d, capogna g, seastiane m, epidural analgesia during and af-ter caesarean delivery. comparison of ve opioids reg. anesth. 1991. mar – apr; 16(2) 79-83. 7. siddik – sayyids, aouad – maroun m, epidural tramadol for post operative pain after caesarean section. can j anaesth 1999 aug; 46(8):731-5. 8. anis baraka, samor jabbour, a comparison of epidural tramadol and epidural morphine for postoperative analgesia can. j. anaesth 1993/40:4 / page 308-13. 9. revill si, robinson jo. the reliability of a linear analogue score for evaluating pain. anaesthesia 1976;31:1191-8. 10. vickers md, o’aterty d, szekely sm, tramadol : pain relief by an opioid without depression of respiration. anaesthesia 1992;47, 291-6. 11. houmes r – jm, voets ma, lachamann b, efcacy and safety of tramadol versus morphine for moderate to severe post operative pain. 12. chrubasik j, warthl, wust h, zindler m, anaesth. analg 1992 ; 75 : 510 – 4, analgesic potency of epidural tramadol after ab-dominal surgery. pain (1987) suppl 4, abstract no. 296, 5th world congress on pain hamburg. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 65gjra global journal for research analysis introduction castleman disease was rst described by benjamin castleman in 1914. c a s t l e m a n d i s e a s e i s u n u s u a l b e n i g n b c e l l lymphoproliferative disorder that involves ln but extranodal sites can also be affected. there are mainly 2 subtype 1) unicentric castleman disease ÿ involve single site ÿ localized and locally treated ÿ associated with good prognosis ÿ cured by surgery 2) multicentric castleman disease – ÿ involves more than one sites ÿ usually in context with hiv infection ÿ caused by hhv-8 ÿ s y s t e m i c d i s e a s e a n d c h a r a c t e r i z e d b y lymphadenopathy, splenomegaly and anemia ÿ systemic inammation symptoms such as fever, malaise and body ache present ÿ poor prognosis and recurrence common after surgery epidemiology 6500-7000 new cases diagnosed each year in usa. common rd th in 3 and 4 decade and more common in female than male. pathophysiology the disease is of unknown aetiology, but most widely accepted theory is that castleman disease is a chronic lowgrade inammatory process. the interleukin-6 in unicentric castleman disease and both interleukin-6 and hhv-8 in multicentric castleman disease are demonstrated to play a role in pathogenesis and symptomatology of the disease. presentationunicentric castleman diseaseincidentally found multicentric castleman diseasedue to systemic inammation symptoms such as fever, night sweat, fatigue, weight loss are common. also associated with genralised lymphadenopathy, hepatosplenomegaly and uid retention. investigations ÿ hematologic investigation are non specic; anemia may be present. ÿ radiological investigations are nonspecic and shows enlarged lymph node like mass lesion. diagnosis – biopsy and histopathological examination are diagnostic modality of choice. on pathological examination disease is characterized by hypervascular lymphoid hyperplasia. there are also subtype based on pathologic examination hyaline vascular: ÿ most common ~90%, corresponding to most cases of the unicentric castleman disease ÿ most commonly found in the mediastinum ÿ classically appears as an avidly enhancing mediastinal mass at ct and mri ÿ increased numbers of small hyalinised blood vessels within and between the lymphoid follicles, which show obliteration of the medullary sinuses ÿ “onion-skinning” arrangement of the small lymphocytes of the mantle zones, forming concentric rings around the germinal centre plasma cell ÿ often multicentric ÿ hyperplastic follicles of varying sizes, which show patent medullary sinuses ÿ less enhancing ÿ may be more symptomatic hhv associated castleman disease multicentric castleman disease not otherwise specied castleman disease is usually diagnosis of exclusion and diagnosed after histopathologic examination. treatmentfor unicentric castleman disease treatment is surgical, with good prognosis(can be curative) multicentric castleman disease may be treated with any combination of surgery, chemotherapy and prednisolone. antiviral agents (targeting hhv 8) and monoclonal antibody therapies targeting cd20 or il-6 . prognosis is relatively poor. case report a 29 year old female presented to civil hospital ahmedabad with c/o left side upper abdominal dull aching pain since 1 year without any aggravating or reliving factor and no associated jocomplaints. she was married since 7 year and was trying to get pregnant but was unable to conceive. she was started on clomiphene citrate for treatment of pcod(polycystic ovarian disease). otherwise her medical and surgical history was unremarkable. castleman disease a rare case report original research paper dr. p. n. kantharia hou and professor, department of general surgery, b.j. medical college, civil hospital, ahmedabad. general surgery castleman disease, also known as angiofollicular lymph node hyperplasia or giant lymph node hyperplasia, is an uncommon benign b-cell lymphoproliferative condition. . it can affect several regions of the body although commonly described as a solitary mediastinal mass.there are mainly 2 types (1) unicentric and (2) multicentric and two basic histopathologic pattern that are hyaline-vascular(hv) and plasma cell(pc) type. abstract keywords : dr. divyesh ahir* rd3 year resident, department of general surgery, b.j. medical college, civil hospital, ahmedabad. *corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 10 x gjra global journal for research analysis she was vitally stable and her per abdomen examination was normal with no palpable organ or palpable lump. we investigated patient by usg (abdo+pelvis) which was s/o approx. 51*35 mm sized well dened homogenously hypoechoic solid lesion with internal vascularity is noted in left paraumbilical region without any communication with bowel loops p/o benign mesenteric mass lesion. we did cect(abdo+pelvis) of this patient which was showing well dened homogenously enhancing mass lesion arising from mesentry with p/o abdominal desmoid tumor. we operated this patient and found out approx. 5*4 cm size well dened lesion in mesentry of jejunum without any communication or adhesion with bowel and no connection with mesenteric vessels. rest of the organs were normal and no other mass lesion found out on exploration. biopsy report was s/o structure of lymph node with marked reactive follicular hyperplasia with evidence of plasma cell inltration in parafollicular region p/o castleman disease. patient had uneventful post-op course and was discharged on post op day 4. discussion castleman disease is a rare diagnosis and extranodal involvement is even more rare as the usual site of occurrence is mediastinum, diagnosed on hpe and it is a diagnosis of exclusion. in our patient radiological investigation was suggestive of intra-abdominal desmoid tumor but it turned out to be castleman disease on hpe. this highlights that one should not rely on cect nding so much; one needs to keep desmoid tumor and gist as other possible diagnosis for intraabdominal mesenteric mass lesion as post operative management is very different. patient's postoperative course was uneventful and for unicentric castleman disease surgical excision is curative. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 11gjra global journal for research analysis 33.padmashini gnanam.cdr introduction: de van's principle states that “perpetual preservation of what remains of the human masticatory apparatus is important rather than meticulous replacement of what is lost.” the main concern in prosthetic rehabilitation is preservation of natural remaining articial teeth. even few remaining teeth present in the oral cavity can help the patient by providing support to the prosthesis, aiding in proprioception and in preserving the alveolar ridge. studies prove that alveolar bone loss occurs when the teeth are extracted followed by rehabilitation with complete 1 dentures. also, the psychological trauma associated with loss of teeth coupled with problems like reduced stability, and retention, compromised masticatory function, unesthetic appearance make the transition from a dentulous state to 2,3edentulous state very difcult for the patient. in such cases, alternative treatment options can be considered which retain the few remaining natural teeth. these include overdentures and transitional dentures. immediate dentures are another option wherein extraction and denture placement are done on the same day. however, there are obstacles associated with each of these treatment modalities. over dentures may not be a favourable option because of the need for endodontic treatment, poor position of the remaining teeth, a greater number of patient visits and 4increased cost of treatment. immediate dentures are not possible if the patient is unwilling to extract the teeth and the associated problems related to loss of natural teeth. transitional dentures are a great technique which preserves the natural teeth as well as an easy and costeffective option. cu-sil denture is a type of transitional denture. it is basically a complete denture with holes in them which allows the natural teeth to emerge through. this article presents a case report of prosthetic rehabilitation using a cu-sil denture. case report: a 57-year-old male patient reported to the department of prosthodontics at srm dental college, ramapuram, chennai, tamil nadu, india. his chief complaint was ill tting and loose maxillary denture. on intra oral examination the patient had a kennedy class 1 modication 1 edentulous space in maxilla with presence of only 13 and 24 (fig. 1) and kennedy's class 2 edentulous space in mandibular arch with missing 34, 35, 36, 45, 46, 47 and 48. patient was already a denture wearer with a satisfactory lower denture but poor retention and esthetics in upper denture. on examination of individual teeth, 13 and 24 had gingival recession in them and the mandibular teeth were supra-erupted. figure 1 – pre-operative maxillary arch with presence of 13 and 24 treatment options were discussed with the patient. he was not willing for any extractions or endodontic treatment. considering the above conditions, a treatment plan was formulated which consisted of a cu-sil denture in the maxillary arch. the treatment procedure was explained to the patient. treatment procedure: in the rst appointment, primary impressions of the maxilla and mandible were made using irreversible hydrocolloid. [ zelgan plus alginate impression material, dentsply]. this was followed by custom tray fabrication for maxillary cast using autopolymerizing acrylic resin. [dpi rr cold cure, dpi india] during the second appointment, border molding was done in the maxilla using green stick compound [dpi pinnacle tracing sticks, dpi india] and the nal impression was made with light body impression material (fig. 2). [aquasil, dentsply sirona, usa]. master cast was prepared and occlusal rims were fabricated. cu-sil denturesan alternative treatment option for management of few remaining natural teeth original research paper lavanya mk bds student, srm dental college, ramapuram, chennai prosthodontics the main responsibility of the dentist is to rehabilitate the patient whilst preserving the remaining natural dentition. it has long been proven that the presence of teeth helps to preserve the alveolar ridge in its place. the current trend in prosthodontics is to rehabilitate the patient using a conventional removable partial denture or to remove the natural teeth and replace it with a complete denture. a conventional rpd will have deleterious effects on the periodontium of the natural teeth. complete dentures will lead to alveolar bone loss and loss of proprioception. transitional dentures are like a bridge which help the patient to transition from a dentulous state to an edentulous state. they will have all the benets of preserving natural teeth while eliminating the ill effects of a complete denture. cu-sil denture is a type of transitional denture which involves making holes in a complete denture through which the natural teeth emerge. this case report discusses a simple and cost-effective method of processing a cu-sil denture. abstract keywords : cu-sil denture, partially edentulous arch, soft liners, transitional denture volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. padmashini gnanam* senior lecturer, prosthodontics, srm dental college, ramapuram, chennai *corresponding author dr. b. muthukumar head of the department, prosthodontics, srm dental college, ramapuram, chennai 34 x gjra global journal for research analysis figure 2 – secondary impression of maxillary arch at the third appointment, vertical and centric jaw relation were recorded and articulated in a mean value articulator. teeth setting was done with the 13 and 24 in place. [acryrock, ruthanium, condent india] at the wax try-in appointment, the occlusion and dental esthetics were examined after obtaining the patient's consent, the trial denture was waxed up for processing. two gasket rings made of silicone rubber were selected to a diameter corresponding to the diameter of a canine and premolar (fig. 3). the rings were altered to t snugly and passively on the cervical margin of 13 and 24 (fig. 4, 5). there is a risk of extreme thinning of the denture base in the nal denture in 13 and 24 region. hence, the buccal area above 13 and 24 was reinforced by placing a small piece of 21 gauge wire. the rings were secured in position by waxing it along with the denture base (fig. 6, 7). maxillary waxed up denture was asked using conventional ask and clamp with type 3 gypsum. [kalstone, kalabhai, india]. figure 3 – silicone gaskets corresponding to diameter of canine and premolar figure 4 – silicone ring t snugly around the canine and reinforced with 21 gauge wire figure 5 – silicone rings in place figure 6 – waxed up denture with the silicone rings figure 7 waxed up denture with the silicone rings dewaxing was done and any residual wax was manually removed. a thin layer of separating medium [cold mold seal, dpi india] was carefully painted over the stone taking care not to touch the silicone rings. polymerization was done using conventional heat curing technique. once the denture was processed, the ask was bench cooled for 30 minutes. deasking was done to retrieve the denture using hammer and plaster knife. the nished and polished denture (fig. 8) was inserted into the patient's mouth. the silicone ring was adjusted chair side to allow passive seating on the tooth (fig. 9). review showed that the patient was comfortable in using the denture and his previous problem of retention was also solved. figure 8 – processed denture with silicone ring figure 9 – post operative intra oral view with denture volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 35gjra global journal for research analysis discussion: cusil dentures are a good treatment option in patients who have isolated, periodontally compromised teeth. these dentures are designed to preserve the remaining natural teeth and thus the alveolar bone. they have a positive effect on retention and stability of denture. the silicone ts snugly around the natural teeth completing the peripheral seal. it also acts like a cushion, distributing forces more evenly. also, it gives patients a psychological satisfaction of retaining their natural teeth and not having to endure any extractions. these natural teeth help in preservation of alveolar bone and aid in proprioception. the main advantage of a cu-sil denture is that if the patient loses his natural teeth in the future, the denture 5can be modied and adjusted to work as a complete denture. the denture is easy to fabricate. the resultant prosthesis is very easy to remove and insert without any hindrance. elimination of clasps makes the denture esthetic and does not injure the soft tissues. however, the longevity of the silicone rings is short lived and may need to be replaced. the silicone ring can also accumulate plaque and calculus if hygiene is 6not maintained properly. conclusion: cu-sil denture serves as a viable treatment alternative for patient with very few remaining teeth. an elastic gasket seals itself around the cervical part of each tooth, thereby providing a stable and healthy t. it promotes healthy stimulation to maintain alveolar bone. retention is improved, vertical dimension and proprioception are maintained. references: 1. crum rj, rooney ge., jr alveolar boneloss in overdentures – a 5 year study. j prosthet dent. 1978;40:610–3. 2. bolender z. 12th ed. st. louis, mo: mosby; 2013. prosthodontic treatment for edentulous patients; pp. 6–23. (160-76). 190-208. 3. zarb ga, bolender cl, hickey jc, carlsson ge. 10th ed. st. louis, mo: mosby; 1997. boucher’s prosthodontic treatment foredentulous patients; pp. 71–99. 4. khandelwal m, punia v. saving one is better than none: technique for cu-sil like denture – a case report. 2011;03(01):41–5. 5. gagandeep k, sangeetha g, deepika s. cusil denture: a novel conservative approacha case report. unique j med dent sci. 2013;01(02):56–8. 6. jain jk, prabhu cr, zahrane ma, esawy ms, ajagannanavar sl, pal ks. cusil dentures a novel approach to conserve few remaining teeth: case reports. j int oral health. 2015;7(8):138–140. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 36 x gjra global journal for research analysis introduction hypertension is a disorder of circulatory regulation.sustained hypertension causes accelerated atherosclerosis with coronary artery disease,heart failure,stroke and renal failure.if untreated,approximately 50 % of patients develop heart disease,33% develop stroke ,10-15 % develop renal failure. microalbuminuria(ma) is dened as urine albumin excretion(uae) in the range of 30-300 mg/24h,is seen in patients with established hypertension and is a predictor of higher risk of cardiovasculars and renal dysfuntion.in 1976,parving et al highlighted the relation between microalbuminuria and severity of hypertension.leoncini g,studied association of microalbuminuria in 345 patients of asymptomatic hypertension and presence of subclinical organ damage.detection of uae could be the best index of an increased global cardiovascular risk in a given patient hypertension affects the heart by increasing afterload causing the lvh (left ventricular hypertrophy)and stiffening of the left ventricle ultimately leading to increase in the left ventricular mass.lvh is the most common abnormality in patients with hypertension and signicant marker of subclinical cardiovascular disease.positive correlation between ma and lvh has been documented in few studies,one such by hitha et al in south india studied relationship between ma and target organ damage in hypertension.hypertension accelerates atherosclerosis and also independently causes vascular damage affecting large and small vessels.this study was undertaken to determine the prevalence of ma in hypertension and to examine its correlation with severity of hypertension,lvh. materials and methods study population this study is conducted among 100 hypertensive(essential hypertension)patients attending general medicine department outpatient clinic and ward at sree balaji medical college and hospital,chennai collabarative deparments: department of cardiology,radiology study period july 2018 to august 2019 ethical concern the project was approved by the ethical comitee study type prospective analysis study sample size 100 cases inclusion criteria 1. hypertensive patients(both male and female) with bp>140/90mmhg 2. age more than 30 years exclusion criteria 1. patients with renal disease 2. diabetes mellitus 3. chronic heart failure 4. ischemic heart disease 5. cerbero vascular disease 6. patients with urinary tract infections 7. pregnancy 8. patients with obstructive uropathy conict of interest :nil financial support :nil methodology patients who were admitted and attending the general medicine department who fullled the inclusion criteria were included in the study.patients fullling the exclusion criteria were excluded from the study.investigations were sent and corellations were made accordingly study of the prevalence of microalbuminuria in patients of essential hypertension and its correlation with the severity of hypertension and left ventricular hypertrophy original research paper dr.papaiah nirmal pudota m.b.b.s,(m.d) x 39gjra global journal for research analysis general medicine objective:to detect the prevalence of microalbuminuria in 100 hypertensive patients and the its association with lvh(left ventricular hypertrophy) and lipid prole methods: we performed a prospective analysis study of 100 patients visiting balaji medical college and hospital, chennai.inclusion criteria :hypertensive patients with bp>140/90 mmhg and age more than 30 years.exclusion criteria:patients with renal disease,t2dm,ischemic heart disease,cva,pregnancy.microalbuminuria was measured using the dip stick test ,dened as having uae in the range of 30-300mg/24h results:100 patients were involved in the study fullling the criteria.30 out of 100 patients had microalbuminuria. 21 males out of 45 were found to have microalbuminuria and 9 out of 25 females were found to have microalbuminuria.serum levels of cholesterol,triglycerides,and uric acid in patients with microalbuminuria were higher than the levels in those with normal uae(urine albumin excretion),and hdl(high density lipid) levels in patients with ma(microalbuminuria)were lower than levels in patient with normal uae.on performing echo in the study patients ,lvh is noted to be seen in 29 out of 100 patients ,out of which 22 (73.3%) of the patients had microalbuminuria,and in 71 patients without lvh ,8 had microalbuminuria.study shows a high statistical signicant correlation between microalbuminuria and left ventricular hypertrophy(p value <0.01). conclusion: hypertension is one of the most common global diseases causing signicant mortality and morbidity.therefore proper screening and assessment is required to identify patients at risk. microalbuminuria is a cause for generalized atherosclerosis and increased renal endothelial dysfuntion,it positively correlates with the end organ damage such as left ventricular hypertrophy .hence it serves as a marker of cardiovascular risk along with other parameters such as bp,lipid prole and smoking. so, screening for microalbuminuria must be considered to be part of initial work up in every hypertensive patient. abstract keywords : volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 40 x gjra global journal for research analysis labaratory investigations 1. clinial blood pressure was recorded using sphygmoma nometer with standard size cuff on 2 to 3 occasions atleast to 10 min apart. 2. microalbuminuria estimation was done using immuno turbidemetric two point assay when a urine specimen is mixed with the reagents,albumin in the specimen combines with the anti human albumin antibody in the reagent to yield an insoluble aggregate that causes increased turbidity in the solution.the absorbance of the reaction turbidity is proportional to the concentration of albumin in the specimen ,and can be measured optically using spectrophotometer. 3. echocardiography-transthoracic echocardiogram was done to detect the presence of left ventricular hypertrophy 4. ecg 5. fasting lipid prole results frequency of ma in 100 essential hypertensive patients is found to be 30% f r e q u e n cy o f m i c r o a l b u m i n u r i a i n 1 0 0 hypertensive patients-30% relation of microalbuminuria with age mean age of the patients is around 60 with ma and without ma is around 45.thus,age showed a signicant positive correlation with ma in the study.patients with higher age group 60 and above patients have increased prevalence of miccroalbuminuria.studies support this characteristic that ma prevalence increases with age.in our study we found ma to be present in 66% of the males and some support more prevalence in males but some studies do not support this correlation.as such,therefore sex of the patient doesn't correlate with increased prevalence of ma(microalb uminuria). correlation between ma and severity of hypertension comparision between microalbuminuria and hypertensive patients 27 out of 59 patients with stage ii hypertension have microalbuminuria and 2 out of 22 patients with stage 1 hypertension have microalbuminuria .p value is highly signicant at <0.01 level correlation between ma and lvh p value <0.01 level ,highly significant lvh is noted to be seen in 29 out of the 100 patients 22 of the 29 patients i.e 73.3% of the patients had microalbuminuria volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra microalbuminuria frequency percent a 70 70.0 p 30 30 total 100 100 age count % ma total a p upto 40 years count % 9 12.9% 0 0.0% 9 9.0% 41-50 years count % 14 20.0% 7 23.3% 21 21% 51-60 years count % 19 27.1% 9 30.0% 28 28.0% 61-70 years count % 20 28.6% 10 33.3% 30 30.0% above 7o years count % 8 11.4% 4 13.3% 12 12% total count % 70 100.0% 30 100.0% 100 100.0% bp count % ma total a p i count % 20 28.6% 2 6.7% 22 22.0% ii count % 32 45.7% 27 90.0% 59 59.0% iii count % 0 0.0% 1 3.3% 1 1.0% n count % 18 25.7% 0 0.0% 18 18.0% total count % 70 100.0% 30 100.0% 100 100.0% lvh count % ma total a p a count % 63 90.0% 8 26.7% 71 71.0% p count % 7 10.0% 22 73.3% 29 29.0% total count % 70 100.0% 30 100.0% 100 100.0% discussion hypertension is one of the most global diseases causing burden worldwide and is one of the most common cause of morbidity and mortality.along with diabetes,it is the most common disease affecting the end organs of the body.hypertension affects almost every organ in the body.in order to detect the end organ damage,patients usually will not present with symptoms unless severely affected.mostly they remain asymptomatic .so to know how can we detect the damage early.so that we can prevent the complications of hypertension.100 patients with essential hypertension presenting to our hospital were looked for age,sex,duration of hypertension ,ecg lipid prole and were screened for the end organ damages mainly lvh correlating with the respective department.patients were included based on the inclusive and exclusion criteria as described above in present study,it was observed that out of 100 cases with hypertension,lvh was noted in 29 patients ,and absent in 71 cases (8 had microalbuminuria-26.7%).out of the 29 cases,22 patients (73.3.%) had ma with a p value of <0.01 which is highly statistically signicant. hence this study shows a positive correlation between the microalbuminuria and prevalence of lvh(p value <0.01). hypertensive patients with ma were 11 times more likely to develop lvh than patients with normal uae. several studies showed the similar ndings. tsiousfus et al in 2002 in their study observed that 21 % of the 250 had lvh.monofred et al in 2003 (life study) observed a higher prevalence of ma 30% vs 9 % in patients with lvh with p <0.001.pontremouli in 2002 observed that patients with ma were 20 times more likely to have both lvh with p <0.01 in a study conducted in 280 patients .stefanadis made a similar observation that lvh was higher in ma patients compared with normoalbuminuria subjects. vishwanath and manohar s et al conducted a study and observed the frequency of ma is higher in hypertensive patients with lvh(72%) with p <0.01.stalin bj, conducted a study and found hypertensives with ma were having higher prevalence of hypertensive lvh with p <0.003. brantsma et al observed ma to be a sensitive marker for detecting onset of cardiovascular risk factors such as hypertension and type ii diabetes.the life study showed that more the angiotensin-ii antagonist losartan lowers albuminuria the more the patient was cardio protected. in this regard, monitoring of uae and lvh rate has ultimately been useful as surrogate for efciency of blood pressure control and cardiovascular risk reduction. conclusions our study demonstrated the presence of ma(microalbu minuria) in a signicant number of newly detected and untreated patients of essential hypertension. furthermore, ma had a statistically signicant relationship with lvhthese ndings imply an underlying vascular relationship between ma and lvh. therefore,screening of all recently diagnosed patients of essential hypertension for ma may be a reasonable strategy to predict the presence of ongoing vascular damage, and future risk for cardiovascular events financial support:nil conicts of intrest:there are no conicts of intrest references 1. systemic hypertension :mechanism and diagnosis in braunwalds heart disease.a text book of cardiovascular medicine 2. brantsma ah,bakker sj.urinary albumin excretion as a predictor of development of hypertension in the general population 3. pontremoli r,leoncini g,ravera m,ratto e,et al.microalbuminuria, cardiovascular,and renal risk in primary hypertension 4. cardio vascular diseases harrisons textbook of medicine 5. bigazzi r,bianchi s,nenci r.increased thickness of the carotid artery in patients with essential hypertension and micro albuminuria. x 41gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction : ocular chemical injury is a true ocular emergency and [1] requires immediate intervention. it can lead to other associated anterior segment involvement producing extensive damage to the ocular surface with visual impairment and disgurement. they represent 11.5%–22.1% of all ocular traumas and require immediate and intensive [2]evaluation and care. the victims of such injuries are usually young men aged 20–30 years, and therefore, vision loss could dramatically affect their remaining lifetime with more number [3 ]of disability years. the clinical course of the disease is divided into immediate, acute, early, and late reparative phases. after chemical injury, the goal of therapy is to restore a normal ocular surface and corneal clarity. treatment starts with simple vision-saving steps and is continued with complicated surgical procedures such as limbal stem cell transplantation, amniotic membrane transplantation, and ultimately keratoprosthesis depending [4]on the patient's needs. ocular chemical injuries can occur under diverse circums tances and in such varied locations as the home, the workplace, and school. automotive battery acid burns have become increasingly more common. during recharging of a lead acid storage battery, which contains up to 25% sulfuric acid, hydrogen and oxygen produced by electrolysis form a [5]highly explosive gaseous mixture. chemical agents commonly causing it are hydrochloric acid, sulfuric acid, nitric acid, oxalic acid, acetic acid, ammonium hydroxide, sodium [6]hydroxide, and calcium hydroxide. common workplace for chemical injury : the aim of this study was to nd out the pattern of ocular injury, nature of causative chemicals, the disabilities incurred and the outcome of treatment. methods : 84 patients (58 males & 26 females) presenting with history of exposure to a varied range of chemicals were analyzed over a period of 1 year (june 2018june 2019) this is a hospitalbased cross sectional observational study of patients with clinical diagnosis of ocular chemical injury . incidence of ocular chemical burns by injury-level characteristics, such as the mode of injury, demographic factors such as age, sex, and income quartile were also examined. injury-setting descri ptions were combined into 4 categories: 1. residential, including home and other residential facilities 2. commercial, including industrial sites, mines, and farms 3. public, including schools and other public buildings, streets and highways, and sports and recreational facilities 4. other locations, or were classied as missing. after initial evaluation patients were also followed up for next 3 months to evaluate the visual outcome ocular chemical injury: a prospective study original research paper dr sharmistha behera associate professor department of ophthalmology, vssimsar burla dr jayashree dora professor & hod department of ophthalmology, vssimsar burla ophthalmology aim : to describe the epidemiologic trends and risk factors for chemical injuries of the eye. methods: this cross-sectional observational study was done among 84 patients of chemical ocular injury by different substances between june 2018 june 2019. clinical history was taken and clinical examination was done to elicit ndings related to eye injury and its complication after initial evaluation patients were also followed up for next 3 months to evaluate the visual outcome results: male : female ratio affected with chemical ocular injury was found to be 2.3:1. most common age group to be affected was 26-40 years. males between 26-35years and 46-55 years and females of 36-45 were affected most. 60 (72%) cases had ocular burn due to alkali and remainder was acid burn. among alkali, hydrated lime ca (oh)2 had highest percentage 84.6%. the whole eyeball was affected in 3 patients. only corneal involvement was seen in 42 patients. patients presenting with only chemical conjunctivitis was 12. corneoscleral involvement was seen rest of the cases. 47.6 % of the study population had grade i severity with 28.5% having grade 2 severity. conclusion : ocular chemical burns is a major ocular problem at workplaces and the risk to young adults is substantially higher. protective glasses at workplace can aid in reducing the hazards leading to ocular injury. early institution of management is essential to prevent sight threatening visual complications. abstract keywords : ocular, chemical, burn volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr kshyanaprava priyadarshini* rd3 year pg resident department of ophthalmology, vssimsar burla *corresponding author dr satya sundar biswal rd3 year pg resident department of ophthalmology, vssimsar burla dr jyotirmayee swain rd3 year pg resident department of ophthalmology, vssimsar burla industrial chemical laboratories machine factories agriculture laborers and construction workers fabric mills automotive repair facilities cleaning and sanitizing crews 36 x gjra global journal for research analysis inclusion criteria: 1. patients with chemical injury to the eyes 2. age 15– 60 years exclusion criteria : 1. associated injury to other parts of the body 2. preexisting ocular pathology 3. age>60 years clinical history was taken and clinical examination was done to elicit ndings related to eye injury and its complication. slit lamp examination, visual acuity test and ophthalmoscopy was also done. conjunctival swab was taken to nd out any eye infection. acidity or alkalinity was conrmed by litmus paper test. statistical analysis was performed by using spss (statistical package for social sciences) for windows version 22. results : male : female ratio affected with chemical ocular injury was found to be 2.3:1. most common age group to be affected was 26-40 years. males between 26-35years and 46-55 years were mostly affected whereas females of 36-45 were affected most.62 % had unilateral eye involvement whereas the rest had both eyes affected. table 1 : distribution of affected population based on age group & gender 60 (72%) cases had ocular burn due to alkali and remainder was acid burn. among alkali, hydrated lime ca (oh)2 had highest percentage 84.6%. 4 patients had chemical conjunctivitis due to kohl. 5 patients had hair dye induced chemical conjunctivitis. 2 patients presented with feviquik induced chemical ocular injury. affected males were predominantly service holders whereas females were predominantly housewives. table 2 : prevalence of affection by different types of chemicals : graph showing the affection of patients by various chemicals the whole eyeball was affected in 3 patients. only corneal involvement was seen in 42 patients. patients presenting with only chemical conjunctivitis was 12. corneoscleral involvement was seen rest of the cases. 47.6% of the study population had grade i severity with 28.5% having grade 2 severity. table 3 : severity of injury based on grade ( according to roper hall classification) : 38% of the patients had bilateral involvement. stromal edema was found to be the most common complication. table 4 : complications following chemical injuries graph showing the various complications due to chemical injuries table 5 : monitoring of visual acuity at various intervals volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra age group (years) male female 15-25 5 (8.62%) 3 (11.5%) 26-35 18 (31.03%) 6 (23.07%) 36-45 9 (15.5%) 14 (53.8%) 46-55 16 (27.5%) 2 (7.69 %) 56-60 9 (15.5%) 1 (3.84%) total 58 26 nature of chemicals patients affected acids sulfuric acid 5 nitric acid 8 alkali lime 51 ammonia 9 grading total grade 1 40(47.6%) grade2 24(28.5%) grade3 15(17.8%) grade4 5(5.9%) complications total stromal edema 60(72%) corneal ulcer 2(2.3%) corneal opacity with or without vascularization 12(10.08%) ectropion 2(2.3%) entropion 5(5.9%) symblepharon 8(9.5%) visual acuity at presentation after 1 month after 2 months at 3 months 6/6 6/12 2 11 12 12 6/18 6/60 28 37 42 44 5/60 3/60 35 24 20 18 < 3-60 – hm 18 12 10 10 pl 1 0 0 0 x 37gjra global journal for research analysis graph denoting the visual outcome discussion : as such distribution of the chemical ocular injuries has shown considerable variations. majority of the patient with ocular affection was young adult. it was found to be almost similar to [6]ndings of saini-sharma . they stated that young people works in laboratories and factories constitute two-thirds of the patients of chemical injury. 42 % of the affected population were service holders. they were accidentally injured by the chemical substance at their work place. a study by mccarty et [8]al. found factory workers and manual daily laborers to be a high-risk population for ocular trauma similar to the present study, which could be explained by involvement of unskilled and semiskilled workers and lack of any eye protection. this is the target population for emphasizing recommendations for safety measures as most of the injuries can be prevented by appropriate use of ocular protection. also accidental injury to housewives and children by hydrated lime was common. accidental entry of feviquik, kohl application was also noted. our study showed 38 % bilateral involvement whereas saini[6]sharma shows 42.1% of bilateral injury. severity of injury depends upon several factors like nature of the chemical, amount of chemical substance, duration of contact with tissue, pattern of management i.e. early or late. most common age group to be affected was 26-40 years in our study. the mean age for ocular injury in a study by syal e et al was 29.87±12.46 years, which is in accordance with most other studies in which a mean age of 30 years has been [7,8,9]reported . this is likely due to work-related injuries that contributed to the largest portion of injuries. [10,11]consistent with other studies , the current study observed male dominance of ocular trauma with a male : female ratio of about 2.3 : 1. this male preponderance is thought to be related to occupational exposure, participation in dangerous sports and hobbies, alcohol use, and risk-taking behavior.in a study [7] by syed e et al observed a male preponderance at workplace trauma and road trafc accidents and women at domestic trauma showing a signicant correlation which is [12]similar to the results found in the study by oum et al in this study the percentage of minor injuries is 80 % that is [7]similar to monestame's study our study showed people are commonly injured by alkali than as it is widely used at home and industries. these ndings are consistent with the previous study. our study showed the different complications caused by chemical injuries. in the present study corneal stromal edema (72%) was found to be the most common complication. [14]this was similar to the study by das et al. conclusion : ocular chemical burns is a major ocular problem at workplaces & the risk to young adults is substantially higher. alkali is the most common agent for chemical ocular injuries. protective glasses at workplace can aid in reducing the hazards leading to ocular injury. early institution of management is essential to prevent sight threatening visual complications. references : 1. https://eyewik i.aao.org/che mical_(alkali _and_acid)_i njury_of_the_ conj u nctiva_and_cornea 2. clare g, suleman h, bunce c, dua h. amniotic membrane transplantation for acute ocular burns. cochrane database syst rev 2012;9:cd009379. 3. singh p, tyagi m, kumar y, gupta kk, sharma pd. ocular chemical injuries and their management. oman j ophthalmol 2013;6:83-6. 4. eslani m, baradaran-rai a, movahedan a, djalilian ar. the ocular surface chemical burns. j ophthalmol. 2014;2014:196827 5. holekamp tl. ocular injuries from automobile batteries. trans sect ophthalmol am acad ophthalmol otolaryngol 1977;83:805-10. 6. saini js, sharma a. ocular chemical burns—clinical and demographic prole. burns 1993;19:67-9 7. syal e, dhawan m, singh sp. to study the epidemiological and clinical prole of ocular trauma at a tertiary health-care facility. delta j ophthalmol 2018;19:259-67 8. mccarty ca, fu cl, taylor hr. epidemiology of ocular trauma in australia. ophthalmology 1999; 106:1847–1852 9. smith ar, o’hagan sb, gole ga. epidemiology of open and closed-globe trauma presenting to cairns base hospital, queensland. clin exp ophthalmol 2006; 34:252–259 10. saxena r, sinha r, purohit a, dada t, vajpayee rb, azad rv. pattern of pediatric ocular trauma in india. indian j pediatr 2002; 69:863–867 11. nirmalan pk, katz j, tielsch jm, robin al, thulasiraj rd, krishnadas r, ramakrishnan r. ocular trauma in a rural south indian population: the aravind comprehensive eye survey. ophthalmology 2004; 111:1778–1781. 12. oum bs, lee js, han ys. clinical features of ocular trauma in emergency department korean j ophthalmol 2004; 18:70–78 13. monestam, bjornstig. eye injuries in northern sweden, department of ophthalmology, university of umea, sweden. 1991;69(1):1-5 14. das s, kabir f, das j et al , pattern of chemical ocular injury: a clinical study chattagram maa-o-shishu hospital medical college journal volume 13, issue 1, january 2014 volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 38 x gjra global journal for research analysis 81.dr. sushant priya bilania online.cdr introduction airway management is the evaluation, planning, and use of medical procedures and devices for the purpose of maintaining or restoring ventilation in a patient. endotracheal intubation is required to provide a patent airway when patients are at risk for aspiration, when airway maintenance by bag mask is difcult, and for prolonged controlled [1]ventilation . this research aimed to investigate the impact of melatonin with dexmedetomidine in mitigating cardiovascular responses to laryngoscopy and endotracheal intubation in [2]candidate in cases supporting voluntary operation . laryngoscopy and endotracheal intubation are considered potent noxious stimuli which provoke haemodynamic responses leading to a marked increase in heart rate and [3]blood pressure . this is probably of no consequence in healthy individuals. however, these events are especially detrimental in individuals who have limited myocardial reserve due to coronary artery disease, cardiac dysrhythmias, congestive heart failure, hypertension, [4]cardiomyopathy and in geriatric age group . melatonin (n-acetyl-5-methoxytryptamine) is an endogenous sleep-regulating hormone secreted by pineal gland. its inhibitory actions on central nervous system responsible for sedation and anxiolysis that have role in attenuating haemodynamic responses to laryngoscopy and intubation. while dexmedetomidine (α2 adrenergic agonist), have been used to induce preoperative sedation, intraoperative reduction of anaesthetic and analgesic requirements and hemodynamic stability along with postoperative analgesia. these pharmacological effects made them suitable for premedication for general anaesthesia. so a comparative evaluation of oral intake of melatonin with i.v dexmedetomidine alone and in combination of both drugs was studied in order to measure the safety prole of these drugs in blunting the haemodynamic response during laryngoscopy and intubation in middle ear surgeries for better airway management. aim ÿ to compare the role of oral melatonin with (i.v) dexmedetomidine alone and in combination of both for attenuation of haemodynamic responses during laryngoscopy and intubation. ÿ to compare the effect on haemodynamic parameters: heart rate (hr), systolic blood pressure (sbp); diastolic blood pressure (dbp); mean arterial pressure (map) and spo2. ÿ to observe complications that occurred during procedure if any hypotension and bradycardia, or o2 saturation (spo2) is less than 90%. this study was a randomized prospective double blinded study conducted in department of anaesthesiology and critical care, mlb medical college, jhansi (up) in patients posted for elective middle ear surgeries during the period of march 2018 to october 2019 and minimum 150 patients was selected for the study. the study will be conducted after a comparative evaluation of oral melatonin, (i.v) dexmedetomidine and combination of both for attenuation of haemodynamic responses to laryngoscopy and intubation in middle ear surgery original research paper dr.roopesh kumar* professor and head, department of anaesthesiology and critical care medicine, m.l.b. medical college *corresponding author x 25gjra global journal for research analysis anaesthesiology introduction: airway management is the evaluation, planning, and use of medical procedures and devices for the purpose of maintaining or restoring ventilation in a patient. endotracheal intubation is required to provide a patent airway when patients are at risk for aspiration, when airway maintenance by bag mask is difcult, and for prolonged controlled ventilation. this research aimed to investigate the impact of melatonin with dexmedetomidine in mitigating cardiovascular responses to laryngoscopy and endotracheal intubation in candidate supporting voluntary operation. aim and objective : to compare the role of oral melatonin with (i.v) dexmedetomidine alone and in combination of both for attenuation of haemodynamic responses during laryngoscopy and intubation and compare the effect on haemodynamic parameters heart rate, systolic blood pressure; diastolic blood pressure; mean arterial pressure and spo2. methods and methods: this study was a randomized prospective double blinded study conducted in department of anaesthesiology and critical care, mlb medical college, jhansi (up) in patients posted for elective middle ear surgeries during the period of march 2018 to october 2019 and minimum 150 patients were selected for the study. following the approval from the ethical committee, asa i and ii patients between the age of 20 to 50 years of either gender and surgery requiring general anaesthesia for duration longer than 30 min, patients with normal airway with mpg i and mpg ii, >90 degree neck movement, no buck teeth undergoing elective surgeries for middle ear were included in this study. exclusion criteria were diabetes, hypertension, psychiatric illness, intake of antipsychotics, sedatives and antiepileptic drugs, sleep disorders, obesity and drug allergy. result and conclusion: both melatonin (6mg) and dexmedetomidine (1g/kg) can attenuate the haemodynamic changes during laryngoscopy and intubation. in dexmedetomidine large dose (1g/kg) there were more cases of hypotension and bradycardia are seen, than in comparison of (0.5 g/kg) of dexmedetomidine. combination of melatonin (6mg) and dexmedetomidine low dose (0.5g/kg) can attenuate the haemodynamic changes during laryngoscopy and intubation better than alone use of melatonin(6mg) and dexmedetomidine (1g/kg). abstract keywords : laryngoscopy, intubation, haemodynamics, melatonin, dexmedetomidine. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. chavi sethi assistant professor department of anaesthesiology and critical care medicine, m.l.b. medical college jhansi dr. sushant priya bilania junior resident department of anaesthesiology and critical care medicine, m.l.b. medical college jhansi 26 x gjra global journal for research analysis obtaining permission from the institutional ethics committee and the identity of the patients would not be revealed. patient selection: following the approval from the ethical committee, asa i and ii, patients between the age of 20 to 50 years of either gender and surgery requiring general anaesthesia for duration longer than 30 min, patients with normal airway with mpg i and mpg ii, >90 degree neck movement, no buck teeth undergoing elective surgeries for middle ear were included in this study. exclusion criteria: exclusion criteria were diabetes, hypertension, psychiatric illness, intake of antipsychotics, sedatives and antiepileptic drugs, sleep disorders, obesity and drug allergy. likewise, patients with anticipated difcult intubation and those requiring more than one attempt or more than 20 seconds for laryngoscopy were excluded from the study. sample size and allocation: all the selected 150 patients were randomly assigned to one of the following 3 groups and each group were containing 50 patients each. ÿ group1-patients received oral melatonin 6mg (2tablets) 2 hours before surgery with (i.v) normal saline (0.9%) 50 ml, 10 min before start of surgery. ÿ group 2patients received oral vitamin d3 (placebo) 2 tablets 2 hours before surgery with (i.v) dexmedetomidine 1 µ/kg in 50 ml, 10 min before start of surgery. ÿ group 3patients received oral melatonin (2 tablets) 2 hours before surgery with (i.v) dexmedetomidine 0.5 µ/kg in 50 ml, 10 min before start of surgery. statistical analysis: the statistical analysis was done by using the spss software v-16. values will be expressed as mean ± standard deviation (sd) and as percentage for categorial parameters. differences between groups was compared with student's ttest for parametric continuous variables. anova t-test for comparison between three or more than three groups. chisquare test was applied for estimating the occurrence of categorical variables. a p value <0.05 was used as the threshold of statistical signicance. result fig.-1: distribution of patients according to type of surgery. fig 1: shows the distribution of patients according to type of surgery. there was no statistically signicant difference between the mean of patients in these groups (p>0.05). fig 2: mean heart rate (h.r) at different time intervals. in fig 2: mean heart rate was lower in group 3 patients, followed by group 2 patients and was more in group 1 patients just after laryngoscopy and intubation. after intubation from (1 mint to 10 mint) the mean heart rate was more stable and shows less variation from the baseline in group 3 patients, followed by group 2 patients and then in group 1 patients. fig 3: mean systolic blood pressure( s.b.p) at different time intervals. fig 3:. mean duration of s.b.p was lower in group 3 patients, followed by group 2 patients and was more in group 1 patients just after laryngoscopy and intubation. after intubation from (1 mint to 10 mint) the mean s.b.p was more stable and shows less variation from the baseline in group 3 patients, followed by group 2 and then in group 1 patients. fig 4: mean diastolic blood pressure (d.b.p) at different time intervals. fig 4: mean d.b.p was lower in group 3 patients, followed by group 2 patients and was more in group 1 patients just after laryngoscopy and intubation. after intubation from (1 mint to 10 mints) the mean d.b.p was more stable and shows less variation from the baseline in group 3 patients, followed by group 2 and then in group 1 patient fig 5: mean arterial pressure (m.a.p) at different time intervals. fig 5: m.a.p was lower in group 3 patients, followed by group 2 patients and was more in group 1 patients just after laryngoscopy and intubation. after intubation from (1 mint to 10 mints) the m.a.p was more stable and shows less variation from the baseline in group 3 patients, followed by group 2 and then in group 1 patient volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra fig 6: mean spo at different time intervals.2 fig 6: mean arterial saturation (spo2) was maintained above 99 % during laryngoscopy and intubation in all the three groups. although fall in saturation are seen in group 2 patients before laryngoscopy and intubation due to sedation but it was not found signicant. (p>0.05) discussion laryngoscopy and endotracheal intubation are potent stressful stimuli that provoke haemodynamic response like tachycardia and hypertension that can lead to myocardial ischemia, ventricular arrhythmia, left ventricular failure, and cerebral hemorrhage. for it an orally administered drug i.e.melatonin (n-acetyl 5-methoxy-tryptamine) with several unique properties that make it ideal for attenuation of haemodynamic changes which occurs during laryngoscopy and intubation in comparison to the (i.v) infusion of dexmedetomidine (alpha 2 agonist) which can also blunt the haemodynamic changes but with more complications such as hypotension and bradycardia in comparison of oral melatonin. [5]premraj nagarwal et. al , (2019) conducted a study on melatonin undergoing a sternotomy (patients undergoing cabg) and concludes that melatonin is an effective drug to attenuate cardiovascular responses of laryngoscopy, endotracheal intubation. [6]adithi devi e, et al ,(2018) conducted a study on melatonin (6 mg tablets) on 60 patients .the study concludes that exogenously administered melatonin 6mg orally 120 min prior to intubation helps in attenuation of hemodynamic responses to laryngoscopy, intubation and extubation. it also helps in maintaining a stable hemodynamics intra-operatively. second, melatonin which is used to allay preoperative anxiety in patients have also antinociceptive, antidepressant anxiolytic, blood pressure reducing activity and pain modulating effects and that when combined with low dose of dexmedetomidine of 0.5 µg/kg can attenuate the haemodynamic changes with less sedation property in better way when compared with large dose of dexmedetomidine 1 µg/kg respectively. third, dexmedetomidine in(0.5g/kg) causes minimal haemodynamic changes alterations and complications like respiratory impairment, hypotension and bradycardia when given in low dose. as compared to larger dose of (1 µg/kg). the primary outcome of our current study showed that orally administered melatonin(6mg) with low dose (0.5µg/kg) of dexmedetomidine can attenuate the haemodynamic changes occurs during laryngoscopy and intubation during middle ear surgeries. [7]bon sebastian, et. al (2017) have used dexmedetomidine in a dose of 0.5µg/kg and 1 µg/kg and found them to be effective in attenuation of stress response to laryngoscopy and endotracheal intubation but with more cases of decreased arterial saturation (spo2) below 92% in some cases, similarly as we noted in group 2 where 3 patient need oxygen supplementation when there spo2 falls below 92%. [4]priyamvada gupta, et. al , (2016) took normal airway sample population and excluded mpg grade iii and iv and with comorbidity (diabetes, hypertension, psychiatric illness, intake of antipsychotics, sedatives and antiepileptic drugs, sleep disorders, obesity and drug allergy). in a study similar to ours, in this study also, we excluded the patients with difcult airway which need laryngoscopy more than 20 seconds and included the patients with mpg grade i and ii with normal weight and bmi ; >90 degree neck movement ; no buck teeth and all the groups were comparable. in a dose of 0.5 µg/kg and 1 µg/kg of dexmedetomidine each and its was found that, both of them to be effective in attenuation of stress response to laryngoscopy and endotracheal intubation but with more cases of decreased arterial saturation (spo2) below 92% in some cases of 1 µg/kg dose of dexmedetomidine, similarly as we noted in group 2 of dexmedetomidine (1µg/kg) dose where 3 patient need oxygen supplementation when there spo2 falls below 92%. conclusions following conclusion were drawn in discussion after the present study: ÿ demographic data i.e. age, male: female ratio, weight comparable in all the groups. ÿ mean heart rate was more stable and showed less variation from baseline heart rate value in group 3 patients (melatonin and dexmedetomidine combination) till upto 10 minutes after intubation as compared to other groups. ÿ mean systolic blood pressure was more stable and showed less variation from baseline systolic blood pressure value in group 3 patients (melatonin and dexmedetomidine combination) till upto 10 minutes after intubation as compared to other groups. ÿ mean diastolic blood pressure was more stable and showed less variation from baseline diastolic blood pressure value in group 3 patients (melatonin ad dexmedetomidine combination) till upto10 minutes after intubation as compared to other groups. ÿ mean arterial blood pressure was more stable and showed less variation from baseline mean arterial pressure value in group 3 patients (melatonin and dexmedetomidine combination) till up to 10 minutes after intubation as compared to other groups. ÿ mean arterial saturation (spo is >95 % in group 1,group 2) 2 and group 3 patients, and in group 2 , there were 6 cases reported where arterial saturation ( spo2) falls below 95% and 3 cases were reported where arterial saturation falls below 92% which is supplemented by oxygen, after iv infusion of study drug (dexmedetomidine 1 µg/kg). it can be therefore be concluded that:ÿ both melatonin(6mg) and dexmedetomidine (1g/kg) can at tenuate the haemodynamic changes dur ing laryngoscopy and intubation. ÿ in dexmedetomidine large dose (1g/kg) there were more cases of hypotension and bradycardia are seen, than in comparison of (0.5 g/kg) of dexmedetomidine. ÿ combination of melatonin(6mg) and dexmedetomidine low dose(0.5g/kg) can attenuate the haemodynamic changes during laryngoscopy and intubation better than alone use of melatonin(6mg) and dexmedetomidine (1g/kg). combination of melatonin (6 mg) and dexmedetomidine low dose (0.5 g/kg)can attenuate the haemodynamics with less x 27gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra sedation property in a better way as compared to larger dose of dexmedetomidine references: 1. amboss prepare and succeed on your medical exams. https://www. amboss.com/us/knowledge/ airway_management. 2. h jarineshin,* a abdolahzade baghaei,* f fekrat,* a kargar,* n abdi,* s navabipour,** a zare,*** and h akhlagh.comparison of two different doses of dexmedetomidine in attenuating cardiovascular responses during laryngoscopy and endotracheal intubation: a double blind, randomized, clinical trial study.j med life. 2015; 8(spec iss 4): 45–51. 3. priyamvada gupta, durga jethava, ruchika choudhary, and dharam das jethava.role of melatonin in attenuation of haemodynamic responses to laryngoscopy and intubation.indian j anaesth. 2016 oct; 60(10): 712–718. 4. priyamvada gupta, durga jethava, ruchika choudhary, dharam das jethava.role of melatonin in attenuation of haemodynamic responses to laryngoscopy and intubation.original article year : 2016 | volume : 60 |issue : 10| page : 712-718. 5. premraj nagarwal1 , swapnil modi2 gaurav goyal3.effect of preoperative oral melatonin on attenuating haemodynamic responses of laryngoscopy, intubation and sternotomy in patients undergoing cabg..iosr journal of dental and medical sciences (iosr-jdms) e-issn: 2279-0853, p-issn: 22790861.volume 18, issue 8 ser. 12 (august. 2019), pp 07-11. 6. adithi devi e1, w r pathanjali rao2*, pavani kalyanam3.a prospective study on role of melatonin in attenuation of haemodynamic responses to laryngoscopy intubation and extubation.table of content volume 8 issue 2 november 2018. 7. bon sebastian, anand t talikoti, dinesh krishnamurthy.attenuation of haemodynamic responses to laryngoscopy and endotracheal intubation with intravenous dexmedetomidine: a comparison between two doses.original article year : 2017 | volume : 61 | issue : 1 | page : 48-54 volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 28 x gjra global journal for research analysis introduction the number of anter ior cruciate l igament (acl) reconstructions has increased over past few years. despite the 1,2,3,4,5high success rate (75 95 % according to various reports the number of revision acl surgery has also risen. recurrent 6symptomatic instability and presence of giving-way episodes are reliable indicators of acl failure. when failure 6has been dened as recurrent laxity (side to-side laxity in excess of 5 mm or grade 2+ or greater on pivot shift testing), the reported prevalence has ranged from 10% -25%.patient selection, graft and xation choice and choice of surgical technique are considered essential to successful revision surgery. with regard to graft choice, allografts seem to have 8,9been gaining in popularity over the past few years , despite the numerous downsides (i.e. prolonged time of biological xation and remodel , reduced availability and costs, possible risk of infection from disease transmission). for this reason, autografts remain the treatment of choice for both primary and revision acl reconstruction. the bone-patellar tendon10bone(bptb) remains the preferred graft source for acl reconstruction in case of hamstring failure and vice versa. the number of anterior cruciate ligament (acl) recon structions has increased over the past few years. despite the high success rate (between 75 and 95 % according to various reports [6,12,21,25,29,34], the number of revision acl surgery has also risen [18]. recurrent symptomatic instability and the presence of givingway episodes are reliable indicators of acl failure. patient selection, graft and xation choice and choice of surgical technique are considered essential to successful revision surgery. with regard to graft choice, allografts seem to have been gaining in popularity over the past few years, despite the the number of anterior cruciate ligament (acl) reconstructions has increased over the past few years. despite the high success rate (between 75 and 95 % according to various reports [6,12,21,25,29,34], the number of revision acl surgery has also risen [18]. recurrent symptomatic instability and the presence of givingway episodes are reliable indicators of acl failure. patient selection, graft and xation choice and choice of surgical technique are considered essential to successful revision surgery. with regard to graft choice, allografts seem to have been gaining in popularity over the past few years, despite the studies have dealt with the outcomes of revision surgery with use of hamstring tendons .in our case we have used 11,12 doubled gracilis and semitendinosus tendon graft for revision acl reconstruction .15 case report: a 34 year old male patient came with chief complaint of instability while walking and climbing stairs since last 5 months. patient had history of acl reconstruction in the same limb 10 years ago after which patient had no complaint regarding instability. thereafter patient suffered an injury while playing football 2 years ago. 5 months ago while playing volleyball patient had again twisting injury after which he had developed gross instability. on examination patient had lachman grade 3 with pivot test grossly positive .(+3) knee rom was normal with mcmurray test negative and was advised some investigations x-ray was taken showing titanium screw xation on both femoral and tibia side with incision over knee s/o bptb graft harvest in the primary acl surgery. fig.1 primary surgery incision(bptb graft ) mri showed high grade acl re-tear in the same previously operated knee. fig.2 arthroscopic revision acl reconstruction with ipsilateral autologous hamstring graft original research paper nirav soni nirav sonivaishvi orthopaedic hospital orthopaedics the number of revision anterior cruciate ligament (acl) surgery has risen over the past few years. revision acl surgery is recommended for patients who have symptomatic objective pathological laxity after a failed primary acl reconstruction. the choice of graft in revision surgery remains a debatable issue. autografts constitute a popular choice as many authors recommend autografts both for primary and revision acl reconstruction. we present a case of 34 year old man with operated case of acl reconstruction using bptb graft 10 years ago with complaint of instability and difculty in walking post trauma since 5 months with mri s/o complete acl tear for which he underwent revision acl reconstruction arthroscopically with ipsilateral hamstring graft( semi t and gracilis). the number of patients with recurrent instability after a failure of an anterior cruciate ligament reconstruction has risen since last 10-15 years. abstract keywords : jaimeen jesalpura* jaimeen jesalpura-vaishvi orthopaedic hospital *corresponding author chirag patel chirag hospital-vaishvi orthopaedic hospital volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 30 x gjra global journal for research analysis fig3.a screws removed fig3.b hamstring graft patient was explained for revision acl reconstruction with planning of taking ipsilateral hamstring graft on the basis of the diameter of screw inserted on the tibia side. fig 4. arrow shows vertical femoral tunnel made in primary surgery according to the images of x-ray and mri ,the tunnel was made vertical as transtibial technique 10 years ago in the primary surgery. fig 5. screw inserted in primary surgery on femoral side fig 6. the diameter of the bio screw removed on the tibial side was 7mm and thus hamstring graft of semi-t and gracilis was taken from the same side with graft diameter of 9mm and anatomical femoral tunnel was made . the femoral side bio screw inserted previously was removed as it was obstructing the new anatomical path of the revised acl. fig 6. a fig 6.b fig 7 thus revision acl reconstruction was done with implants of titanium screw on tibial side of 9*30mm and femoral side adjustable endobutton was used . post op lachman and pivot both were negative and thus the idea of doing extra articular illiotibial band tenodesis for stability was not avoided after reconstruction. patient was advised physiotherapy of static quads extension, closed chain knee rom gradual active, and ankle pumping. since it was a revision surgery, accelerated rehabilitation program was avoided. discussion the number of patients with recurrent instability after a failure of an anterior cruciate ligament reconstruction has risen during the last 10-15 years because of increase in the primary acl reconstructions . it is accepted that not all patients with a 1-5 failed anterior cruciate ligament reconstruction are candidates for revision surgery. patients who have recurrent symptoms of instability during sports activities or activities of daily living as well as objective ndings of laxity (positive lachman and pivot shift tests) are candidates for revision surgery . however, patients with pain and swelling alone, 7-8 without laxity, could have a meniscal tear or cartilage degeneration and probably are not suitable for anterior cruciate ligament revision surgery. these case had knee pain and instability during sports and daily activities and instability on objective evaluation. the most common etiologic factor in failures of anterior cruciate ligament reconstructions is considered to be an error in surgical technique—i.e., improper intra-articular placement of the graft with impingement of the graft in the intercondylar notch, improper tensioning of the graft, or inadequate graft xation. surgical revision of a failed anterior cruciate ligament reconstruction requires thorough preoperative planning and evaluation of the factors that may have caused the failure . the evaluation 10 should include a radiographic examination to evaluate the volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 31gjra global journal for research analysis orientation of the tunnels (and any possible enlargement of them) and the type of pre-existing xation devices. in our case, there was no need to undergo two stage procedure as the primary surgery was done with transtibial technique thus having vertical femoral tunnel and we created anatomic tunnel in the revision surgery . the use of allograft tissue for a 11 revision anterior cruciate ligament reconstruction has been criticized . the cost of the tissue, the efciency of the 12 procedure in patients with chronic instability, and disease transmission should all be considered. use of a bone-patellar tendon-bone graft from the contralateral side necessitates harvesting of the graft from the contralateral, healthy leg and often patients are reluctant to pursue this approach . our rst choice for revision anterior cruciate ligament reconstruction is the use of ipsilateral hamstring tendons. some authors have criticized the use of hamstring tendons for revision of a primary reconstruction that had been performed with a bonepatellar tendon-bone graft because the hamstring tendons are generally several millimeters smaller in diameter than the patellar tendon bone plugs. thus, many of these patients have expanded tunnels, and one of the keys for a successful hamstring reconstruction is appropriate “t and ll” of the graft in its host tunnel . therefore, the problem with revision 13 anterior cruciate ligament surgery with a doubled gracilis and semitendinosus tendon graft seems to be secure xation of the graft in the tunnels employed.in the last few years, the use of an accelerated rehabilitation program after anterior cruciate ligament reconstruction has become widely accepted. however, it is well known that secure tendon-to-bone healing requires at least twelve weeks. therefore, accelerated rehabilitation, and the related micro motion of the graft in the tunnels, could compromise the bone-tendon interface, resulting in poor biological xation . when hamstring grafts 14 are used, especially in revision surgery and even when strong and stiff xation devices are utilized, we believe that a slower rehabilitation program such as the one employed in the present study should be followed. conclusion: hereby we present a case of revision acl reconstruction where primary surgery done with bptb graft had vertical tunnel due to transtibial approach gave us an opportunity to make a more strong anatomical femoral tunnel for acl with better prognosis for which hamstring graft was enough providing good tension and strength without any extra articular illiotibial band tenodesis. references: 1. wirth cj, kohn d. revision anterior cruciate ligament surgery: experience from germany. clin orthop relat res. 1996;325:110-5. 2. greis pe, steadman jr. revision of failed prosthetic anterior cruciate ligament reconstruction. clin orthop relat res. 1996;325:78-90. 3. johnson dl, swenson tm, irrgang jj, fu fh, harner cd. revision anterior cruciate ligament surgery: experience from pittsburgh. clin orthop relat res. 1996;325:100-9. 4. uribe jw, hechtman ks, zvijac je, tjin-a-tsoi ew. revision anterior cruciate ligament surgery: experience from miami. clin orthop relat res. 1996;325:91-9. 5. noyes fr, barber-westin sd. revision anterior cruciate ligament surgery: experience from cincinnati. clin orthop relat res. 1996;325:116-29. 6. yoshiya s, matsui n, matsumoto a, kuroda r, lee s, kurosaka m. revision anterior cruciate ligament reconstruction using the regenerated semitendinosus tendon: analysis of ultrastructure of the regenerated tendon. arthroscopy. 2004; 20:532-5. 7. harner cd, gifn jr, dunteman rc, annunziata cc, friedman mj. evaluation and treatment of recurrent instability after anterior cruciate ligament reconstruction. instr course lect. 2001;50:463-74 8. pearl aj, bergfeld ja, editors. extraarticular reconstruction in the anterior cruciate ligament decient knee. champaign, il: human kinetics; 1992 9. getelman mh, friedman mj. revision anterior cruciate ligament reconstruction surgery. j am acad orthop surg. 1999;7:189-98. 10. jaureguito jw, paulos le. why grafts fail. clin orthop relat res. 1996;325:25-41 11. ferretti a, de carli a, conteduca f, mariani pp, fontana m. the results of reconstruction of the anterior cruciate ligament with semitendinosus and gracilis tendons in chronic laxity of the knee. ital j orthop traumatol. 1989; 15:415-24. diamantopoulos ap, lorbach o, paessler hh (2008) anterior cruciate ligament revision reconstruction: results in 107 patients. am j sports med 36:851–8607. drogset jo, strand t, uppheim g, odega ˚rd b, bøe a, grøntvedt t (2010) autologous patellar tendon and quadrupled hamstring grafts in anterior cruciate ligament reconstruction: a prospective randomized multicenter review of different xation methods. knee surg sports traumatol arthrosc 18:1085–1093 8. ferretti a, conteduca f, labianca l, monaco e, de carli a (2005) evolgate xation of doubled exor graft in anterior cruciate ligament reconstruction: biomechanical evaluation with cyclic loading. am j sports med 33:574–582 12. diamantopoulos ap, lorbach o, paessler hh (2008) anteriorcruciate ligament revision reconstruction: results in 107 patients.am j sports med 36:851–8607. 13. drogset jo, strand t, uppheim g, odega˚rd b, bøe a, grøntvedtt (2010) autologous patellar tendon and quadrupled hamstringgrafts in anterior cruciate ligament reconstruction: a prospectiverandomized multicenter review of different xation methods.knee surg sports traumatol arthrosc 18:1085–10938. 14. ferretti a, conteduca f, labianca l, monaco e, de carli a(2005) evolgate xation of doubled exor graft in anterior cru-ciate ligament reconstruction: biomechanical evaluation withcyclic loading. am j sports med 33:574–582 15. paxton es, kymes sm, brophy rh (2010) cost-effectiveness ofanterior cruciate ligament reconstruction: a preliminary compari-son of single-bundle and double-bundle techniques. am j sportsmed 38:2417–2425 volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 32 x gjra global journal for research analysis introduction there are three major types of cold sensitive antibodies producing clinical manifestations : cold agglutinins causing cold agglutinin disease , donath landsteiner antibodies causing paroxysmal nocturnal hemoglobinuria and cryoglobulins causing systemic vasculitis . 1. cold agglutininsthese are antibodies that recognize antigens on the surface of rbcs at temperatures below the normal body temperature and cause agglutination of rbcs and extravascular hemolysis resulting in anemia , typically without hemoglobinuria . these are typically ig m antibodies directed against i or i antigens on the rbc surface . 2. donath landsteiner antibodies – these are typically igg antibodies that recognize rbc antigens at lower temperatures and bind specically to p antigen on the rbc surface and cause complement mediated lysis of rbc and not agglutination unlike cold agglutinins. thus, causing intravascular hemolysis with hemoglobinuria .leading to paroxysmal nocturnal hemoglobinuria . 3. cryoglobulins – these are antibodies occurring in association with hcv , autoimmune disorders or monoclonal gammopathy that form immune complexes at lower body temperature without involving rbc and thus lead to systemic vasculitis. cold agglutinin disease is primarily of two types 1. primary cold agglutinin disease – that which occurs in absence of an underlying disorder . this is extremely rare with an estimated incidence of 1 per million and an estimated prevalence of 16 per million .the female to male ratio is 2:1 and the mean age at presentation is 67 years with a range from 30 to 92 years. cold agglutinin aiha constitutes only 20 to 25% , of all the aiha cases . 2. secondary cold agglutinin disease – that which occurs in the setting of an underlying disease which mostly are infections, autoimmune disorders and lymphoid malignancies . ÿ infections – these are the cause of cold agglutinin disease in adolescents and young adults .the mechanism implicated is sharing of antigens on the rbc membrane and the infectious agents. the most common infections implicated are mycoplasma pneumoniae and ebstein bar virus . although there have been cases reported following hiv , rubella , inuenza and vzv virus . all the indiviuals having cold agglutinins following infection may not develop the cold agglutinin disease . but , amongst those who develop disease , the symptoms typically occur after two weeks of infection and begin to subside gradually as the infection resolves and typically last for 2 to 3 months . ÿ autoimmune disorders – mainly systemic sclerosis and rheumatoid arthritis . ÿ lymphoid malignancies – mainly implicated are b cell mal ignanc ies l i ke lymphoma , waldens t rom m a c r o g l o b u l i n e m i a , m g u s o r u n s p e c i  e d lymphoproliferative disorders . some salient features of cold agglutinins : ÿ type – majority of cold agglutinins are of ig m subtype . although iga and igg type may also occur .( iga subtype doesn't cause cold agglutinin disease . )ig m antibodies are pentameric which places antigen binding sites on rbc far apart to allow a bridge formation in the distance between two rbcs. thus , multiple rbcs binding to the same igm molecule is the basis of agglutination by this molecule . ÿ light chainsare of kappa type mainly. ÿ specicity – is for i or i antigens on the rbc membrane . ÿ titre – is the number of dilutions after which the antibody can still cause agglutination . it reects antibody concentration and avidity . antibody titre of ≥64 is considered clinically signicant . ÿ thermal amplitude – the usual temperature range at which the antibodies i.e. cold agglutinins are active is 3 to 4 ◌֯c .but , many antibodies are active at a higher temperature such as that occurs in the acral areas of the body . this is because , at lower temperatures , the spontaneous brownian movements are reduced , thus strengthening the interaction i.e. weak hydrogen and van der waals bonds between the antibody and rbc antigens . primary cold agglutinin disease in adolescent age – a rare presentation original research paper dr. v. c. singel ex professor and head of department, department of medicine, b.j. medical college, ahmedabad. medicine cold agglutinin disease is a rare form of autoimmune hemolytic anemia caused by cold reacting auto anti bodies directing against the rbc membrane antigens . majority of cases of cold agglutinin disease are secondary to infections , autoimmune diseases and lymphoproliferative disorders . primary cold agglutinin disease is extremely rare with estimated incidence of 1 per million and prevalence of 16 per million with the mean age of presentation being 67 years . a high index of suspicion and meticulous work up is required for diagnosis of primary cold agglutinin disease . hereby , we aim to discuss a case of primary cold agglutinin disease presented at adolescent age and it's management abstract keywords : cold agglutinins , direct coomb's test , antibody titre , antibody specicity , complement pathway, anemia ,immunosupressants. dr. jitendra h. parikh professor and head of unit , department of medicine, b.j. medical college, ahmedabad. dr. sangita malaviya 2nd year resident, department of medicine, b.j. medical college, ahmedabad. dr. swansu batra* 3rd year resident, department of medicine, b.j. medical college, ahmedabad. *corresponding author dr. krunal patel 2nd year resident, department of medicine, b.j. medical college, ahmedabad. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 54 x gjra global journal for research analysis thermal amplitude is dened as the highest temperature range at which the antibody binds to rbc . most of the clinically signicant cold agglutinins have thermal amplitude that exceeds 28◌֯ to 30◌֯c. ÿ clonality – in primary cold agglutinin disease / those associated with lymphoproliferative disorders , the cold agglutinins are monoclonal in origin and the implicated mutations involve kmt2d and card11 genes . while , in cold agglutinin disease following infections / autoimmune disorders , the cold agglutinins are polyclonal in origin . monoclonal agglutinins require treatment while the poly clonal antibodies generally do not require treatment and disappear spontaneously once the infection resolves. mechanism of hemolysis by cold agglutinins : igm cold agglutinins binds to its cognate ag , i or i on the surface of rbcs and recruits the components of classical complement pathway such as c1 , c4 and c2 . c1-esterase activates c4 and c2, leading to production of the c3 convertase, which cleaves c3 to c3a and c3b, as illustrated in the gure. c3b-coated rbcs are phagocytosed by macrophages in the reticuloendothelial system (ie, extravascular hemolysis), predominantly kupffer cells in the liver. phagocytes tend to engulf the entire cell rather than a portion of the cell membrane, as occurs in phagocytosis mediated by igg. this may explain the absence of spherocytosis in cad (or a relatively less impressive spherocytosis), compared with warm autoimmune hemolytic anemia (aiha). on the remaining circulating rbcs (i.e., those that are not phagocytosed), igm dissociates upon warming, but c3b remains attached. surface c3b undergoes cleavage to c3d, which can be detected by the direct antiglobulin (coombs) test. complement inhibitors such as cd55 and cd59 on the rbc surface prevent the complement cascade from progressing to the terminal pathway in which the membrane attack complex (mac; c5b-9) lyses the cells intravascularly. however, when hemolysis is especially brisk (eg, with concomitant infection, surgery, or other inammatory states), a component of intravascular hemolysis may occur. clinical manifestations of cold agglutinin disease : it can have either of the two manifestations : ÿ features related to cold exposure – acrocyanosis , livedo reticularis , raynaud's phenomenon , cutaneous necrosis/ digital ulceration and pain or discomfort on swallowing cold foods /liquids . all these features reverse on warming. ÿ features related to anemia – generalized weakness , easy fatiguability , breathlessness on exertion or signs and symptoms suggestive of hyperdynamic state . some individuals may also develop jaundice or mild splenomegaly. diagnosis of cold agglutinin disease : diagnostic criteria includes the following : ÿ evidence of hemolysis (eg, high reticulocyte count, high ldh, high indirect bilirubin, low haptoglobin) ÿ positive direct antiglobulin (coombs) test for c3d only (or, in a minority, c3d plus igg) ÿ cold agglutinin titer of ≥64 at 4°c the accepted threshold for diagnosis is >1:64 and most experts consider a titer above 1:512 to be clinically signicant; in many cases, the titer is greater than 1:2048. most clinically signicant cold agglutinins have a thermal amplitude that exceeds 28° to 30°c. case report a 17 year old female presented to the emergency room of civil hospital ahmedabad on 29/6/19 with chief complaints of generalized weakness, easy fatiguability and breathlessness on exertion since 2 months . she also had associated complaints of yellowish discoloration of urine and sclera , nausea and abdominal pain since 2 months . she did not have any complaints of pedal edema , chest pain ,palpitations, diarrhea , black stools , decreased urine output or bleeding from any site. also , there were no complaints fever , arthralgia , skin rashes ,weight loss , abnormal swelling in axillary /inguinal region ,back pain ,cola colored urine or bluish discoloration of toes or ngers on exposure to cold. she did not have past history of tb, jaundice, surgery, ischemic heart disease , hypertension, autoimmune disease or a past history of similar illness . also there was no history of patient having any viral illness/ pneumonia in the recent past. there was no signicant family history . she had reduced apetite and was on a vegetarian diet . she had adequate sleep and normal bowel and bladder habits . she had no addiction and no history of drug consumption / blood transfusion before the onset of symptoms . though , she had received 3 blood transfusions at a private hospital in the week prior , before she was admitted at civil hospital , ahmedabad. on examination temperature – normal pulse – 96/min . blood pressure – 110/72 mm hg tongue , conjunctiva and nail – severe pallor sclera – icterus present there was no evidence of cyanosis , clubbing , oedema or lymphadenopathy . respiratory system – bilateral air entry present and no adventitious sounds heard cardiovascular system – s 3 was heard . s1 s2 – normal cns – conscious, oriented. per abdomen – soft , non tender and no palpable hepatomegaly or splenomegaly. investigations hemoglobin – 4.10 gm/dl. (12-15 gm/dl) 3 3 wbc – 10.10 ×10 /cu mm (4-10 ×10 /cu mm ) 6 6 rbc – 0.84×10 / cu mm (3.8-4.8 ×10 /cu mm ) hematocrit – 12.70% (36-47%) mcv – 151  (80-99 ) mch – 49.10 pg (27-32pg ) mchc – 32.50 g/dl (31.5-34.5 g/dl) 3 platelets – 328.00 ×10 /cu mm rdw – 9.30 polymorphs – 74.00% (60-80%) lymphocytes – 17.00% (20-40%) eosinophils – 3.00% (1 – 6%) monocytes – 6.00% ( 2 – 10% ) basophils – 0.00% (0.3-1.5%) peripheral smear – dimorphic picture predominantly macrocytic rbc s with few normocytic normochromic rbcs. rouleaux formation seen . moderate anisopoikilocytosis . macroovalocytes , few spherocytes and polychromatin rbc seen . wbc and platelets within normal limits . malarial parasite not seen . volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 55gjra global journal for research analysis sgpt – 21.10 iu/l (0 – 34 iu/l) sgot – 28 .00 iu/l (0-31 iu/l ) alp – 59 iu/l (58-460 iu/l) total bilirubin – 4.97 mg/dl (0.2-1.2 mg/dl) direct bilirubin – 0.89 mg/dl(0-0.2 mg/dl) total protein – 6.2 mg/dl (6-8.3gm/dl) albumin – 3.6 mg/dl (3.2-5 gm/dl) rbs – 113.8 mg/dl (70-160 mg/dl) urea – 34.70 mg/dl (10-45 mg/dl) creatinine – 0.72 mg/dl (0.6-1.4 mg/dl) sodium – 138 meq/l (136-145 meq/l) potassium – 3.8 meq/l ( 3.5-5.1 meq/l ) aptt – 29.8 (22.1-36.1) pt – 11.5 (9.9-12.3) inr – 1.04 iron – 155 µg/dl (50-170 µg/dl) ferritin – 255 ng/ml (4.63-204 ng/ml) vit b12 > 1500 pg/ml (206-678 pg/ml) reticulocyte count (rc)– 18% (0.5-2.5%) corrected reticulocyte count – 7% lactate dehydrogenase(ldh ) – 729 u/l (81-234 u/l) stool routine micro – occult blood positive urine routine micro – nad 2 am urine specimen routine micro – nad direct coomb's test – grade 4 + indirect coomb's test – grade 3+ sickling test – negative hb electrophoresis – wnl protein electrophoresis – all major fractions within normal limit . monoclonal band not seen . hiv – nr hbsag – nr hcv – nr ana – negative ana prole – negative esr – 2.00 mm . tsh – 0.8750 µiu/ml (0.38-5.33 µiu/ml ) free t 3 – 2.00 pg/ml (2.1 -4.4 pg/ml) free t 4 – 1.21 ng/dl (0.8-2.7 ng/dl) mp by card – negative dengue igm – negative chikungunya igm – negative ebv igm – negative mycoplasma pneumoniae igm – negative sucrose lysis test – negative flow cytometry (pnh immunophenotyping) – in peripheral blood , 86% neutrophils were gated with cd15 apc and 10% monocytes were gated with cd45 percp. on neutrophils , decreased expression of gpi linked antigens cd24 with flaer was not observed in >3% of gated cells . on monocytes , decreased expression of gpi linked antigens cd14 with flaer was not observed in >3% of gated cells . on red blood cells , decreased expression of gpi linked antigens cd59 was not observed in >3% of cells. diagnosis – pnh clone was not detected . advanced red cell serology report antibody screening – agglutination with c3d . antibody titre – 1:512 autoantibody specicity – igm type bone marrow biopsy – normocellular marrow with severe erythroid hyperplasia with normoblastic maturation . few granulocytic precursors and polymorphs seen . m:e ratio is 1:5.5 ( reduced ). ecg – s. tachycardia. chest x ray – nad . usg ( abdo + pelvis ) – liver normal in size and echotexture , spleen 13 cm in size . rest nad. usg for lymph nodes – no evidence of lymph node enlargement seen. course in the hospital patient was admitted at civil hospital ahmedabad on 29/6/19. routine investigations were suggestive of anemia . a high mean corpuscular volume was misleading towards vit b 12 deciency as the cbc was not suggestive of pancytopenia . the routine anemia work up done for the patient, was suggestive of indirect hyperbilirubinemia , high retic count , high ldh , and a positive direct coomb's test thus established the diagnosis in favour of hemolytic anemia . by history , the possibility of drug induced hemolytic anemia was ruled out rst . paroxysmal nocturnal hemoglobinuria was ruled out by 2 am urine sample screening , urine for hemoglobin , sucrose lysis test and flow cytometry . the possibili ty of cryoglobulinemia was ruled out from the history , physical examination of the patient not suggestive of any features of vasculitis and hcv negative status. warm autoimmune hemolytic anemia was ruled out by the antibody specicity negative for igg and positive for c3d in the direct coomb's test . further test done with antibody specic antisera showed a specity of agglutinins to be of igm subtype in the titre of 1 :514. a high mcv found in this case is probably spurious due to rbc agglutination analyzed by an automated blood counter . also , the probable causes for secondary cold agglutinin disease were ruled out by mycoplasma pneumoniae igm , ebv igm , ana prole ,usg abdomen, usg for lymph nodes and bone marrow biopsy. after all the above enumerated work up , a diagnosis of primary cold agglutinin disease was established. till the diagnosis was conrm , patient was empirically started on steroids , methylprednisolone 1 gm diluted in 100 cc ns daily . after 5 days of methylprednisolone pulse therapy , patient was shifted to oral steroids 1 mg/kg/day slowly tapered off to 0.3 mg/kg/day after one month and then to 0.2mg/kg/day during second month and then 0.1mg/kg/day from the third month ,along with maintenance immuno suppression with azathioprine in a dose of 2mg/kg/day . patient was discharged from hospital on 9/7/2019 with oral steroids , azathioprine as mentioned above and rest of the supportive treatment and was called for follow up after 1 month . cbc on follow up , was suggestive of hemoglobin of 10.2 6 3 gm/dl , rbc 2.43×10 /cu mm . , wbc – 6.60 ×10 / cu mm , 3 platelets – 3.54 ×10 /cu mm , mcv – 98 , peripheral smear – normocytic normochromic and no evidence of any abnormal cells . this was a rare case of primary cold agglutinin disease , that was responsive to glucocorticoids , most probable reason being agglutinins having a higher thermal amplitude . discussion regarding treatment of cold agglutinin disease. avoidance of cold is the primary measure to be undertaken . warm blankets are to be provided to the patient . blood products and iv solutions administered should be prewarmed fever or infection should be promptly treated . autoimmune disease if any , should be treated aggressively. glucocorticoids and splenectomy are not effective therapy in the majority of patients with cad, in contrast to warm aiha volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 56 x gjra global journal for research analysis where these therapies are generally very effective . glucocorticoids may downregulate phagocytosis, but they do not block antibody production. exceptions may include individuals with igg cold-reacting antibodies, antibodies with a higher thermal amplitude that cause some warm hemolysis, or mixed warm and cold aiha. splenectomy is likely to be ineffective because the liver is the main site of rbc phagocytosis in cold agglutinin disease unlike that in warm agglutinin disease wherein , spleen is the main site of rbc phagocytosis. for cri t ical hemolysis , when the t ime taken by immunosupressants to take effect is long and not affordable , plasmapheresis and ivig come into rule . plasmapheresis acts by removing igm antibodies in the circulation , but has no effect on the production of igm agglutinins . the optimal exchange volume and number of exchange procedures is unknown and should be guided by clinical ndings and antibody titers; at least one plasma volume per exchange is reasonable. the procedure should be performed in a warm environment and precautions taken to prevent cooling, which could exacerbate cold symptoms and hemolysis. after removal, the half-life for re-accumulation of the igm is approximately ve days. ivig – there is less experience using ivig in cad, and the efcacy has not been well characterized.there have been case reports of it being used in mycoplasma infections and prior to surgery . transfusions — transfusions should be provided when indicated. some individuals may have mild disease and may only require transfusions in the setting of severe hemolysis precipitated by infection or during the winter months specic b cell directed therapies for individuals likely to have a monoclonal cold agglutinin, a specic therapy directed against the clone of b cells or plasma cells producing the antibody is required. rituximab containing regimens — rituximabmay be used alone or in combination with other agents. typical rituximab doses when used as a single agent are based on those used to treat b-cell malignancies (eg, 375 mg/m2 weekly for four weeks) . lower doses (eg, 100 mg xed dose weekly for four weeks) have also been used, but with more frequent failures in cad than in warm aiha. for those with a specic pre-neoplastic b-cell disorder such as monoclonal gammopathy of undetermined signicance (mgus) or for those in whom a rituximabcontaining regimen is ineffective, bortezomib is used. rituximab has been used in combination with bendamustine , udarabine , interferon and steroids . in case of rituximab failed regimens, other immuno supressants like cyclophosphamide, chlorambucil, interferon alpha are also tried . complement directed therapies are under trial . complement component c1 is an attractive target because it has enzymatic activity and is upstream of a number of other classical pathway components . c1 consists of three subunits (c1r, c1s, and c1q) sutimlimab (previously called tnt009) is a humanized monoclonal antibody that targets c1s and has the potential to reduce extravascular hemolysis mediated by c3b. inhibitors of c1q are also candidate drugs for reducing hemolysis in cad. complement protein c3 is another potential target for therapy in cad. c3 is the point of convergence between all three complement-activating pathways and the initiation of the terminal (lytic) pathway. therefore, c3 inhibition is expected to block the entire complement system, including the classical pathway and ensuing c3b opsonization, which are the main drivers of hemolysis in cad. pegcetacoplan (previously termed apl-2) is a pegylated cyclic peptide inhibitor of c3 that is designed for subcutaneous administration. anti-complement therapies such as eculizumab, which targets the more distal complement component c5, would not be expected to lessen hemolysis, which is mostly extravascular and mediated by earlier components of the classical complement pathway, although reports have described reduction of hemolysis in selected individuals.complement directed therapies target the complement mediated lysis and thus prevent extravascular hemolysis but have no effect on the cold induced symptoms. further , it has been proposed that , complement directed therapies have to be used for a long period unlike the immunosupressants that have to be used temporarily . conclusion in patients of hemolytic anemia, an extensive work up is required to establish the cause of hemolysis . antibody specicity is must to determine the type of autoimmune hemolytic anemia . amongst patients with cold sensitive antibodies , it is also necessary to rule out the possibility of donath landsteiner antibodies and cryoglobulins before establishing the diagnosis of cold agglutinin disease . the diagnosis of primary cold agglutinin disease can be established only after completely ruling out the possibility of lymphoproliferative disorders , infections and autoimmune disorders . though primary cold agglutinin disease is rare and usually seen in elderly age , it may be exceptionally seen in the adolescent age also. references 1. harrison’s principle of internal medicine 20th edition chapter 96‘hemolytic anemias’ 2. williams hematology 9th edition chapter 54 ‘ hemolytic anemias resulting from immune injury’ 3. sl schrier , c brugnara – cold agglutinin disease – uptodate.com 4. salman abdullah , aljubran oct 2 , 2018 cold agglutinin disease – medscape. com volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 57gjra global journal for research analysis background stroke is a growing disease. stroke is dened as per the who (world health organization) denition, 'a syndrome of rapidly developing clinical signs of focal or global neurological disturbance lasting for more than 24 hours with no apparent cause other than a vascular origin'. stroke is the third common cause of death in the world after coronary heart disease and (1,2)cancer especially in the elderly .stroke is the second cause of disability and dementia in adults aged ≥ 65 years worldwide: close to 25% of stroke survivors develop dementia (3).uric acid is the ultimate catabolite of purine metabolism in (4)human and higher primates . it exists in the extracellular compartment as sodium urate, and it is cleared from the (5)plasma through the kidney . uric acid levels are inuenced by age and sex. prior to puberty, the average serum uric acid is 3.6 mg/dl for males and females. following puberty, value rises to adult levels with women typically 1 mg/dl less than men. this lower level in women apparently reects estrogen (4)related enhancement of renal urate clearance . cerebral ischemia initiates a complex cascade of metabolic events, (6)generating nitric oxide and free oxygen radicals. these radicals and reactive oxygen species (ros) mediate a great part of injuries appearing after a transitory ischemic attack or during permanent ischemia, modifying macromolecules especially dna , initiating apoptosis and necrosis.uric acid has been known to exert neuroprotective effects by acting as a (14)free radical scavenger . aim and objectives : 1. to estimate serum uric acid levels in patients of acute ischemic stroke and nd correlation. 2. to study the relationship between serum uric acid levels and clinical severity of acute ischemic stroke. 3. to study the variation related to gender and age. materials and method : this is an observational , case control study which was conducted on 50 patients diagnosed with acute ischemic stroke admitted in icu, neurology and medicine ward in geetanjali medical college and hospital, udaipur. 50 controls will also be included in the study with unrelated ailments.the study was conducted from june 2018 to december 2018.data of patients were collected by detailed history, clinical examination, investigations and diagnosis conrmed by mri or ct brain. apart from routine invest igations, serum uric acid estimation was done. the severity of stroke was assessed as per glasgow coma scale (gcs). selection of cases: inclusion criteria: patients with acute ischemic stroke >18 years of age exclusion criteria: patients with evidence of space occupying lesions,patients with hemorraghic stroke patients with ischemic conditions other than stroke, patients with a known or possible cardiac source of emboli, history of intake of drugs known to alter uric acid levels, history of gouty arthritis or clinical evidence of gout, patients with venous infarct, history of renal insufciency, patients with acidosis including dka, lactic acidosis and starvation acidosis, history of thyroid dysfunction, malignancy, recent excessive alcohol consumption, patients with down's syndrome. selection of controls: patients with unrelated illess >18 years of age were selected and exclusion criteria included acute ischemic stroke patients and rest same as for cases. results : with equal number of cases and controls, i.e. 50 in each group. mean age of 100 patients was 59.06±13.32 years.the mean age group in cases was 60.56±13.53 years and in control was 57.56±13.06 years.mean blood uric acid level in cases was 4.98±1.45 and in control was 4.36±1.45 mg/dl, this difference was statistically signicant at p value of 0.035.the correlation between serum uric acid levels and severity of stroke was not statistically signicant.(p value-0.6154). for cases pearson's correlation between serum uric acid level and age was 0.348 which is statistically signicant.(p value =0.012) table 1. blood uric acid level distribution correlation between serum uric acid levels and acute ischemic stroke original research paper dr. ashutosh dudhatra resident, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india x 21gjra global journal for research analysis general medicine background– in this study, we determined serum uric acid levels in patients with acute stroke and assessed its relationship with disease severity. methodthis is an observational, case control study on patients diagnosed with acute ischemic stroke in geetanjali medical college and hospital, udaipur.50 cases and 50 controls were included in the study.serum uric acid levels along with other blood routine tests were done. resultsthe mean age group in cases was 60.56±13.53 years and in control was 57.56±13.06 years. male preponderance was seen in both cases and control.mean blood uric acid level in cases was 4.98±1.45 and in control was 4.36±1.45 mg/dl, this difference was statistically signicant at p value of 0.035. the correlation between serum uric acid levels and severity of stroke on basis of gcs score was not statistically signicant.(p value-0.6154). conclusionthis study concludes that serum uric acid can be used as pathological biomarker in patients of acute ischemic stroke but of severity of disease cannot be predicted by its levels. abstract keywords : uric acid, stroke volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. sanjay paliwal* associate professor, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india *corresponding author uric acid levels cases controls total 0-6 36 41 77 6.01-6.50 5 6 11 6.51-7 4 2 6 7.01-7.50 3 0 3 7.51-8 2 1 3 22 x gjra global journal for research analysis table 2. severity of gcs and s.uric acid level in cases table 3. difference between cases and controls discussion : a stroke can be dened as an abrupt onset of a neurologic decit that is due to a focal vascular cause. stroke is an important cause of morbidity and long term disability.serum uric acid is one of the major aqueous antioxidant in human beings. thus it should have a protective role in stroke. however there are only few studies that have concluded higher levels of serum uric acid being neuroprotective in [19-22]patients with stroke. in our study,mean blood uric acid level in cases was 4.98±1.45 and in control was 4.36±1.45 mg/dl, this difference was statistically signicant at p value of 0.035.kaur i et al, 2017 reported higher serum uric acid level i.e. 6.15±1.91 in cases and 5.1±1.4 in controls, and this difference was statistically signicant. srikrishna r et al found that serum uric acid levels were signicantly higher in cases as compared to controls (6.56±0.73 versus 4.66±0.47, p (23)< 0.05) .in, the rotterdam study, high serum uric acid levels (24)were associated with the risk of stroke .mbenza lb et al found signicantly higher serum uric acid level in males (6.6±7 versus 5.8±6 mg/dl, p < 0.01) which is contrasting to (25)present study where we found no signicant difference .the correlation between severity of stroke based on gcs score and uric acid levels was not statistically signicant in our study (p value being 0.6154).this nding is in contrast to kaur i et al, 2017 where they reported statistically signicant difference in serum uric acid level nding when the gcs score (26)is severe . conclusion : serum uric acid can be used as pathological biomarker in patients of acute ischemic stroke.however the levels do not correlate with severity of the disease. references : 1. hariklia vd, apostolos h, haralambosk the role of uric acid in stroke. the lssue remains unresolved. the neurologist. 2008;14:238–242. 2. feigin vl, lawes cm, bennett da, et al. worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. lancet neurol. llibre j, valhuerdi a, fernandez o. prevalence of stroke and associated risk factors in older adults in havana city and matanzas provinus, cuba (10/66 population-based study) medicc review. 2010;12:20–24. 3. llibre j, valhuerdi a, fernandez o. prevalence of stroke and associated risk factors in older adults in havana city and matanzas provinus, cuba (10/66 population-based study) medicc review. 2010;12:20–24. 4. barr wg. uric acid. in: walker hk, hall wd, hurst jw, editors. clinical methods. the history, physical, and laboratory examination. 3rd ed. boston: butter worth; 1990. pp. 760–763. 5. heo sh, lee sh. high levels of serum uric acid are associated with silent brain infarctivn. jaurnal of the neurol scien. 2010;297:6–15. 6. love s. oxidative stress in brain ischemia. brain pathol zurich switz.1999;9(1):119-31. 7. fang j, alderman mh. serum uric acid and cardiovascular mortality the nhanes i epidemiologic follow-up study 1971-1992. national health and nutrition examination survey. jama. 2000;283(18):2404-10. 8. chamorro a, obach v, cervera a. prognostic signicance of uric acid serum concentration in patients with acute ischemic stroke. stroke. 2002;33(4):104852. 9. romanos e, planas am, amaro s, chamorro a. uric acid reduces brain damage and improves the bents of rtpa in a rat model of the thromboembolic stroke. j cereb blood flow metab. 2007;27(1):14-20. 10. bansal bc, gupta rr, bansal mr, et al. serum lipids and uric acid relationship in ischemic thrombotic cerebrovascular disease. stroke. 1975;6:304–307. 11. milionis hj, kalantzi kj, goudevenos ja, et al. serum uric acid levels and risk for acute ischaemic non-embolic stroke in elderly subjects. j intern med. 2005;258:435–41 12 cazzato g, zorzon m, mouti f, et al. the blood level of uric acid as a risk factor in transient cerebral ischemic attack and non-embolic acute infarct. riv neurol. 1982;52:355–369. 13 hozawa a, folsom ar, ibrahim h, et al. serum uric acid and risk of ischemic stroke: the aric study.atherosclerosis. 2006;187(2):401–407. 14. bos mj, koudstaal pj, hofman a, et al. uric acid is a risk factor for myocardial infarction and stroke. the rotterdam study. stroke. 2006;37:1503–1507. 15. newman ej, rahman fs, lees kr, weir cj, walters mr. elevated serum urate concentration independently predicts poor outcome following stroke in patients withdiabetes. diabetes metab res rev. 2006;22(1):79-82. 16. amaro s, urra x, gomez-choco m. uric acid levels are relevant in patients with stroke treated with thrombolysis. stroke. 2011;42:28–32. 17. weir cj, muir sw, walters mr, et al. serum urate as an independent predictor of poor outcome and future vascular events after acute ischemic stroke. stroke. 2003;34:1951–1956. 18. yadav sk, nep al n, niroula d. prevalence of hyperuricemia among people of morang district of nep al. journal nobel medical college. 2014;3(6):1621. 19. brouns r, wauters a, van d, vijver g. decrease in uric acid in acute ischemic stroke correlates with stroke severity, evolution and outcome. clin chem lab med. 2010;48(3):383-90. 20. log allo n, naess h, idicula tt. serum uric acid: neuroprotection in thrombolysis. the bergen norstroke study. bmc neurol. 2011;11:114. 21. wang z, lin y, liu y. serum uric acid levels and outcomes after acute ischemic stroke. mol neurobiol. 2016;53(3):1753-9. 22. chamorro a, obach v, cervera a, revilla m, deulofeu r, aponte jh. prognostic signicance of uric acid serum concentration in patients with acute ischemic stroke. stroke 2002; 33: 1048-1052 23. shrikrishna r, suresh dr. biochemical study of antioxidant prole in acute ischemic stroke. british j med practitioners. 2009:2(1):35-7. 24. bos mj, koudsta al pj, hofman a, witteman jc, breteler mm. uric acid is a risk factor for myocardi al infarction and stroke: the rotterdam study. stroke. 2006 jun;37(6):1503-7. epub 2006 may 4. 25. mbenza b, luila el, mbete p, vita ek. is hyperuricemiaa risk factor of stroke and coronary heart disease among africans? int j cardiol. 1999;71(1):1722. 26. kaur i, khurana a, sachdev jk, mohan g. evaluation of serum uric acid in acute ischaemic stroke. int j adv med 2017;4:60-5. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra gcs sua <6 sua >6 p value <12 3 2 0.6154 >12 33 12 cases(n=50) controls(n=50) p value age 60.56±13.53 57.56±13.06 0.262 sex male 32 27 0.4162 female 18 23 uric acid level 4.98±1.45 4.36±1.45 0.035 introduction non communicable diseases are the leading cause of mortali ty which includes cardiovascular disease, cerebrovascular disease, cancer, chronic respiratory disease and diabetes. diabetes mellitus is assuming epidemic proportion in india as non communicable disease. the prevalence of diabetes mellitus in indian population has consistently increased from 5 % in 1982 to 9% in 2014 which has been proposed to increase futher in future. increasing body weight and reduced physical activity are the two most important risk factor for diabetes mellitus with a prevalence rate of 21.4 % and 12.1% respectively. among all ages, 2% of all deaths in india accounts alone for diabetes mellitus and hence posing a major public health threat. the prevalence of diabetes is expected to differ among subgroups of the population in india because of its large socio-economic and lifestyle differences. the prevalence of type2 diabetes mellitus in urban areas is 2.1 % and in rural areas is 1.5%. in various samples in various studies on indian population, the overall prevalence of diabetes mellitus was 12%, 5.9%, 33.5% and 4.5% hence indicating the high prevalence of diabetes mellitus in indian population and an urgent need of intervention. the current diagnostic criteria for diagnosis of diabetes is based on oral glucose tolerance test where the fasting plasma glucose of 126mg/dl or two hour plasma glucose of 200mg/dl. glycosylated hemoglobin(hba1c) has generated a lot of interest in recent times and is a modied hemoglobin molecule with stable addition of glucose that is linked covalently to the n-terminal valine of the beta chain. hba1c has been recently proposed as a new test to diagnose diabetes with the cutoff value of 6.5%. hba1c is independent of last meal, has less variability and is consistent in reecting glucose level over the last 8 to 12weeks. the aim of our study is to nd correlation between body mass index(bmi), duration of illness, fasting blood glucose(fbg), postprandial blood glucose(ppg) and hba1c level. material and methods after taking the ethical committee from the hospital, 100 patients who were diagnosed of type2 diabetes mellitus attending the opd and on treatment with oral hypoglycemic agents metformin and/or glimepiride were taken. informed consent was taken. detail history including all the vital parameter including age, height, weight, duration of illness, etc was taken from all the patient and duly noted down. body mass index was calculated using the formula of weight divided by square of height. fasting blood glucose and postprandial 2 hours glucose was estimated by glucose oxidase peroxidase method.hba1c was estimated by modied ion-exchange high performance liquid chromatography method using an automatic calibrated chemistry analyser on blood in edta vial. data was collected by various methods on to microsoft excel and spss25.0 software was used for statistical analyses. the correlation of bmi, duration of illness, fasting blood glucose and postprandial blood glucose with hba1c was analysed using spearman correlation. to assess whether bmi, duration of illness, fasting blood glucose and postprandial blood glucose are predictors of hba1c value, linear regression was applied. result out of hundred patients, 60 were male and 40 were female. the mean age of the study population was 55yyears with the range of 40 to 8 years. the duration of illness in the study population was 9years. the mean bmi was 29.6 kg/m² with range of 18 to 48 kg/m². patient had a mean fasting blood glucose of 160 mg/dl and a mean postprandial glucose of 240 mg/dl. the mean hba1c was 8.3 % with maximum value of up to 14%. hba1c was found to be correlated to fasting blood glucose with a correlation coefcient of 0.476 (p<0.01). hb a1c was found to be corelated to ppg with correlation coefcient of 0.456 (p<0.01) as shown in tables. bmi was found to be not correlated with hba1c. there was no statistically signicant correlation between duration of illness and hba1c value. fasting blood glucose, postprandial blood glucose, duration of illness and bmi were found to be predictor of hba1c value when linear regression was applied to test the relationship. the predicted value of hba1c on the basis of these variables lies close to the actual values of hb a1c on y axis and x axis respectively. we can predict the hb a1c value in the in a linear manner if if we know the fbg values and is statistically signicant (p<0.05). correlation between duration of illness, fasting and random blood glucose and hba1c levels in diabetic patients original research paper dr vijay singh baghel associate professor, department of medicine, rkdf medical college bhopal. medicine introduction: type2 diabetes mellitus is reaching epidemic proportions in the indian subcontinent over the year. in this study we test for relationship between duration of illness, bmi and blood glucose levels with hba1c value. material and methods: 100 patients with diabetes mellitus were taken for this study. their anthropometric and disease history was noted down and hba1c and blood glucose levels were estimated biochemically and tests were applied to study correlation between various values. result: the duration of diabetes and bmi were not related to hba1c levels, however fbg and ppg were correlated signicantly with hba1c levels. also bmi, duration of diabetes, fbg and ppg were found to be independent predictors of hba1c levels in these patients. abstract keywords : volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr archana saxena* assistant professor, department of medicine, rkdf medical college bhopal. *corresponding author 58 x gjra global journal for research analysis table 1. variables of type 2 dm patients table 2. correlation between ppg and hba1c values. table 3. correlation between fbg and hba1c values. discussion the majority of study population i was in the middle age category of 40 to 60 years similar in pattern to the global data where 30 to 70 years of age was studied to study the majority of diabetes morbidity and mortality. mohan v et al in his study colaborate it at national level the percentage of diagnosed diabetes in males was higher than in females. satyawati duration range from 1 years to 13 years. increase hb a1c values was seen with increase duration of diabetes in studies by arnetz et al. and kilpatrick et al. vinod study hb a1c and duration of diabetes had no correlation. kabadi et al. in their study found no signicant relationship between duration of diabetes and blood glucose. the bmi in the study group range from 23 to 31 kg per metre square and no correlation was found between bmi and hb a1c. however various studies have shown that there is increased risk of diabetes and insulin resistance with increased bmi. bmi and glucose metabolism are complex li related and free lipids which are deposited in hepatocytes are shown to alter glucose metabolism this may be the reason behind lack of correlation between bmi and hb a1c. in our study we found a statistical is signicant correlation between fasting and postprandial glucose and hb a1c value. gupta et a l. conrmed our ndings and reported signicant correlation between fbg and hba1c value. gazafari et al. and rohlng et al. also found similar correlation between fbg and hba1c value. i our study be found statistical is signicant relationship between bmi duration of illness fasting blood glucose and postprandial with hba1c values. to study the relationship we applied linear regression to the study data. the results were in correlation with the study by rufing etal. which showed a productive relationship between plasma glucose and hba1c values. in our study we observed plasma glucose along with bmi and duration of illness action to protect the value of hba1c. conclusion hb a1c maybe used for monitoring type 2 diabetes mellitus in conjunction with plasma glucose. hba1c is dependent on bmi duration of illness and blood glucose levels and therefore involved in pathogenesis and morbidity and mortality of diabetes mellitus. references 1. who diabetes country proles 2016. www. searo. who. int /india/ topics/diabetes_mellitus/en/ 2. mohan v, anjana rm, pradeep r, unnikrishnan r, kaur t, das ak. the icmr india b study-a compendum of type 2 diabetes in india: lesson learnt from the nation; chapter 241:1104-1110. 3. ramachandran a, snehalatha c, kapur a, vijay v, mohan v, das ak et al. diabetes epidemiology study group in india(desi).high prevalence of diabetes and impaired glucose tolerance in india:national urban diabetes survey. diabetologia. 2001; 44:1094-1101. 4. sadikot sm, nigam a, das s, bajaj s, zargar ah, prasannakumar km et al. diabetes indiathe burden of diabetes and impaired glucose tolerance in india using the who 1999 criteria: prevalence of diabetes in india study(podis).diabetes res clin pract.2004;66:301-307. 5. singh rb, pella d, mechinova v, kartikey k, demeester f, tomar rs et al. five city study group.prevalence of obesity,physical inactivity and undernutrition ,a triple burden of diseases during transition in a developing country. acta cardiol.2007 apr;62(2):119-27. 6. mohan v, mathur p, deepa r, deepa m,shukla dk, menon gr, ananad k, desai ng, joshi pp, mahanta j, thankappam kr, shah b. urban rural differences in india-the who-icmr indian ncd risk factor surveillance .diabetes research and clinical practice.2008;80: 159-168. 7. world health organization. denition and diagnosis of diabetes mellitus and intermediate hyperglycemia. report of a who/idf consultation, geneva, who.2006:39. 8. world health organization. use of glycated hemoglobin in the diagnosis of diabetes mellitus: abbreviated report of a who consultation.geneva, who.2011:1-25. 9. d’embden m. glycated haemoglobin for the diagnosis of diabetes.australian prescriber.2014;37(3):98-100. 10. american diabetes association. standards of medical care in diabetes2012.diabetes care.2012;35 suppl 1:511-63. 11. nathan dm, turgeon h, regan s. relationship between glycated haemoglobin levels and mean glucose levels over time. diabetologia. 2007;50:2239-44. 12. trinder p. determination of glucose in blood using glucose oxidase with an alternative oxygen acceptor. ann clin biochem.1969;6:24-7. 13. bisse e, abraham ec. new less temperature sensitive microchromatographic method for the separation and quantitation of glycosylated haemoglobins using a non-cyanide buffer system.j.chromatogr.1985;344:81-91. 14. najeeb q, singh j, pandey r, mahajan r. a comparative study of fasting, postprandial blood glucose and glycosylated haemoglobin for diagnosing diabetes mellitus in staff members of mmimsr, mullana, ambala. medical journal of dr d.y.patil university. march-april 2015;8(2):158-164. 15. a r n e t z b.b, k a l l n e r a , t h e o r e l l t. t h e i n  u e n c e o f a g i n g o n hba1c.j.gerontol.1982;37:648-650. 16. kilpatrick es, dominiczak mh, small m. the effects of aging on glycation and the interpretation of glycemic control in type 2 diabetes.q.j.med.1996;89:307312. 17. kabadi um. glycosylation of proteins. lack of inuence on aging.diabetes care.1998;11:421-432. 18. colditz ga, willett wc, stamofer mj, masson je, hennekens ch, arky ra, seizer fe. we i g h t a s a ris k f a c t o r f o r c l i n i c a l d i a b e t e s i n w o m e n . a m j epidemniol.1990;132(3):501-513. 19. guilherme a, virbasius jv, puri v, czech mp. adipocyte dysfunction linking obesity to insulin resistance and type 2 diabetes. nat rev mol cell biol.2008;10(4):412-419. 20. gupta s, puppalwar pv, chalak a. correlation of fasting and post meal plasma glucose level to increased hba1c levels in type 2 diabetes mellitus.int j adv med.2014;1(2):127-131. 21. ghazanfari z, haghdoost aa, alizadeh sm, atapour j, zolala f.a comparison of hba1c and fasting blood sugar tests in general population.int j prev med.2010;1(3):187-194. 22. rohing cl, wiedmeyer hm, little rr, engkand jd, tennill a, glodstein de. dening the relationship between plasma glucose and hba1c.diabetes care;25(2):275-273. 23. tahara, shima k. the response of ghb to stepwise plasma glucose change over time in diabetes patients. diabetes care.1993;16:1313-1314. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra variables mean standard deviation age in years 55.4 15.2 duration in years 9.2 6.1 bmi 29.6 10.4 fbg 160 60.8 ppbg 240.2 90.2 hba1c 8.3 1.9 spearman's ratio hba1c correlation coefcient 1.000 0.456 sig. (2 tailed) . .000 n 100 100 ppg correlation coefcient 456 1.000 sig. (2 tailed) .000 . n 100 100 spearma n's ratio hba1c correlation coefcient 1.000 0.476 sig. (2 tailed) . .000 n 100 100 fbg correlation coefcient 476 1.000 sig. (2 tailed) .000 . n 100 100 x 59gjra global journal for research analysis 1. introduction over the decades our country has been developed drastically, now we are in this state that we have a lot of well contacted roads, commercial building and increasing number of automobiles. while parking these automobiles in parking space we use the manual procedure of parking. which most of the cases is unplanned and lack of discipline due to this, people can park their cars anywhere they want to, which creates a mess as people do not follow the particular cue most of the time. as a result of this, a huge trafc jam takes place in that place. while parking in and retrieving car due mismanagement cars can get dent by bumping with each other as there is lack of sufcient space. this leads to arguments, ghts among people which sometimes make huge trafc jam. this is also an economical loss as we need to repair our damaged car and also cars consume extra fuel while parking in or out. trafc jam is an issue here as it kills our precious time. due to this chaos in parking our valuable time gets wasted. it harms the students, ofce going staffs and emergency patients to a great extent [1]. it also causes economical loss to commercial places like shopping malls, amusement parks as people are more likely not to visit these places due to this parking hazard. as we are advancing with time, the manual car parking system in commercial spaces is creating hurdle which is causing wastage of time and some economic losses as well. therefore we need a solution which can overcome these problems. here we are introducing automated parking systems as a solution of these problems as well ascar parking system in commercial spaces is creating hurdle which is causing wastage of time and some economical losses as well. therefore we need a solution which can overcome these problems. here we are introducing automated car parking systems as a solution of these problems as well as a replacement to the manual car parking systems at commercial spaces. this system not only saves time and money, it can also earn money by charging for parking spaces [2]. 2. literature review steering wheel, accelerator pedal and brake pedal need to be completed by drivers. the latter is automatically controlled. automatic parking system can intelligently control steering wheel to complete parking operations through the environmental information collected by sensors. sensor technology of parking assist system is the foundation for the development of automatic parking system. many specic commercial applications of typical parking system can be described as follows. citroen was assembled a parking assist system-city park on the c3 in sina (2005). the system is used for parallel parking. it requires the parking speed below 25 km/h. through the built-in three ultrasonic sensors in the front and rear bumpers, it can detect distance and parking space. when the space is not enough, the system sounds to warn the driver. when the space is sufcient, the reverse gear is engaged. the steering wheel is automatically controlled, and the vehicle is driven forward and back to park. a parking assist system “park4u” developed by valeo ( 2008) a french automotive parts manufacturer, is applied to touran parallel parking situation. it relies on many ultrasonic sensors of car body to scan both sides of the road and measure the length of parking space. when the sye is an ample parking space, it advises the motorist through indicators. the motorist continues moving l the system prompts “starting position”, then letting go of the steering wheel, just controlling the speed and brake to park the car. in 2007, the top sedan ls series of toyota's luxury brand lexus series was installed a smart parking assist-ipa w.wang (intelligent parking ) ( 2009) automatic car parking original research paper sunil kumar ojha department of mechanical engineering,iimt college of engineering, greater noida x 125gjra global journal for research analysis mechanical engineering now a day's vehicle parking is an important issue and day by day its necessity is increasing. in bangladesh we are still using the manual vehicle parking system and that is why we are facing problems like wastage of time and fuel nding free space around the parking ground when we need to park our car which requires a good amount of lighting. another issue is chaos that happens while parking because there is no particular system anyone can park anywhere that sometime causes damage to the vehicles while moving out or in the parking lot. security is also an issue there. to solve these problems we are introducing new car parking system. the system works as follows: the driver will place the vehicle in front of the garage door and there will be a monitor available where the number of available parking slots will be displayed. the user will have to provide his mobile phone number and car's registration number and the operator will give command to open the gate, a car parking tray will come & will park the car in the garage. the user will receive a sms which will contain a code. after the car is parked a time counter will count the amount of money to be deducted till the car is parked out. while parking out the driver will have to provide the code to the operator at the exit gate. the user will receive a sms stating the amount to be paid. after paying the amount the car parking tray will park out the car using the same process it was parked out. abstract keywords : car parking, sms, trafc, automated parking shashank dhakad* department of mechanical engineering,iimt college of engineering, greater noida*corresponding author sadab parvez department of mechanical engineering,iimt college of engineering, greater noida volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra shahzad alam department of mechanical engineering,iimt college of engineering, greater noida shariq ali department of mechanical engineering,iimt college of engineering, greater noida 126 x gjra global journal for research analysis the system uses electric power steering (eps). during parking process, the steering wheel can be automatically controlled to complete the operation of parking. this set of the ipa system uses ultrasonic sensors to detect the parking position, and can be combined with cameras to identify the parking line. when passing by or near the parking position, the car automatically detects the parking location and distance, and mark the parking location with lines on its display. subsequently the driver simply conrms and engages the reverse gear to start the ipa system. the steering wheel can be automatically controlled for parking. during this process, the ultrasound detection system is used to avoid collision until the parking h. deng(2011) 3. applicability of our project over the decades with the development of our country we've reached in a situation where the manual car parking system in commercial spaces needs to be replaced [3,4]. the manual car parking system is causing hurdle and chaos in parking space, therefore resulting in wastage of time and some economic losses as well. therefore introducing automated car parking systems in commercial spaces can be replacement to the manual car parking systems at commercial spaces. we can install this system in the places like: 3.1 office buildings: it will help the staff to park their car without any hurdle and wastage of time. it will also relieve their mind from the unnecessary parking hurdle. also if someone is already late he wouldn't be late any further by having to search for the parking space and park his car. it will also provide security to their cars from stealing. 3.2 hospitals: in hospital when there are a lot of emergency cases there are a lot of a cars and ambulances coming in the parking space. this creates jam which cause delay for the patients to receive the medical services, which often can be fatal to them. if we install the automated system, it will take less time to park car and the patients to reach the medical services. also they can earn revenue for cars other than the ambulances. it will also provide security to their cars from stealing. 3.3 amusement parks: if we install automated car parking systems in amusement parks it will attract more people to come to these places. the more the people will come the more revenue will be earned. moreover these amusement parks relieve us from our dull and monotonous lives, refreshes our mind. the more people can enjoy these places due to the advanced parking facility. it again increases the revenue as people need to pay for parking their cars. it will also provide security to their cars from stealing. 4. calculation initially: count = n; allocated slot = 0; number of slot = a; stopwatch no = allocated slot; stopwatch value (n) = elapsed time; price of slot (n) = stopwatch value*price per unit; st time to reach the 1 slot from entrance = m; distancea = n*m; distanceb = o*n; time to reach the last slot from exit = o; distance1= n+ distancea; distance2 = n+ distanceb; after every input: allocated slot = allocated slot + 1; n = n+1; 5. prototype mechanism, algorithm and flowchart the automated car parking system is made up with 3 major components: arduino uno r3, gsm module and rf module. the core part of this system is the microcontroller in arduino r3. the coding of this system has been done using arduinoide programming language. the lcd display will display the number of available slots and price it will have a rf receiver module to get updates about the parking when a car will come, the operator will send instruction through arduino to open the gate using rf transmitter module and update the lcd display at the entrance. dc motor helps the gate to open up when it gets the signal from arduino, arduino will only get the signal to dc motor using rf receiver module. the operator will send a sms containing a code to the user's mobile phone using arduino& gsm module. the stopwatch will be started as soon as the gate opened. this code will be saved in the system against a slot which will be sent to the car parking tray using rf transmitter module. the car parking tray will also be called by using rf receiver module &arduino. the car parking tray will park the car & will come out to park the next car. the wheels of the car parking tray will be controlled by arduino so that it reaches the particular slot. for parking out the user will have to give the provided code to the operator at the exit gate. the user will receive a sms stating the amount to pay for the parking again by using arduino& gsm module. after the user makes payment the operator will give command to park out the car. the operator will update the slot information to the lcd display at the entrance using rf transmitter module. the car will be parked out the same way it was parked in. 5.1 flowchart: fig. flowchart for the display references: 1. d.j. bonde, rohit sunil shende, akash sambhaji kedari, ketan suresh gaikwad and amol uday bokre, “automated car parking system commanded by androidapplication” 2. mohammed y aalsalem, wazir zada khan and khailid mohammed dhabba, “an automated vehicle parking management and monitoring system using anpr cameras 3. m. m. rashid , a. musa, m. ataur rahman and n. farhana, a. farhana, “automatic parking management system and parking fee collection based on number plate recognition” 4. vanessa w.s. tang, yuan zheng and jiannong cao, “an intelligent car management system based on wireless sensor networks volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 13.bluetree.cdr type 2 diabetes mellitus (t2dm) is characterized by relative insulin deciency, decreased peripheral and hepatic 1sensitivity to insulin and raised plasma glucose levels . t2dm treatment begins with lifestyle interventions, before progressing to pharmacological interventions with advancing disease. despite the introduction of numerous antihyperglycemic medications, many patients with t2dm require insulin, and basal insulin continues to be frequently used either as rst-line insulin treatment or as part of multiple daily 2injection regimens . oral hypoglycemic agents are effective agents for diabetes management, although secondary drug failure rates of 5-10% are bothersome. the disappointing results with monotherapy especially the worsening metabolic control is often seen within ve years after the initiation of an oral hypoglycemic agent, with more than 50% patients requiring shifting to the insulin-based regimen to achieve 3optimal glycaemic control . basal insulin therapy is recommended if lifestyle modications and oral antidiabetic agents fail to maintain hba1c levels <7.5% and has been 4shown to improve glycemic control . this highlights the fact that adequate basal insulin levels are an essential component of diabetes management. the ideal basal insulin should provide a sustained level of insulin, mimicking physiological basal insulin secretion, reproduce physiological basal insulin secretion, thereby restoring glycemic control, without 1hypoglycemia . such therapy should have relatively at/constant insulin concentration prole over time, no pronounced peak, duration of action of at least 24 h, low within-patient variability in fasting plasma glucose (fpg), a favorable safety prole, including low risk of hypoglycemia 2and weight gain, and be easy to administer and titrate . however, traditional insulin does not fully accomplish this goal. this stimulated the search for insulins with a more prolonged duration of action that could better replicate the 5physiological basal insulin secretory response . this eventually led to the development of basal insulin-like, neutral (porcine) protamine hagedorn (nph) insulin, lente insulin, insulin detemir, etc. still, all these variants are also not able to achieve the desired therapeutic insulin levels. for instance, nph insulin, intermediate-acting insulin, has a duration of action that is considerably less than 24 h and an activity prole that peaks 3–5 h after administration. nph insulin administered at bedtime results in high insulin levels when insulin requirements are low. this activity prole is not 1ideal as it increases the risk of nocturnal hypoglycaemia . a greater understanding of the protein structure of insulin and the roles of key amino acids has opened up new avenues for the rational design of insulin analogs with more predictable absorption and time–action characteristics. insulin glargine (iglar) was the rst long-acting basal analog to be introduced into clinical practice in 2000 and was a breakthrough in the eld of insulin therapy. it continues to be a gold standard of basal insulin treatment and a benchmark for new injectable antihyperglycemic treatments, including newer basal insulin 2analogs . iglar is a biosynthetic, long-acting, clear human insulin analogue with an acidic ph. upon subcutaneous injection, iglar is neutralized and forms microprecipitates that 6release insulin in a constant prole over 24 h . structure of iglar iglar differs from human insulin by the replacement of a21 asparagine with glycine and the addition of two arginine residues at b31 and b32 (glya21, argb31, and argb32). these mutations endow glargine with an isoelectric point of 6.4–6.8, implying that it is easily soluble at acid ph and less soluble at neutral ph. as a result, upon subcutaneous injection, iglar forms an amorphous precipitate in the subcutaneous tissue, which slowly dissociates, providing a sustained release of 5insulin into the circulation . once injected, iglar gets immediately metabolized into two main active metabolites m1 (glya21) and m2 (glya21, des thrb30). the m1 metabolite accounts for approximately 90% of the daily plasma insulin available. this protracted release of glargine from the subcutaneous depot translates into longer bioactivity than either human nph or human ultra lente insulin. thus, iglar can be administered once daily, unlike the earlier 'intermediate'/'long-acting' insulin 5preparations . iglar once daily has been shown to achieve superior glycemic control with equivalent or lower rates of hypoglycemia compared with nph insulin in patients with 4t2dm . clinical efficacy of iglar usage of nph insulin is most often limited due to the high risk of nocturnal hypoglycemia when taken at bedtime, as its peak of the action occurs 4–6 h post-injection. in contrast, the smoother activity of the long-acting insulin analog, iglar, allows more exibility in dosing, and its administration is less strictly bound to the time of injection. this is especially important for certain patient populations where hypoglycemia 5poses a greater risk, such as the elderly . hence, iglar is approved for administration at any time of day, provided it is 7at the same time each day . to conrm the non-occurrence of hypoglycemia post-iglar administration, porcellati et al., 7carried out a study in t2dm insulin-treated patients . the study was carried out in 10 t2dm insulin-treated persons were studied during 24-h euglycemic glucose clamp, after glargine injection (0.4 units/kg s.c.), either in the evening (2200 h) or the insulin glargine in type 2 diabetes original research paper dr. sanjay mahajan 150 duplex apartments b-5 vasundhara enclave delhi-110096 medicine keywords : volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. shweta bhanot pandit* pandit medical near mini stadium padmnabhpur durg ( cg ), 491001 *corresponding author dr jitendra b patel pruthvi med. nursing home & heart centre, s. p. colony, naranpura, ahmedabad dr. sunil shirsikar dwara hospital, 101, rajanvan society near centreal bank, n-9 hudco aurangabad, 431003 dr m. g. binu gknm, avinashi road, coimbatore-641028 36 x gjra global journal for research analysis morning (1000 h). it was concluded from the study that, the pharmacodynamics of insulin glargine differs depending on the time of administration. with morning administration insulin activity is greater in the rst 0–12 h, while with evening administration the activity is greater in the 12–24 h period following dosing. however, glargine pharmacokinetics and plasma c-peptide levels were similar, when analyzed by 24-h clock time independent of the time of administration. thus, insulin sensitivity in t2dm is affected by circadian rhythm 7rather than glargine per se . diabetic kidney disease is one of the most frequent microvascular complications related to diabetes mellitus and is the leading cause of end-stage renal disease. kidneys play an important role in the regulation of glucose homeostasis, because they release a signicant amount of glucose in the post-absorptive state, and they are responsible for approximately one-third of insulin degradation. the progressive loss of kidney function, and its consequent reduction in parenchyma and blood ow, has been associated with a lower capacity of renal glucose release, drug metabolism, and excretion and insulin extraction, resulting in prolonged half-life of some oral antihyper gl ycemic agents and insulin, besides an impaired response to hypoglycemia thus, glycemic control in patients with chronic kidney disease (ckd) is particularly hard to achieve because of a slower insulin degradation by the kidney. it might modify the long-acting insulin analogue pharmacokinetics, 8increasing its time of action and the risk of hypoglycemia . betonico et al. examined the efcacy and safety prole of long-acting basal analogues in patients with signicant loss of renal function. a comparison of the glycemic response to treatment with iglar u100 or nph insulin in patients with type 2 diabetes mellitus (t2dm) and ckd stages 3 and 4 was done in 34 patients. after 24 weeks, mean hba1c was found to decrease on iglar u100 treatment (−0.91%; p < 0.001), however, this benet was not observed for nph (0.23%; p ¼ 0.93). moreover, the incidence of nocturnal hypoglycemia was found to be 3 times lower with iglar than with nph insulin (p ¼ 0.047). thus indicating the potential of iglar u100 in patients 8with t2dm and ckd stages 3 and 4 without resulting in signicant hypoglycemia. traditionally, basal insulin is initiated on the failure of a standard therapeutic oral anti-diabetic regimen and is given as an additional hypoglycemic agent along with oral antidiabetics. eliaschewitz et al., compared the efcacy and safety of iglar and nph insulin, both in combination with a once-daily xed-dose of glimepiride, in terms of glycemic control and incidence of hypoglycemia in an open-label, 244week randomized trial in ten latin american countries . it was found that iglar and nph insulin achieved similar hba1c reductions (adjusted mean difference 20.047; 90% ci 20.232, 0.138; per-protocol analysis). however, conrmed nocturnal hypoglycemia was signicantly lower with iglar vs. nph insulin (16.9 vs. 30.0%; p<!0.01; safety analysis). patients receiving iglar were signicantly more likely to achieve hba1c levels <7.0% without hypoglycemia (27 vs. 17%; p =0.014; per-protocol analysis). there was a more pronounced treatment satisfaction improvement with insulin glargine vs. nph insulin (p <0.02; full analysis). thus, once-daily iglar plus glimepiride is effective in improving metabolic control with a reduced incidence of nocturnal hypoglycemia 4compared with nph insulin . another major complication of diabetes is the occurrence of cardiovascular complications. cardiovascular disease is the leading cause of mortality in t2dm. hyperinsulinemia has been reported to be associated with increased cardiovascular risk. progression of atherosclerosis has been proposed to be associated with hyperinsulinemia. however, the effects of exogenous insulin on cardiovascular disease progression has not been well studied. the origin trial is the only study to date dedicated to investigate the effects of iglar on cardiovascular outcomes. origin enrolled 12,537 patients with a mean age of 63.5 years, cardiovascular risk factors and impaired fasting glucose, impaired glucose tolerance or type 2 diabetes. patients were randomized to receive iglar with a target fasting glucose of less than 95 mg/dl or standard glycemic care. at the end of the study, 83.6% of patients in the glargine group were on insulin compared with 11.4% in the standard care group. the hba1c in year 7 was 6.2% in the glargine group and 6.5% in the standard care group. however, the study found no difference in co-primary outcomes of nonfatal mi, nonfatal stroke or death from cardiovascular 9disease after a median follow-up of 6.2 years . further, a metaanalysis of outcomes from accord, advance, and vadt found that intensive therapy of older adults with type 2 diabetes, the majority of whom were insulin-treated and followed for a mean 3.5–5.6 years, resulted in a 10% reduction in microalbuminuria, but no signicant change in other 9microvascular complications . thus, although insulin has been shown to have both cardioprotective and athero scl erosis-promoting effects in laboratory animal studies, human trials have not shown insulin to increase cardiovascular events and need further in-depth study. conclusion hypoglycemia is considered to be one of the major barriers in initiating insulin therapy and is often a deciding factor while selecting an insulin regimen. therefore, it makes clinical sense to adopt a treatment regimen that minimizes this risk. iglar has been shown to result in fewer hypoglycemic events than nph insulin, along with comparable glycemic control. thus, iglar-is the benchmark basal insulin and may continue to be an important part of treating t2dm. references 1. kacerovsky-bielesz g, dressler a, freunscht r. long-term glycaemic control with insulin glargine in type 2 diabetes. diabetes res clin pract. 2006;71(2):184-191. doi:10.1016/j.diabres.2005.06.007 2. hirose t, chen cc, ahn kj, kilja�ski j. use of insulin glargine 100 u/ml for the treatment of type 2 diabetes mellitus in east asians: a review. diabetes ther. 2019;10(3):805-833. doi:10.1007/s13300-019-0613-7 3. agarwal sk, singh bk, wadhwa r. insulin glargine as add-on therapy to oral hypoglycaemic agents to achieve target fasting plasma glucose levels in type 2 diabetes patients in an indian setup. indian j med spec. 2014;5(2):89-92. doi:10.7713/ijms.2014.0002 4. eliaschewitz fg, calvo c, valbuena h, et al. therapy in type 2 diabetes: insulin glargine vs. nph insulin both in combination with glimepiride. arch med res. 2006;37(4):495-501. doi:10.1016/j.arcmed.2005.10.015 5. owens dr. optimizing treatment strategies with insulin glargine in type 2 diabetes. expert rev endocrinol metab. 2012;7(4):377-393. doi:10.158 6 /ee m.12.29 6. glargine i. issues in emerging health technologies insulin glargine for type 2 diabetes. 2004;(59). 7. porcellati f, lucidi p, cioli p, et al. pharmacokinetics and pharmacodynamics of insulin glargine given in the evening as compared with in the morning in type 2 diabetes. diabetes care. 2015;38(3):503-512. doi:10.2337/dc14-0649 8. betônico cc, titan smo, lira a, et al. insulin glargine u100 improved glycemic control and reduced nocturnal hypoglycemia in patients with type 2 diabetes mellitus and chronic kidney disease stages 3 and 4. clin ther. 2019;41(10):2008-2020.e3. doi:10.1016/j.clinthera.2019.07.011 9. gerstein hc bj. the origin trial basal insulin and cardiovascular and other outcomes in dysglycemia. n engl j med. 2012;367(4):319–328. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 37gjra global journal for research analysis introduction in india, women are still largely under-privileged in terms of wealth, education and access to basic services. thus economic and social inequalities rooted in traditions and cultural norms need to be changed as political measures alone cannot bring empowerment. to understand the complexity of women empowerment and its different aspects, one has to study the existent denitions of the concept, its measurement and the conclusions taken with regards to micronance. kabeer (1999), stresses that women's empowerment is about the process by which those who have been denied the ability to make strategic life choices acquire such ability. it is important to understand empowerment as a process and not an instrumentalist form of advocacy, which requires measurement and quantication of empowerment. kabeer emphasizes that the ability to exercise choice incorporates three interrelated dimensions: 1. resources (dened broadly to include not only access, but also future claims, to both material and human and social resources); 2. agency (including processes of decision-making, as well as less measurable manifestations of agency such as negotiation, deception and manipulation); and achievements (well-being outcomes). the world bank denes empowerment as “the process of increasing the capacity of individuals or groups to make choices and to transform those choices into desired actions and outcomes. central to this process are actions which both build individual and collective assets, and improve the efciency and fairness of the organizational and institutional context which govern the use of these assets.” thus, as the world bank (2001) report conrms, societies that discriminate on the basis of gender pays the cost of greater poverty, slower economic growth, weaker governance and a lower living standard of their people. the world bank also identies four key elements of empowerment to draft institutional reforms: access to information; inclusion and participation; accountability; and local organizational capacity. nobel laureate amartaya sen (1993) explains that the freedom to lead different types of life is reected in the person's capability set. the capability of a person depends on a variety of factors, including personal characteristics and social arrangements. however, the full accounting of individual freedom goes beyond the capabilities of personal living. if there are systematic gender differences in these very basic functioning achievements, they can be taken as an evidence of inequalities in underlying capabilities rather than differences in preferences. empowerment is also related to the concepts of social capital and community driven development with which it is sometimes confused. according to krishna (2003) empowerment means increasing the capacity of individuals or groups to make effective development and life choices and to transform these choices into desired actions and outcomes. empowerment can range from personal empowerment that can exist within the existing social order. thus this kind of empowerment would correspond to the right to make one's own choices, to increased autonomy and to control over economic resources. empowerment signies increased participation in decision-making and it is this process through which people feel themselves to be capable of making decisions and the right to do so (kabeer, 2001). malhotra (2002) emphasis that even after identifying empowerment as a primary development goal, neither the world bank nor any other major development agency has developed a rigorous method for measuring and tracking changes in levels of empowerment. the undp's human development report of 1995 introduced two new complem entary indices: the gender-related development index (gdi) and the gender empowerment measure (gem). the gdi indicator measures the inequalities between men and women in terms of access to basic needs. gem evaluates women's access to political and economic posts. based on amartaya sen's work, the undp makes the distinction between the measure of inequality and empowerment. the gdi focuses on the extension of capabilities, the gem is concerned with the use of those capabilities to take advantage of the opportunities of life. the undp found a very strong correlation between its gender empowerment measure and gender-related development indices and its human development index. the importance of women to the economic development of india was rst recognized during the country's struggle for independence. empowerment is a social action process that promotes participation of people, organization and communities in gaining control over their lives in their community. there is urgent need of empowering women especially in rural areas. the formation of self help group and micro financing will enhance their socioeconomic position in the society. rural financial services, shgs and women empowerment in india – a study original research paper dr. padmavathi surepalli department of sociology osmania university, hyderabad. sociology a concern with gender issues in nancial services is not new. from the early 1970s, women's movements in a number of countries with india also, became increasingly interested in the degree to which women were able to gain access to and benet from poverty-focused credit programmes and credit cooperatives. women are facing discrimination in terms of access to credit and other nancial services from traditional days. there is a need of micronance, a powerful tool, for empowering women especially belong to villages and rural areas. micronance plays a critical role in empowering women and it is an inductive tool of poverty reduction which has leads to the empowerment of women relieving them from debt and nancial burden. the success of micronance initiatives has often been attributed to their particular focus on empowering women and encouraging their self-reliance through developing their own means of income. in other words, where nancial institutions failed, micronance earmarked by tackling the tradeoff between outreach and sustainability. abstract keywords : women, micronance volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 18 x gjra global journal for research analysis women and financial services woman is an important segment for nancial inclusion. the very fact that almost 50% of the world (49.66%) and indian (48.45%) population comprises of women, it becomes imperative to nancially empower women so as to enable them to make meaningful contributions towards the development of the economy. the problem of nancial empowerment becomes even graver when it comes to poor women which again are a sizeable population in india as well as in the other developing nations. no developing nation can actually think of progressing economically by excluding its women population. to add to the woes the socio-economic environment of such countries has always been causing great impediments to involving the women in economic activities. commercial banks took initiative to help these women through self help groups but certainly has had limited reach as these banks are not able to relate to the poor women from rural areas to the extent required. poor, illiterate women nd it useful to deal with a bank only if its services are tailored to suit their needs. banking with the poor and the illiterate requires special procedures and mechanisms suited to their culture, their needs and their economy. this entails simple procedures, designing schemes that allow for small savings, training & assistance in understanding and dealing with banking procedures, door to door service, banking policies that adapt to their crisis situations and credit based on savings performance or loan repayment instead of collateral. it is also to be understood that access to nancial services alone is not enough for poor people to transform their economic activities into protable economic enterprises. access to markets, information, technical know-how and social support services is as important as money. all these factors limit the role that commercial banks can play in their socio-economic empowerment. rural financial services, shgs and women empowerment shgs are of recent origin in rural india to helping more than 17 million women from villages improve their incomes, educate their children, and buy assets. shgs have also helped women campaign against oppressive social practices and become a force of development in their villages. before 1990s, credit schemes for rural women were almost negligible. the concept of women's credit was born on the insistence by women oriented studies that highlighted the discrimination and struggle of women in having access to credit. women in rural india lived in virtual isolation, unable to access even the most basic of services. but, with the formation of women's selfhelp groups, these women are now achieving social and physical mobility. it is recognized that while the empowerment of women is a process that will not happen automatically, shg is a suitable means for the empowerment of women. the impacts of shgs on socio-economic status of women were found signicant. 1. providing clients friendly products and services by designing savings and loan products to match their typical cash ows and distinctive needs. 2. the bank has collaborated with insurance companies and has designed micro insurance products for shareholders. 3. with the support of the parent ngo (the mann vikas samajik sanstha) the bank has initiated vocational training programme, anti-alcohol campaign, training in veterinary practices, adopt a grand-child & grand-mother programme etc. 4. the bank's asset building approach is a remarkable activity that has brought about 6ooo women to get the share in the household property. credit co-op bank for women, jharkand-tribal women in india's eastern jharkhand province have been running a micro credit society that benets the impoverished tribal folks to earn livelihoods and cater to emergencies. the bank was set up by the tribal village women of karamjora in giridih district with the help of institute of rural management (irma), a non-governmental organization. it has now 352 account holders including some local bodies. the bank is called the ificco bank after the irma finance initiative credit cooperative (bank) and it is the answer to the apathy of mainstream banks to the needs of the marginalized population of under-developed region. role of nabard nabard, an apex institution, provides support and guidance for rural nance. it accredited with all matters concerning policy, planning and operations in the eld of credit for agriculture and other economic activities in rural india with a vision to facilitate sustained access to nancial services for the unreached poor in rural areas through various micro finance innovations in a cost effective and sustained manner. nabard has been working as a catalyst in promoting and linking more and more shgs to the banking system. the pioneering efforts at this direction were made by nabard. in 1991-92, a pilot project for linking about 500 shgs with banks was launched by nabard in consultation with the rbi. it is considered as a landmark development in banking for the poor. on the recommendation of the nabard the reserve bank advised that the banks nancing of shg would be reckoned as part of their lending to weaker sections. as a follow up of the recommendations of the nabard working group, the rbi took some measures in 1996 to give a thrust to micro nance based lending. banks were advised to consider lending to the shgs as part of their mainstream credit operations, to identify branches having potential for linkage with shgs and provide necessary support services to such branches. further, it was decided that nabard would continue to provide renance to banks under the linkage project at the rates stipulated from time to time. micro finance institutions in india 1. existing micronance institutions can expand their operations to areas where there are no micronance programs. 2. cooperatives/credit unions may be more active in providing nancial services to the poor. 3. more ngos can incorporate micronance as one of their programs. 4. in places where there are no micronance institutions, the government channels at the grassroots level may be used to serve the poor with micronance. 6. more commercial banks may participate both in micronance wholesale and retailing. they many have separate staff and windows to serve the poor without collateral. programs in areas or countries where micro nancing is not a very familiar concept in reducing poverty. asia and the pacic asia is the home of the largest number of mfis and mfi outreach. but even in asian countries there is still high scope for expanding and deepening mfi outreach. consider the case of the four most populous countries in asia (china, india, indonesia and pakistan) that have many micronance programs but at the same time have millions of poor people without any access to formal or semiformal volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra particulars 2004-2005 no. of members (all women) 44,938 no. of depositors 2,76,680 deposits (in lacs) 6247.66 advances (rs. in lacs) 1841.72 working capital (rs. in lacs) 8914.47 paid up share capital(rs. in lacs) 205.98 prot (rs. in lacs) 62.20 x 19gjra global journal for research analysis nancial services. only an estimated 10 to 12 percent of the poor in india are reached by micronance including the outreach of shgs, ngo mfis, nbfcs, commercial banks and cooperatives. there are various models of micronance are available in nancial system of india, some important are as follows: 1.micro finance institutions (mfis) – mfis are an extremely heterogeneous group comprising nbfcs, societies, trusts and cooperatives. they are provided nancial support from external donors and apex institutions including the rashtriya mahila kosh (rmk), sidbi foundation for micro-credit and nabard and employ a variety of ways for credit delivery. since 2000, commercial banks including regional rural banks have been providing funds to mfis for on lending to poor clients. 2.bank partnership model – this model is an innovative way of nancing mfis. the bank is the lender and the mfi acts as an agent for handling items of work relating to credit monitoring, supervision and recovery. in other words, the mfi acts as an agent and takes care of all relationships with the client, from rst contact to nal repayment. the model has the potential to signicantly increase the amount of funding that mfis can leverage on a relatively small equity base. 3.banking correspondents – the proposal of “banking correspondents” could take this model a step further extending it to savings. it would allow mfis to collect savings deposits from the poor on behalf of the bank. it would use the ability of the mfi to get close to poor clients while relying on the nancial strength of the bank to safeguard the deposits. service company model – under this model, the bank forms its own mfi, perhaps as an nbfc, and then works hand in hand with that mfi to extend loans and other services. the mfi uses the branch network of the bank as its outlets to reach clients. this allows the client to be reached at lower cost than in the case of a stand–alone mfi. in case of banks which have large branch networks, it also allows rapid scale up. the service company model has the potential to take the burden of overseeing micronance operations off the management of the bank and put it in the hands of mfi managers who are focused on micronance to introduce additional products, such as individual loans for shg graduates, remittances and so on without disrupting bank operations and provide a more advantageous cost structure for micronance micro finance and women empowerment it has been noticed that women in particular stand to gain a lot from micro-nance because it gives them an independent means of generating wealth and becoming self-reliant in a society that does not of fer them much scope for entrepreneurship. the success of micronance initiatives has often been attributed to their particular focus on empowering women and encouraging their self-reliance through developing their own means of income. various case studies show that there is a positive correlation between credit availability and women's empowerment. ÿ empowerment approaches al low micronance institutions to realize their full potential in contributing to a number of critical dimensions of women's empowerment. tese approaches will allow mfis to maximize their potential contribution to empowerment along multiple dimensions. the changes that have occurred in the lives of participants in some programs that have adopted empowerment approaches have been signicant. some women, including some very poor women, have beneted from even minimalist micronance delivered by some programs, such as the mbonweh women's development association, where empowerment is integrated throughout the program. some programs like the selfemployed women's association (sewa) has also provided a very effective entry point for organizing women at the local level linking them with movements for wider social and political change. other impacts on empowerment that micronance organizations can have include: 1. signicantly increasing incomes from women's activities and increasing choice of these activities 2. enabling women to control (have a choice over use of) income from loans and activities generated by loans 3. enabling women to negotiate improvements in their wellbeing within the household conclusion given this detailed investigation of women with respect to the control of resources, changes in behaviour and the decisionmaking reveals that many strides have been made in the right direction and women are in the process of empowering themselves. but examining the evidence on some key issues both within the quantitative household data and the fgds, suggests that a lot needs to change to make women truly empowered. based on the evidence along with a more strict interpretation of women empowerment, it is difcult to believe that a minimalist micronance programme would have sustainable impact on the empowerment of women. shgs, where a majority of groups are linked with the help of ngos that provide support in nancial services and specialised training, have a greater ability to make a positive impact on women empowerment. if women empowerment is to be pursued as a serious objective by shg programmes in particular and the larger micronance community in general, greater emphasis needs to be placed on training, education and creating awareness in order to achieve a larger and more lasting empowerment. micro-nance interventions are well-recognized world over as an effective tool for poverty alleviation and improving socioeconomic status of rural poor. in india too, micro-nance is making headway in its effort for reducing poverty and empowering rural women. micro-nance through the network of cooperatives, commercial banks, regional rural banks, nabard and ngo's has been largely a supply driven recent approach. micro-nance institutions are other than banks which are engaged in providing nancial services to the poor. there are three types of lending technologies: (i) the document based and asset based conventional technology, which is followed by almost all existing banks. (iii) the group lending technology, which comes in variousshapes and forms having its own advantages as well as drawbacks individual based lending technology is one where the micro-nance institutions have to be very careful in assessing the repayments capacity of the borrowers. in fact, a major innovations in this area is that the mfi's have to train loan ofcers to assess the repayment capacity of the potential borrowers. 219 the above technologies are focused on micro-nance through shg's, however, credit accessibility to poor through shg's has been enhanced tremendously and the recovery has become comparatively higher. rural women play a signicant role in the domestic and socioeconomic life of the society and therefore, holistic national development is not possible without developing this segment of the society. the review of studies related to credit accessibility to women simply demonstrates that the direct volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 20 x gjra global journal for research analysis access to institutional credit to rural women is very limited and suffers from the sex bias in extending it to them. however, women from the non-farm sector have better access to banks than the women working in the farm sector. even, male members of women borrowers have greater inuence on accessibility to credit utilization and its repayment. references 1. bali swain r, 2006: micronance and women’s empowerment, sida working paper, division of market development, sida, stockholm. 2. basu p and srivastava p, 2005: ‘scaling-up micronance for india’s rural poor’, world bank policy research working paper 3646, wb, washington dc. 3. fisher t and sriram ms, 2002: beyond micro-credit: putting development bank into micronance, vistar, new delhi. 4. hashemi sm, schuler sr and riley ap, 1996: ‘rural credit programmes and women’s empowerment in bangladesh’, world development, vol. 24, no. 4, pp. 635-653. 5. malhotra, a. schuler s.r. and boender, carol, 2002: measuring women’s empowerment as a variable in international development, background paper for world bank workshop on poverty and gender: new perspectives. 6. mayoux l., 1997: the magic ingredient? micronance and women’s empowerment, a brieng paper prepared for the micro credit summit, washington. 7. myrada, 2002: impact of self help groups (group processes) on the social empowerment status of women members in southern india, paper presented at the seminar on shg bank linkage programme, new delhi. 8. nabard, 2005: progress of shg – bank linkage in india, 2004-2005, microcredit innovations department, nabard, mumbai. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 21gjra global journal for research analysis introduction lesions within the retrorectal, or presacral, space are uncommon and therefore present a challenge to diagnose and manage. although retrorectal tumors are estimated to account for approximately 1 in 40,000 hospital admissions, the true incidence in the general population is unknown. the retrorectal space contains embryologic remnants that have pluripotent capability; hence, a heterogeneous histologic (1)group of tumors arise in this region. lesions may be solid or cystic, the solid variety having a higher predilection for malignancy. surgical resection is the principal therapy for retrorectal tumors. even benign cystic lesions are excised because doing so eliminates or prevents symptoms and addresses the risks of subsequent infection or malignant transformation. ct and mri have been found effective for differentiating benign from malignant entities. ct or mri can be used for surgical planning because the size and extent of the tumor can be delineated, and the presence of local invasion can be assessed with either modality. retrorectal lesions can be resected via one of three approaches: anterior (abdominal), posterior (perineal), or combined. (2)anatomy: anatomically, the retrorectal space is the pelvic continuation of the retroperitoneum. in adults, this space is lled with loose areolar tissue, fat, and connective tissues. its boundaries are the rectum anteriorly and the sacrum and investing sacral fascia posteriorly. although the rectosacral (waldeyer's) fascia separates the true retrorectal space from the more inferior/caudal horseshoe-shaped supralevator space, lesions in both regions are typically considered together, with the levator and coccygeal musculature constituting the inferior boundary. the ureters, internal iliac arteries, and lateral rectal stalks mark the lateral extent of the retrorectal space, and it extends cranially to the peritoneal reection. various classication schemes have been reported for retrorectal tumors. most commonly, these tumors are broadly categorized as inammatory, congenital, neurogenic, osseous, and miscellaneous (table 1). (3)table 1. classication of retrorectal tumors. case presentation: a 20year old female presented at outpatient clinic with complaint of bowel disturbance and lower abdominal pain since 5 days. per abdomen examination was normal, digital rectal examination did not reveal any enlarged hemorrhoids or mass. usg abdomen was done showed 37*34mm sized hypoechoic lesion without signicant vascularity in pelvis displacing the rectum right laterally. all routine blood investigations were within normal limits and stool routine and culture examination were also normal. cect abdomen and pelvis was done which revealed approx 41*50*80 mm sized lobulated soft tissue density lesion showing homogenous enhancement deep to the natal cleft anterior to coccyx in midline reaching upto left mesorectum retrorectal tumor : a rare entity original research paper dr. mayur. g. rabari assistant professor, department of general surgery, svpimsr, ahmedabad. x 25gjra global journal for research analysis general surgery introduction: primary neoplasms of the retrorectal (presacral) space are very rare. these lesions may be congenital or acquired, benign or malignant. they often arise with subtle clinical symptoms, or they may be found incidentally during evaluation for other conditions. preoperative imaging can provide useful information for operative planning, however, it does not replace ndings for surgery. approaches for resection include posterior only and combined abdominoperineal, depending on the characteristics of the lesion. case presentation: a case of 20 years old female, presented in outpatient clinic with bowel disturbance and lower abdominal pain. investigations were done including contrast enhanced computed tomography (ct)and magnetic resonance imaging (mri) of whole abdomen and pelvis which revealed ill dened heterogenously enhancing mass in retrorectal space; followed by which patient was taken for surgery and biopsy taken. conclusion: retrorectal tumors remain a difcult diagnostic and therapeutic challenge despite the use of newer imaging modalities and improvements in perioperative care. complete resection with negative margins is the standard for benign retrorectal tumors. abstract keywords : retrorectal tumor, presacral space. dr. esha bansal* nd2 year resident, department of general surgery, svpimsr, ahmedabad. *corresponding author dr. vaibhav parekh rd3 year resident, department of general surgery, svpimsr, ahmedabad. dr. sunny gajjar rd3 year resident, department of general surgery, svpimsr, ahmedabad. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 26 x gjra global journal for research analysis without any evidence of calcication,necrosis or fat density within it. lesion displaces anus anteriorly; laterally on the right side it compresses and displaces rectum and shows focal obliteration of fat plane with the distal rectum. exploratory laparotomy was done with lower midline incision and on entering the peritoneal cavity, hard impacted mass was palpable over the pre-coccygeal region and so small part was resected and sent for frozen section histopathology. hard mass was adherent to coccyx and hence was difcult to separate. hpe showed spindle cell tumor; possibility of (1) low grade fibromyxoid sarcoma (2) spindle cell tumor of neurogenic origin later mri abdomen was done which showed approx 41*45*32mm sized ill dened hetergenously enhancing altered signal intensity lesion noted involving retrorectal space (left>right). the lesion invades both levator ani/puborectalis muscle; inltrates in fat of both ischiorectal fossa, displaces rectum anteriorly with loss of fat plane and possible invasion into postero-lateral wall of rectum. the lesion extends inferiorly upto natal cleft. patient was then again taken for surgery, and jack-knife position was given. vertical incision put on gluteal cleft, approx 6*4*3cm sized rm-hard consistency mass visualised and removed from left ischio-rectal space. another 2*2*3cm sized mass with similar consistency removed from right ischiorectal space (figure 2 &3) and sigmoidostomy done. both the tissues were sent for hpe. biopsy from the mass revealed low grade spindle cell sarcoma and immunohistochemical staining was advised which conrmed the diagnosis of spindle cell sarcoma but sensitive to vimentin. fig 1. mri showing heterogenous mass in retrorectal space. fig 2. two masses removed from both ischiorectal fossae. fig 3. photograph showing bilateral ishiorectal fossae after removal of mass. fig 4. histopathology and immunohistochemical staining showing broblasts and myxoid stroma. discussion the true incidence of tumors occurring in the retrorectal (presacral) space is unknown, yet several retrospective series suggest that between one and six patients will be diagnosed (4)annually in major referral centers . the retrorectal space contains multiple embryologic remnants derived from a variety of tissues. tumors that develop in this space are both macroscopically and histologically heterogeneous. most lesions are benign, but malignant neoplasms are not uncommon. solid lesions are more likely to be malignant than are cystic lesions. neurogenic lesions typically arise from peripheral nerves and represent about 10% of retrorectal (5)tumors . these tumors include neurobromas and sarcomas, neurilemomas, ependymomas, and ganglioneuromas. fibromyxoid sarcoma is a rare soft tissue sarcoma usually located in the deep soft tissue in the groin or lower extremities. no case located in retrorectal space has been reported in (4)literature review . thus, it is important to differentiate this (6)tumor from other soft tissue tumors . symptoms of retrorectal tumors are often nonspecic and are related to the location and to the size of the lesion. the majority of benign cystic lesions are asymptomatic and usually discovered on routine rectal examination. pelvic mri is emerging as the most sensitive and specic imaging study of these tumors. nonsurgical treatment, such as radiation treatment and chemotherapy, might improve local control making the appearance of clinically evident metastatic disease less likely. although adjuvant therapy has enhanced the chance of cure for retroperitoneal sarcomas, there are no studies for tumors of retrorectal space. in fact, chemotherapy for retrorectal sarcomas seems to be ineffective. thus, further studies are necessary to clarify the role of adjuvant treatment (6)for local control of these tumors . overall survival appears to (7)be good if the resection is complete . conclusion surgery followed by adjuvant chemotherapy depending upon histological grade and immuno-histo-chemical staining remains the mainstay of treatment. for larger tumors, aggressive resection may be required to achieve n0 margin. references 1. surgical management of retrorectal tumors. ajr 2015; 204:386–395 0361–803x/15/2042–386 2. retrorectal tumors. clinics in colon and rectal surgery/volume 19, number 2 2006 3. table 1. published in abdominal imaging 2015.mr imaging of the retrorectal–presacral tumors: an algorithmic approach. hooman hosseininik, keyanoosh hosseinzadeh, rajesh bhayana, kartik s. jhaveri. 4. hobson kg, ghaemmaghami v, roe jp, goodnight je, khatri vp (2005) tumors of the retrorectal space. dis colon rectum 48: 1964-1974. 5. glasgow sc, birnbaum eh, lowney jk, fleshman jw, kodner ij, et al. (2005) retrorectal tumors: a diagnostic and therapeutic challenge. dis colon rectum 48: 1581-1587. 6. evans hl (1993) low-grade bromyxoid sarcoma. a report of 12 cases. am j surg pathol 17: 595-600. 7. du f, jin k, hu x, dong x, cao f (2012) surgical treatment of retrorectal tumors: a retrospective study of a ten-year experience in three institutions. hepatogastroenterology 59: 1374-1377. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: hernia repair is one of the most commonly performed operations by competent general surgeons. last two decades have witnessed huge growth in minimally invasive laparoscopic hernia repair. most of the publications in the last two decades have been dominated by lap hernia repair. this study and presentation of over 15 years is to analyse and prove that minimal invasive is equally effective in all 1,2prospects compared to lap . with laparoscopic hernia repair, you may return to work sooner, have less after surgery, and have a shorter pain hospital stay and a shorter recovery time. surgery to remove the gallbladder with a laparoscope does not require that the 3,4muscles of your abdomen be cut, as they are in open surgery . the incision is much smaller, which makes recovery go quicker. with laparoscopic hernia repair, you probably will only have to stay in the hospital for a few hours or overnight. with open hernia repair, you would have to stay in the hospital for about ve days. because the incisions are smaller with laparoscopic hernia repair, there isn't as much after this pain operation as after open hernia repair. minimal invasive open hernia repair is a very safe procedure which can be conducted in small cities and towns where the patients are poor and no laproscoic instruments in govt hospitals and majority of private hospitals as we have seen in this large series which is conducted across many small cities and towns procedure is very safe with no mortality and with a very few complications. the procedure does not require any special instruments, patients will have very less post-operative pain, very less 5hospital stay and go back to work early . aims and objectives: to study the minimal invasive open hernia vs lap hernia repair. materials and methods this study was done in the department of surgery, kanachur institute of medical sciences, mangalore. sixty cases that was admitted to the department were studied in detail and an attempt has been made to report promptly. exclusion criteria: 1.differently abled who met with accidents. inclusion criteria: 1.all the patients were 20-60 years. this was done to understand the patterns especially in the working group. results: results: table 1: age distribution graph 1: sex distribution graph 2: types of hernias graph 3: parts injured table 2: success rate discussion: this surgery is very simple to perform but has to be performed with at most care, with a very good anaesthesia followed up with good post-operative care. the total numbers of patients with complications are low. total complication proportions in the lap vs. invasive comparison are 24.3% and 21.2% respectively including intra-operative static calculations, 6,7which are generally not considered a complication . excluding perforations decreases total complication proportions to 15.6% and 16.4% respectively. these percentages are still higher than gures (up to 5%) known from other reviews including non-randomized series. such a study of minimal invasive open hernia repair vs lap hernia repair original research paper sandeep k k associate professor, department of surgery, kanachur institute of medical sciences, mangalore. * corresponding author general surgery most of the publications in the last few years have been dominated by laparoscopic hernia repair. this study and presentation of over 5 years is to analyse and prove that invasive hernia repair is equally effective in all prospects compared to its counterpart. abstract keywords : invasive hernia repair, laparoscopic hernia repair. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra number mean age std deviation 60 48.71 years 13.38 years 92 x gjra global journal for research analysis 8studies represent lower levels of evidence . one has to assume that especially interested and skilled surgeons conducted the trials and carried out the interventions. everyday clinical practice and complication rates ought to be followed through clinical databases and compared with benchmark values. the situation in the real world may therefore even be worse. the complication proportions in the other two comparisons are substantially lower compared with the proportions in the lap vs . si comparison. probably, d i f ferences in methodological quality of the trials play a role. as results from low-bias risk trials are considered more reliable, we believe that the proportions in the lap vs. si comparison are closer to the truth. conclusion this is an excellent alternative to laparoscopic hernia repair . references: 1. french associations for surgical research, oberlin p, boudet mj, et al. recurrence after inguinal hernia repair: prognostic facts in a prospective study of 1706 hernias. br j surg 1995;82:suppl 1:65-65 abstract. 2. friis e, lindahl f. the tension-free hernioplasty in a randomized trial. am j surg 1996;172:315-319 3. sondenaa k, nesvik i, breivik k, korner h. long-term follow-up of 1059 consecutive primary and recurrent inguinal hernias in a teaching hospital. eur j surg 2001;167:125-129 4. the mrc laparoscopic groin hernia trial group. laparoscopic versus open repair of groin hernia: a randomised comparison. lancet 1999;354:185-190 5. mccormack k, scott nw, go pm, ross s, grant am. laparoscopic techniques versus open techniques for inguinal hernia repair. cochrane database syst rev 2003;1:cd001785-cd001785 6. fitzgibbons rj jr, camps j, cornet da, et al. laparoscopic inguinal herniorrhaphy: results of a multicenter trial. ann surg 1995;221:3-13 7. neumayer l, jonasson o, fitzgibbons r, et al. tension-free inguinal hernia repair: the design of a trial to compare open and laparoscopic surgical techniques. j am coll surg 2003;196:743-752 8. wright d, o'dwyer pj. the learning curve for laparoscopic hernia repair. semin laparosc surg 1998;5:227-232 volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 93gjra global journal for research analysis introduction benign prostate hyperplasia is a common disease in adult men and its incidence is age related. prevalence of bph is approximately 25% in men aged 40 to 49 years, 50% in men aged 50 to 59 years and 80% in men aged 70 to 79 years. 1 renal failure and symptomatic benign prostatic hyperplasia (bph) are two common health problems, they usually co-exist in 5.9–13.6% of the male population over 50 years of age. actually going by the natural history of the disease and its progression with relation to benign prostatic hyperplasia and its complications, it is noted that 13.6% of patients who presented to undergo transurethral resection were in renal failure. it is usually not clear in this group of patients whether the reason for renal insufciency is or is not benign prostatic hyperplasia. however, it has been reported in some studies that the incidence of diabetes mellitus and hypertension is higher in patients with renal failure (rf) and lower urinary tract symptoms (luts) due to benign prostatic hyperplasia. on the other hand, it is known that due to chronic urinary obstruction, bph can lead to renal failure and even death occasionally. turp remains the gold standard surgical procedure for treatment of these cases. however, patients in renal failure have an increased risk for complications after turp compared with patients with normal renal function, so we wanted to study the treatment outcome and complications associated with its management. the purpose of this study was to determine the incidence of renal failure associated with bph , effect of turp in the morbilidity and mortality of patients with renal failure. materials and methods prospective study from october 2017 to november 2019 setting : govt. stanley medical college and hospital, chennai, this is a clinical study of 80 cases of benign prostatic hyperplasia in normal and in patients with non dialysis requiring renal failure who underwent surgical therapy-turp. patient selection inclusion criteria all patients with non dialysis requiring renal dysfunction associated with benign enlargement of prostate in the department of urology in our institute. exclusion criteria histologically proven malignant prostatomegaly patients undergoing open prostatectomy results patients with end stage renal disease requiring hemodialysis. in a total of 20 patients in group 1, the youngest was 45 years and oldest was 83 years with a mean age of 64 years and standard deviation of 5.62 with the predominant age group 6170 years. pss (majority had obstructive symptoms) with a mean score of 28.95 in group 1 and 26.65 in group 2 ,minimum and maximum score of 19 and 235 respectively with a standard deviation of 1.98. on analysis of ipss score it was found that mean obstructive symptoms score was 15.3 as compared to the mean irritative symptoms score of 11.5. comparing the prostate size by ultrasound in both groups, the mean prostate volume was 46cc in group 1 with a standard deviation of 12.47 and 42 cc in group 2 with a standard deviation of 14.19. once the serum creatinine values stabilized, the readings prospective study of effects of turp on outcome,morbidity and mortality in patients with non dialysis requiring renal insufficiency original research paper dr. prashanth adiga mbbs , ms gen surgery , mch (urology assistant professor department of urology x 45gjra global journal for research analysis surgery introduction : benign prostate hyperplasia is a common disease in adult men and its incidence is age related. prevalence of bph is approximately 25% in men aged 40 to 49 years, 50% in men aged 50 to 59 years and 80% in men aged 70 to 79 years. 1 renal failure and symptomatic benign prostatic hyperplasia (bph) are two common health problems, they usually co-exist in 5.9–13.6% of the male population over 50 years of age. turp remains the gold standard surgical procedure for treatment of these cases. however, patients in renal failure have an increased risk for complications after turp compared with patients with normal renal function, so we wanted to study the treatment outcome and complications associated with its management. the purpose of this study was to determine the incidence of renal failure associated with bph , effect of turp in the morbilidity and mortality of patients with renal failure. materials and methods: prospective study from october 2017 to november 2019 setting : govt. stanley medical college and hospital, chennai, this is a clinical study of 80 cases of benign prostatic hyperplasia in normal and in patients with non dialysis requiring renal failure who underwent results: once the serum creatinine values stabilized, the readings were recorded. out of 40 patients who presented with elevated renal parameters, (patient with s.creatinine more than 1.3mg/dl ) ten patients subsequently showed fall in serum creatinine below 1.3, hence were considered along with normal patients in group 1. because of this, the subsequent serum creatinine values of rest of 30 patients stabilized at a mean of 1.7 with a standard deviation of 0.3. interestingly patients whose serum creatinine which stabilized at a value of more than 1.3, some of them had coexistent diabetes, hypertension. this might be an explanation that these patients have developed preexisting renal disease which was worsened by their developing benign prostatic hyperplasia in group 1, out of 30 patients, three people had bleeding, one had retention, one perioperative death due to myocardial infarction was recorded, one patient had infection. in all the patients with bleeding as complication, blood transfusion was given. whereas in group 2, two people had bleeding out of 40 patients studied. ( 8% compared to 20% in group 1). conclusion: the incidence of associated with benign prostatic hyperplasia in our study was about 12.5%. . abstract keywords : benign prostate , turp , renal failure volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 46 x gjra global journal for research analysis were recorded. out of 40 patients who presented with elevated renal parameters, (patient with s.creatinine more than 1.3mg/dl ) ten patients subsequently showed fall in serum creatinine below 1.3, hence were considered along with normal patients in group 1. because of this, the subsequent serum creatinine values of rest of 30 patients stabilized at a mean of 1.7 with a standard deviation of 0.3. interestingly patients whose serum creatinine which stabilized at a value of more than 1.3, some of them had coexistent diabetes, hypertension. this might be an explanation that these patients have developed preexisting renal disease which was worsened by their developing benign prostatic hyperplasia in group 1, out of 30 patients, three people had bleeding, one had retention, one perioperative death due to myocardial infarction was recorded, one patient had infection. in all the patients with bleeding as complication, blood transfusion was given. whereas in group 2, two people had bleeding out of 40 patients studied. ( 8% compared to 20% in group 1). when we taken retention, three people have developed in group 2. in case of infection, none had developed, compared to one patient in renal failure group. death was not noted in group 2, whereas one recorded in group1 fall in serum creatinine between the time of presentation and post operative period, was signicant. this implies that transurethral resection has made a positive outcome in this group of patients. discussion but, the european association of urology guidelines on benign prostatic hyperplasia (2004) and the nephrologyfocused nice (national institute for health and clinical excellence) guidelines advocated measuring serum creatinine levels in all patients. this is relied on the fact, that bladder outlet obstruction due to benign prostatic enlargement can cause hydronephrosis and renal failure.23 patients with benign prostatic enlargement and renal insufciency have relatively higher postoperative complicat ions (25% complication rate compared with 17% for patients without renal failure) and mortality goes up to sixfold than those with normal renal function.37,38, 45 estimated glomerular ltration rate (egfr) is a much more reliable measure to dene chronic kidney disease and is better than simple serum creatinine measurement. a cross-sectional survey in spain of 2,000 randomly sampled men who were 50 years or older showed a 2.4% prevalence of self-reported renal failure related to a prostate condition (9% reported renal failure from any cause).63,9 another study21 showed that men presenting for prostate surgery had a 7.7% prevalence of renal failure compared to a 3.7% prevalence in age matched men presenting for nonprostate surgery conclusion the incidence of renal failure associated with benign prostatic hyperplasia in our study was about 12.5%. if intervention done early the renal failure can be reversed references 1. arrighi hm, metter ej, guess ha, fozzard jl. natural history of benign prostatic hyperplasia and risk of prostatectomy. the baltimore longitudinal study of aging. urology. 1991; 38(1 suppl): p. 4-8. 2. kumar r, hill cm, mcgeown mg. acute renal failure in the elderly. lancet. 1973 jan; 1(7794): p. 90-91. 3. wein a. campbell-walsh urology wein aj, editor.: elsevier; 2012. 4. berry sj, coffey ds, walsh pc, ewing ll. the development of human benign prostatic hyperplasia with age. j urol. 1984 sep; 132(3): p. 474-479. 5. nielsen kk, nordling j, hald t. critical review of the diagnosis of prostatic obstruction. neurourol urodyn. 1994; 13(3): p. 201-217. 6. hong sk, oh jj, jeong sj, jeong cw, kim is, park jm, et al. prediction of outcomes after radical prostatectomy in patients diagnosed with prostate cancer of biopsy gleason score ≥ 8 via contemporary multi (≥ 12)-core prostate biopsy. bju int. 2011 jul; 108(2): p. 217-222. 7. mebust wk, holtgrewe hl, cockett at, peters pc. transurethral prostatectomy: immediate and postoperative complications. a cooperative study of 13 participating institutions evaluating 3,885 patients. j urol. 1989 feb; 141(2): p. 243-247 8. roehrborn cg. bph progression: concept and key learning from mtops, altess, combat, and alf-one. bju int. 2008 mar; 101 suppl 3: p. 17-21. 47. koch wf, debruyne fm,. the outcome of renal ultrasound in the assessment of 556 consecutive patients with benign prostatic hyperplasia. j urol. 1996 jan; 155(1): p. 186-189 9. sutaria pm, staskin dr. hydronephrosis and renal deterioration in the elderly due to abnormalities of the lower urinary tract and ureterovesical junction. int urol nephrol. 2000; 32(1): p. 119-126. 10. kojima m, inui e, ochiai a, naya y, ukimura o, watanabe h. noninvasive quantitative estimation of infravesical obstruction using ultrasonic measurement of bladder weight. j urol. 1997 feb; 157(2): p. 476-479. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra s. creat mean n std.dev se p value per op 1.7 40 0.237 0.067 p=o.o46 6 weeks 1.5 40 0.271 0.057 75.sanjeev kumar khichi online.cdr evaluation steps ÿ association between the predictor and the predicted ÿ predictor variables used to predict values of variable interest, sometimes called independent variables ÿ predicted variable = dependent variable ÿ regression technique for tting a line to a set of points ÿ linear regression is the most widely used form of regression ÿ the objective is to obtain an equation of a straight line that minimizes the sum of squared vertical deviations of data points from the line. ÿ y = a + bx ÿ where ÿ y = predicted (dependent) variable ÿ x = predictor (independent) variable ÿ b = slope of the line ÿ a = value of y when x = 0 (the height of line at the y intercept) given n data points, nd the intercept a and the slope b to ÿ time-ordered sequence of observations taken at regular intervals over a period of time ÿ future values of the series can be estimated from past values. types of variations in time series data ÿ trend long-term movement in data ÿ seasonality short-term regular variations in data ÿ cycles – wavelike variations of long-term ÿ irregular variations caused by unusual circumstances ÿ random variations caused by chance ÿ forecast error:=actual – forecast =a(t-1)-f(t-1) forecast today=forecast yesterday+(alpha)*(forecast error yesterday) each new forecast is equal to the previous orecast plus a percentage of the previous error. ÿ step 1 smoothing the level of the series ÿ step 2 – smoothing the trend statistical evaluation of forecasting methods. original research paper sanjeev kumar khichi associate professor, community medicine, shkm govt. medical college, nalhar, nuh, haryana medical science in this paper some systematic steps were used for forecasting. generate forecasts for data with different patterns: level, trend, seasonality, and cyclical.describe causal modeling using linear regression compute forecast accuracy .explain how forecasting models should be selected, decide what needs to be forecast.level of detail, units of analysis & time horizon required.evaluate and analyze appropriate data.identify needed data.select and test the forecasting model, cost, ease of use & accuracy,generate the forecast accuracy over time. abstract keywords : dr.nand kishore singh* associate professor& statistician, community medicine, shkm govt. medical college nalhar, nuh, haryana *corresponding author neha nehra research scholar in sun rise university. sarita dahiya assistant professor, psychology, govt. college for women, rewari, haryana å = -= = n t tt bxay 1 2)( minimize line thefrom deviations of sum theminimize errors squared of sum theminimize 2 11 2 1 1 1 ÷ ø ö ç è æ = åå å å å == = = = n t t n t t n t n t n t tttt xxn yxyxn b n x b n y a n t t n t t åå == -= 11 )( 111 ---+= tttt faff a )tα)(s(1αas 1t1ttt -+-+= 1t1ttt β)t(1)sβ(st --+-= 10 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra y=a + bx forecast software ÿ spreadsheets ÿ microsoft excel, quattro pro, lotus 1-2-3 ÿ limited statistical analysis of forecast data ÿ statistical packages ÿ spss, sas, ncss, minitab ÿ forecasting plus statistical and graphics ÿ specialty forecasting packages ÿ forecast master, forecast pro, autobox, sca guidelines for selecting software ÿ does the package have the features you want? ÿ what platform is the package available for? ÿ how easy is the package to learn and use? ÿ is it possible to implement new methods? ÿ do you require interactive or repetitive forecasting? ÿ do you have any large data sets? ÿ is there local support and training available? ÿ does the package give the right answers? arima and ses model for forecasting discussion three basic principles of forecasting are: forecasts are rarely perfect, are more accurate for groups than individual items, and are more accurate in the shorter term than longer time horizons. the forecasting process involves ve steps: decide what to forecast, evaluate and analyze appropriate data, select and test model, generate forecast, and monitor accuracy. forecasting methods can be classied into two groups: qualitative and quantitative. qualitative methods are based on the subjective opinion of the forecaster and quantitative methods are based on mathematical modeling. time series models are based on the assumption that all information needed is contained in the time series of data. causal models assume that the variable being forecast is related to other variables in the environment. there are four basic patterns of data: level or horizontal, trend, seasonality, and cycles. in addition, data usually contain random variation. some forecast models used to forecast the level of a time series are: naïve, simple mean, simple moving average, weighted moving average, and exponential smoothing. separate models are used to forecast trends and seasonality. a simple causal model is linear regression in which a straightline relationship is modeled between the variable we are forecasting and another variable in then environment. the correlation is used to measure the strength of the linear relationship between these two variables. three useful measures of forecast error are mean absolute deviation mean square error and tracking signal. there are four factors to consider when selecting a model: amount and type of data available, degree of accuracy required, length of forecast horizon, and pattern. references 1. kahneman daniel; tversky, amos (1979). "prospect theory: an analysis of decision under risk" (pdf). econometrica. 47 (2): 263–291. 2. jump up to:a b kahneman, daniel; tversky, amos (1977). "intuitive prediction: biases and corrective procedures" (pdf). decision research technical report ptr-1042-77-6. in k ahneman daniel; t versky, amos (1982). "intuitive prediction: biases and corrective procedures". in kahneman, daniel; slovic, paul; tversky, amos (eds.). judgment under uncertainty: heuristics and biases. pp. 414 3. "week 10: reference class forecasting". conceptually. retrieved 20 april 2017. 4. "outside view". less wrong wiki. retrieved 20 april 2017. 5. flyvbjerg, bent (2006). "from nobel prize to project management: getting risks right". project management journal. 37 (3): 5–15. arxiv:1302.3642. bibcode:2013arxiv1302.3642f. ssrn 2238013. 6. "council to borrow £231m for edinburgh trams project". bbc news. bbc. 19 august 2011. retrieved 19 august 2011. 7. aace international, "total cost management framework, section 7.3, cost estimating and budgeting", 2011. p. 147 8. marrow, e. and yarossi, m., "assessing project cost and schedule risk", 1990 aace transactions. pp h.6.1-7 9. lovallo, d; kahneman, d (2003). "delusions of success. how optimism undermines executives' decisions". harvard business review. 81 (7): 56–63. pmid 12858711. 10. flyvbjerg, bent (2008). "public planning of mega-projects: overestimation of demand and underestimation of costs". in priemus, hugo; flyvbjerg, bent; van wee,bert (eds.). decision-making on mega-projects. doi:10.4337/ 9781848440173.00014. isbn 9781848440173. 11. flyvbjerg, bent (2011). "over budget, over time, over and over again: managing major projects". in morris, peter w. g; pinto, jeffrey k; söderlund, jonas (eds.). the oxford handbook of project management. å å = 22 xnx yxnxy b xbya -= x 11gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra breast is the most common site of cancer in women.breast cancer is a disease in which breast cells proliferate abnormally and may present as a breast lump, thickening, or skin change. when breast cancer cells metastasize from the original tumor and enter the blood stream or lymphatic system, they can form secondary tumors, locate in other parts of the body. a biopsy is necessary to conrm the diagnosis and determine the type of cancer present. the incidence of breast cancer increases with age, being uncommon below the age of 32 years; however its behaviour varies from slow to rapid progressive disease despite available treatment. carcinoma of the breast is the second commonest malignancy affecting half a million women worldwide each year. it is one of the major causes of death among women between 40 and 44 years age group that has become a genuine public health problem. epidemiological studies have revealed that 1 in 50 women in india can develop breast cancer in their lifetime.1 according to globocan (who), for the year 2012, an estimated 70218 women died in india due to breast cancer, more than any other country in the world (second: china 47984 deaths and third: us 43909 deaths). 2 the etiology of lipid changes associated with breast cancer is multifactorial and relationship of lipid changes to breast cancer is still a subject of controversy. some studies have found that malignant proliferation of breast tissue in women is associated with changes in plasma lipid and lipoprotein levels. a number of epidemiological studies have shown the inc reased r i sk o f dea th f rom cancer w i th hypo cholesterolaemia, although several studies proposed the low levels of cholesterol is a predisposing factor for carcinogenesis3 so the present study was planned to investigate the alteration in the lipid proles of patients with carcinoma of breast in comparison with age matched control women. the aim of this study, therefore, is to nd out the effect of lipids on breast cancer risk. and an attempt made to investigate the levels of total cholesterol (tch), triglycerides (tg), low density lipoproteins (ldl) very low density lipoproteins (vldl), high density lipoproteins (hdl) in breast cancer patients. aim & objectives: ÿ estimate the serum lipid prole in breast cancer patients. ÿ compare the serum lipid prole of patient group with control groups. materials & methods: a hospital based case-control study was planned, including 156 clinically diagnosed female cases of breast cancer from opd/ipd of surgery and oncology department and same number of normal individuals or control group has been taken from the opd/ipd of medicine department and emergency department, s.m.s. medical college and hospital, jaipur. the blood samples of the breast cancer patients taken from outdoor & indoor in morning after overnight fasting. blood samples of control group taken after overnight fasting. the samples left standing for one hour; serum separated at 2500 rpm centrifugation and analyzed on fully automated analyzer randox(imola). principle of assay:ÿ in this study we will investigate serum levels of hdlcholesterol, ldl-cholesterol, total cholesterol and comparision study of lipid profiles in breast cancer patients and healthy control group original research paper dr. renu meena senior demonstrator,department of biochemistry,r.n.t. medical college, udaipur (rajasthan) x 55gjra global journal for research analysis medical science carcinoma of the breast is the second commonest malignancy affecting half a million women worldwide each year. epidemiological studies have revealed that 1 in 50 women in india can develop breast cancer in their lifetime. a number of epidemiological studies have shown the increased risk of death from cancer with hypocholesterolaemia, although several studies proposed the low levels of cholesterol is a predisposing factor for carcinogenesis. so the present study was planned to investigate the alteration in the lipid proles of patients with carcinoma of breast in comparison with age matched control women. aim: estimate and compare serum lipid prole for both in breast cancer patients and normal individuals. materials & methods: overnight fasting blood samples of 156 clinically diagnosed female cases of breast cancer from opd/ipd of surgery and oncology department and same number of normal individuals or control group has been taken from the opd/ipd of medicine department and emergency department, s.m.s. medical college and hospital, jaipur.esmination of serum lipid proles such as total cholesterol,hdl-cholesterol, etc. were determine by enzymatic method in fully automated chemistry analyzer. observation & result:mean±sd (mg/dl) for serum tg level, in case of breast cancer patients & control group were 202.74±53.45 and 178.77±99.36 respectively and p value was 0.008. similarly, for serum cholesterol were 205.62±46.09 and 158.73±41.59 for breast cancer and control group respectively.also, p value of s.cholesterol was 0.000. mean and sd of s.hdl-cholesterol level for both the groups were 39.20±5.30 and 40.46±8.96 respectively, p value was non signicant. as far as s.ldl level was concert for breast cancer patients was 125.87±46.97 and for the control group was 81.54±29.21 and p value was 0.000. level of s. vldl were 40.55±10.69 and 35.70±19.49 for test group and control group respectively and p value was 0.008. summary & conclusion:serum cholesterol,serum ldl was signicantly lower in breast cancer patients whereas serum tg,vldl was signicantly higher in breast cancer patients. carcinoma breast is commonest cancer in urban and rural females. many women donot present themselves for check-up at hospitals or medical because of varied reasons like illiteracy, monetary reasons and lack of knowledge. .lots of efforts are needed both from the health systems as well as from local population for early diagnosis of cancer breast abstract keywords : breast cancer, hdl,vldl,ldl,cholesterol dr. shakuntala saini professor, department of biochemistry, s.m.s. medical college, jaipur (rajasthan)*corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 56 x gjra global journal for research analysis triglycerides in breast cancer patient and healthy controls. ÿ serum levels of lipids will be measured by colorimetric technique in fully automated chemistry analyzer randox(imola) methodology ÿ estimation of total cholesterol: enzymatic method (chodpap) principle the enzyme cholesterol esterase is used to hydrolyze the cholesterol esters present in the serum to free cholesterol and free fatty acids. the enzyme cholesterol oxidase in the presence of oxygen to oxidizes the cholesterol to cholest-4-en3one and hydrogen peroxide. hydrogen peroxide oxidizes phenol and 4-aminoantipyrine to produce red color that can be measured spectrophotometrically. calculation: normal value total cholesterol desirable: <200 mg/dl borderline high: 200 -239 mg/dl high: > or =240 mg/dl ÿ estimation of serum hdl-cholesterol: principle: the method is in a two reagent format and depends on the properties of a unique detergent, as illustrated. this method is based on accelerating the reaction of cholesterol oxidase (co) with non-hdl un-esteried cholesterol and dissolving hdl selectivity using a specic detergent. in the rst reagent, non-hdl unesteried cholesterol is subject to an enzyme reaction and peroxide generated is consumed by a peroxidase reaction with dsbmt yielding a colorless product. the second reagent consists of a detergent capable of solubilizing hdl specically, cholesterol esterase (ce) and chromagenic coupler to develop color for the quantitative determination of hdl cholesterol. this may be referred to as the accelerator selective detergent methodology. expected values hdl cholesterol low hdl: <40 mg/dl borderline low: 40-59 mg/dl normal: > or =60 mg/dl ÿ estimation of serum triglycerides:(gpo-pap method) principle: serum triglycerides are hydrolyzed to glycerol and free fatty acids by lipase.in the presence of atp and glycerol kinase (gk), the glycerol is converted to glycerol-1-phosphate. the glycerol-1-phosphate is then oxidized by glycerol phosphate oxidase (gpo) to yield hydrogen peroxide. the condensation of hydrogen peroxide with 4-chlorophenol and 4aminophenazone (4-aa) in the presence of peroxidase (pod) produces a red colored quinonimine dye which absorbs at, or near 500nm. the intensity of the colored complex formed is directly proportional to the triglycerides concentration of the sample. calculation: expected values: triglycerides normal: <150 mg/dl borderline high: 150-199 mg/dl high:≥ 200 mg/dl ÿ estimation of serum vldl-cholesterol and ldlcholesterol: ÿ ÿ vldl was estimated by tg/5 based on the average ratio to cholesterol in vldl ÿ serum ldl was estimated from the freidwald and fredrickson’s (1972) formula, which is ldl=total cholesterol-[hdl+vldl] expected values: ÿ best: less than 100 mg/dl (less than 70 mg/dl for persons with a history of heart disease or those at very high risk) ÿ near best: 100 129 mg/dl ÿ borderline high: 130 159 mg/dl ÿ high: 160 189 mg/dl ÿ very high: 190 mg/dl and higher observation: *values presented as mean± sd this table shows the level of s. triglyceride level in breast cancer patients and control group of 156 individual each are 202.74±53.45 mg/dl and 178.77±99.36 mg/dl respectively . value presented as mean ±sd. the value of t-value and pvalue are 2.654 and 0.008 respectively. figure 1: comparison of s. triglyceride levels in the study groups this gure shows the comparison graph between mean serum triglycerides level in breast cancer patients & control group are 202.74 mg/dl and 178.77mg/dl respectively whereas sd in breast cancer group and control group are 53.45mg/dl and 99.36mg/dl respectively. table 2: comparison of s. cholesterol levels in the study groups volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra groups no. of cases (n) s. tg (mg/dl) t-value p-value breast cancer patients 156 202.74 ± 53.45 2.654 0.008 control 156 178.77 ± 99.36 groups no. of cases (n) s. cholesterol (mg/dl) t-value p-value breast cancer patients 156 205.62 ± 46.09 9.439 0.000 control 156 158.73 ± 41.59 *values presented as mean± sd this table shows the level of s. cholersyerol level in breast cancer patients and control group of 156 individual each are 205.62±46.09 mg/dl and 158.73±41.59 mg/dl respectively . value presented as mean ±sd. the value of t-value and pvalue are 9.439 and 0.000 respectively figure 2: comparison of serum cholesterol levels in study groups this gure shows the comparison graph between mean serum cholesterol level in breast cancer patients & control group are 205.62 mg/dl and 158.73mg/dl respectively whereas sd in breast cancer group and control group are 46.09mg/dl and 41.59mg/dl respectively. table 3: comparison of s. hdl-chol levels in the study groups *values presented as mean± sd this table shows the level of s. hdl-cholesterol level in breast cancer patients and control group of 156 individual each are 39.20±5.30 mg/dl and 40.46±8.96 mg/dl respectively . value presented as mean ±sd. the value of t-value and pvalue are -1.512 and ns respectively figure 3: comparison of s. hdl-chol levels in the study groups this gure shows the comparison graph between mean serum hdl-cholesterol level in breast cancer patients & control group are 39.2 mg/dl and 40.46mg/dl respectively whereas sd in breast cancer group and control group are 5.3mg/dl and 8.96mg/dl respectively. *values presented as mean± sd this table shows the level of s. ldl level in breast cancer patients and control group of 156 individual each are 125.87± 46.97mg/dl and 81.54±29.21 mg/dl respectively . value presented as mean ±sd. the value of t-value and p-value are 10.010 and 0.000 respectively figure 4: comparison of s. ldl levels in the study groups this gure shows the comparison graph between mean serum ldl level in breast cancer patients & control group are 125.87mg/dl and 81.54mg/dl respectively whereas sd in breast cancer group and control group are 46.97mg/dl and 29.21mg/dl respectively. table 5: comparison of s. vldl levels in the study groups *values presented as mean± sd this table shows the level of s. vldl level in breast cancer patients and control group of 156 individual each are 40.55± 10.69mg/dl and 35.70±19.94 mg/dl respectively . value presented as mean ±sd. the value of t-value and p-value are 2.667 and 0.008 respectively. figure 5: comparison of s. vldl levels in the study groups this gure shows the comparison graph between mean serum vldl level in breast cancer patients & control group are 40.55mg/dl and 35.70mg/dl respectively whereas sd in breast cancer group and control group are 10.69mg/dl and 19.94mg/dl respectively. results & discussion: in this study, the mean serum tg level in breast cancer patients was 202.74±53.45 mg/dl while in case of control group it's was 178.77±99.36 mg/dl.this difference was statistically signicant (pvalue=.008). the present study was supported by some scholars. according to j.r.peelain et al4 in 2012, the tg levels were signicantly higher in women with node-negative invasive cancer(0.94+/-1.04mg/ml) than in t h o s e w i t h n o e p i t h e l i a l p r o l i f e r a t i o n ( 0 . 8 3 + / 1.04mg/ml,p=0.03). another study conducted by vinayak v kshirsagar et al5 in 2016 showed that total triglyceride incase of casesis 135mg/dl as compared with controls which is143mg/dl. this was statistically not signicant (pvalue0.30). a study conducted by vatten and foss et al6 in 1990 demonstrated negative,but notstatistically signicant association for tg with breast cancer incidence, which showed further insignicance after adjustment for bmi and serum tc. in this study we found mean serum cholesterol level of breast cancer patients was 190.93+42.80mg/dl while for controls was x 57gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra groups no. of cases (n) s. hdl-chol (mg/dl) t-value p-value breast cancer patients 156 39.20 ± 5.30 1.512 ns control 156 40.46 ± 8.96 groups no. of cases (n) s. ldl (mg/dl) t-value p-value breast cancer patients 156 125.87 ± 46.97 10.010 0.000 control 156 81.54 ± 29.21 groups no. of cases (n) s. vldl (mg/dl) t-value p-value breast cancer patients 156 40.55 ± 10.69 2.667 0.008 control 156 35.70 ± 19.94 191.25+42.31mg/dl this difference was statistically signicant(pvalue=0.018). our study correlated with the study conducted by dr.seema mishra7 in 2015 and she observed that hypocholesterolaemia with decresed hdl cholesterol and increased triglycerides in patients of breast cancer. similarly, according to vinayak v kshhirsagar et al5 in 2016, total cholesterol level in breast cancer patients was 165 mg/dl as compared with control group which was 176mg/dl. this was statically signicant (p value 0.05). contrast study conducted by j.k.peela et al4 in 2012, showed that serum tc was signicantly elevated in patients with carcinoma of breast when compared with control group and p value 0.0046. another study conducted by kamal eldin a. et al8 in 2012, showed that the value of t-c was signicantly increased in all four stages of breast cancer compared with that of control group. in this study we found mean serum hdl level of breast cancer patients was 41.16+5.56mg/dl while for controls was 42.91±8.40mg/dl. this difference was statistically signicant(pvalue=0.016). vinayakv kshirsagar et al5 in 2016,which showed high density lipoproteins in cases of cases is 43mg/dl as compared with the control which is 52mg/dl. this was stat ist ically highly signicant (pvalue0.007). according to j.r.peela et al4 in 2012 showed that serum hdl-c was signicantly elevated in patients with carcinoma breast when compared with controls(p=0.004). another scholar, dr.seema mishra7 in 2015 observed that hypocholesterolaemia with decreased hdlcholesterol in breast cancer patients. in this study we found mean serum ldl level of breast cancer patients was 107.46 + 43.70 mg/dl while for controls was 122.10 ±47.71mg/dl.this difference was statistically signicant (pvalue=0.005). according to study conducted by vinayak v kshirsagar et al5 in 2016 which showed that low density lipoprotein in cases of cases were 180mg/dl ascompared with the control which were 198mg/dl.this was statistically signicant (pvalue0.011). another study conducted by j.r.peela in et al4 in 2012 showed that levels of ldl-c and tgs did not show any signicant changes between the cases studied and the controls (p=0.42and0.092respectively). in this study we found mean serum vldl level of breast cancer patients was 44.60+11.76mg/dl while for controls was 38.29±11.71mg/dl.this difference was highly statistically signicant (p value=0.000).according to pikul l et al9,the level of tg, ldl-c, vldl-c (mean ± sd) in breast cancer patients were 148.20+94.95,143.68+40.01and29.63+18.9 while in control group were 217.48+47.66 and 59.45+15.89 respectively.they found thattg, ldl-c and vldl-c levels in breast cancer group were signicantly higher than controls group(p <0.001). contrast study conducted by vinayak v kshirsagar et al5 in 2016showed verylow densitylipoprotein in case of cases was 27mg/dl as compared with controls which was 28 mg/dl . this was s tat is t ical ly not signicant(pvalue0.39). summary & conclusion: india is the country of diversity ,which accounts for variation in the health care infrastructure.the health care facility pattern in india is heterogeneous,there are some regions where basic health facility have yet to reach.there are also some regions where people are aware of breast cancer.carcinoma breast is commonest cancer in urban and rural females. many women donot present themselves for check-up at hospitals or medical because of varied reasons like illiteracy, monetary reasons and lack of knowledge. there are many patients who present themselves late when the disease has progressed to metastaticst age and at this stage they come to seek treatment.lots of efforts are needed both from the health systems as well as from local population for early diagnosis of cancer breast. conclusion of this study were that: ÿ serum cholesterol,serum ldl was signicantly lower in breast cancer patients in compare with healthy ÿ women. ÿ this study shows serum tg,vldl was signicantly higher in breast cancer patients in compare with control group. ÿ the current study has shown a signicant alteration in the serum lipid prole in breast cancer patients .it is highly recommended that people should reduce weight and control blood cholesterol levels in order to reduce risk of breast cancer since there is contrasting evidence on the correlation of lipid levels and breast cancer,there is a need for large ,multicentric and randomized trials. references: 1. shah f d,shukla s,shah p,patel h,patel p. signicance of alterations in plasma lipid prole levels in breast cancer.integr cancerther 2008;7:33-41. 2. agarwal g,pradeepp v,aggarwal v,yip c h,cheung p s (2007).spectrum of breast cancer in asian women.world j surg,31,1031-40. 3. raste as,naik pp. clinical signicance of lipid prole in cancer patients.indian j medsci2000;54:435-41 4. j.r.peela,a.m.jarari,s.o.elsaiety,s.elbusai,h.el awamy and shakila srikumar: the relationship between serum lipids and breast cancer in libya biochem anal biochem 2012,1:6 5. vinayak v kshirsagar ,dhananjay d vaze ,bandu k dhamane,seema g, prasanna a yawalkar ,shilpa a.pratinidhi .comparative study of lipid prole in patients with carcinoma breast attending a tertiary care hospital of western maharashtra :international journal of contemporary medical research issn (online) :2393-915x;(print):24547379. 6. vatten lj, foss op (1990). total serum cholesterol and triglycerides and risk of breast cancer:a prospective study of 24,329 norwegian women.cancer res 50:2341-2346. 7. dr. seema mishra :lipid prole in breast cancer patients: international journal of pharmaceutical and medical research 2015 3(1): 29-35. 8. kamal el din a. abdelsalam, ikhlas k.hassan, and isam a . sadig:the role of developing breast cancer in alteration of serum lipid prole :j res med sci.2012jun;17(6):562–565. 9. pikul l, warayupa t, saowakon s, adisak s, yuiiana s : comparison of serum lipid proles between normal controls and breast cncer patients , journal of laboratory physicians 2013 5(1):38-41. 58 x gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: gandhiji presented khadi as a symbol of nationalism, equality and self-reliance. it was his belief that reconstruction of the society and effective satyagraha against the foreign rule can be possible only through khadi. it is my duty to induce people, by every honest means, to wear khadi."1. gandhiji started his movement for khadi in 1918. his emphasis at �rst was on khadi as providing relief to our povertystricken masses. but one �nds a change in his emphasis from 1934, more especially from 1935, when he began on insisting on khadi for the villager's own use, rather than merely for sale to others. his further over his khadi movement, and when he came out of jail he came with a determination to give a new turn to khadi work in order to make khadi serve the needs of villagers themselves �rst and foremost. he poured out his soul to his fellow-workers in 1944, and urged them to effect the change. 2. the spinning wheel was atone time the symbol of india's poverty and backwardness. gandhiji turned it into a symbol of self-reliance and non-violence. khadi enabled him to carry his message of swadeshi and swaraj to the people and to establish connection with them. importance of khadi "like swaraj, khadi is our birth-right, and it is our life-long duty to use that only. anyone who does not ful�ll that duty is totally ignorant of what swaraj is. we cannot claim to have understood the meaning of swaraj till khadi becomes as universal as currency. i have only one message to give and that concerns khadi. place khadi in my hands and i shall place swaraj in yours. the uplift of the antyajas is also covered by khadi and even hindumuslim unity will live through it. it is also a great instrument of peace. this does not mean that i do not favors boycott of councils and law-courts, but in order that people may not have a grievance against those who go to them, i desire that the people should carry on work concerning khadi even with the help of lawyers and members of legislatures. keep the moderates highly pleased; cultivate love and friendship for them. once they become fearless, that very moment they will become one with us. the same holds good also for englishmen. "ever since the commencement of our present struggle, we have been feeling the necessity of boycotting foreign cloth. i venture to suggest that, when khaddar comes universally in use, the boycott of foreign cloth will automatically follow. gandhiji on khadi speaking for myself, charkha and khaddar have a special religious signi�cance to me because they are a symbol of kinship between the members of both the communities and the hungerand diseasestricken poor. it is by virtue of the fact that our movement can today be described as moral and economic as well as political."1 (letter written to abdul bari from sabarmati jail, after 12-3-1922. "you have asked me why wearing of indian mill cloth does not amount to boycott of foreign cloth. this is colossal ignorance. for ful�lling the boycott it is not enough if we wear mill cloth. the bengalis even today complain of the exploitation of bengal by the mill-owners at the time of the partition. their experience should teach us that boycott cannot be achieved with the help of only mill cloth. the propaganda should, therefore, be infavour of khadi only. it is obvious that mill cloth has no place in the house of the congress."2 (a speech at public meeting, poona, on 4-9-1924.) "i am convinced that swaraj cannot come so long as the tens of millions of our brothers and sisters do not take to the charkha, do not spin, do not make khadi and wear it."3 (opening speech at belgaum congress, 26-12-1924.) "what is the national programme today? removal of untouchability by the hindus, khaddar and hindumuslim unity. i think all the three items are calculated to help a solution of your difficulties. even hindu-muslim unity means more or less a solution of the untouchability question too, and khaddar can unite us as nothing else can."4 (young india, 14-5-1925.) objectives the objectives of this study are: ÿ to know propagation of khadi, ÿ to know mahatma gandhiji's views on khadi methodology information in this study has been secondary sources. a secondary source includes books, articles, journals and news papers etc. propagation of khadi "using khadi is the foundation of swadeshi, since khadi is the only thing which can be made from thick yarn, and made easily. it has not so far had to compete with machine-made cloth. the consumption of khadi alone enables lakhs of poor people to earn an honest living, staying at home. boycott of foreign cloth by means of handspinning and hand weaving, i.e., khaddar, not only saves the peasant's money, but it enables us workers to render social service of a �rst class order. it brings us into direct touch with the villagers. it enables us to give them real political education and teach them to become self-sustained and self-reliant. organization of khaddar is thus in�nitely better than co-operative societies or any other form of village organization. "the two issues of khadi and political organization should be kept absolutely separate. there must be no confusion. the aim of khadi is humanitarian; but so far as india is concerned, its effect is bound to be immensely political. "if khadi is not constantly kept in view, the result will be that the price of cloth made in mills in india — not indian mills — will keep increasing and the boycott will never become effective. 1. in this age, no amount of effort would make it possible for mills to make cloth sufficient to meet the country's needs. 2. the concern of mills generally is, and will be, pro�ts. mahathma gandhiji thought on khadi original research paper dr. d. vijay chander* department of philosophy osmania university, hyderabad. *corresponding author philosophy gandhiji presented khadi as a symbol of nationalism, equality and self-reliance. it was his belief that reconstruction of the society and effective satyagraha against the foreign rule can be possible only through khadi. khadi is the central core of the constructive activities as recommended by him. according to him there could be no swaraj without universal and voluntary acceptance of khadi. in his words, "i am a salesman of swaraj. i am a devotee of khadi. it is my duty to induce people, by every honest means, to wear khadi. the spinning wheel was at one time the symbol of india's poverty and backwardness. gandhiji turned it into a symbol of self-reliance and non-violence. khadi enabled him to carry his message of swadeshi and swaraj to the people and to establish connection with them. this paper is based on secondary sources. it focus on concepts of khadi, gandhiji's ideas on khadi. abstract keywords : importance of khadi, propagation of khadi, gandhi's views on khadhi, 8 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 3. the government can, at any time, suppress the mills. 4. as mills are dependent upon foreign machines and foreign techniques, they could, all of a sudden, be faced with a difficult situation. while on the contrary: 1. if the sentiment for khadi becomes widespread in the country, we can produce today as much khadi as we require. 2. khadi does not require as much capital as mills do gandhiji's views on khadhi (a) to harijans "gandhiji has given up all those things which were only a means for securing swaraj. you must, however, pursue that which helps the attainment of self-puri�cation — khadi, the abolition of un touchability and hindu-muslim unity. hinduism will be destroyed if un touchability is not ended and, without khadi, there will be such starvation in the country that our �esh will be eaten up by crows and dogs, leaving only bones behind." "universalization of spinning means the automatic solution of many other questions. take the un touchability problem. it is impossible to universalize the wheel without tackling un touchability. the two things hang together. you can thus see that spinning alone does lead to swaraj. "very few people have any notion of what khadi mean to harijans. simple weaving is almost an exclusive speciality of harijans, and even though mill spinning and weaving have deprived many harijans of a source of livelihood, thousands of them are still dependent upon weaving. i personally believe that hand-ginning, handcarding, hand-spinning and hand-weaving have a brilliant future, at least in india. if the millions are to live with any degree of comfort, the mills must seek main custom outside india. those who, apart from the whole programme of anti-untouhability, are interested in the economic betterment of harijans should know that khadi gives employment to thousands of harijan men, women and children who otherwise had no employment. it entirely supports some families and supplements the slender resources of many more and keeps the wolf from the door. its capacity to be the only universal source of employment to the starving millions is not now seriously questioned. it is this poor man's stay which is being under mined by unscrupulous methods. (b) to muslims "spinning is such an activity that both hindus and muslims can take equal part in it. in respect of some crafts, muslims lead the world and weaving is one of them. the dacca muslin used to be woven by muslims alone. "i have not known many muslim organizations devoted specially to khadi work. indeed during the bakr-id in ahmedabad, mussalmans could be counted on the �ngers of one hand who were dressed in khadi. they were not even dressed in indian mill-cloth. it was all foreign. let me hope this committee will change this state of things. i hope, too, that the members are all "you can win swaraj only with non-violence and never with violence. if you are convinced of that, you will not take time to be convinced that by spinning alone can you win swaraj. non-violence in action can be achieved by nothing but a successful working out of a peaceful programme of the universalization of the spinning-wheel. how will you solve the hindu-muslim question but by getting the hindu to work in the cause of khadi for the mussalman, andvice versa?and in order that you get the mussalman and the hindu and the untouchable to work together, you have to plod away in faith and con�dence in yourselves. the maulana hopes that he will be able to bring around three thousand members from among the mussalmans before the year closes. it has been complained that, whereas there are many hindus in the khadi service, there are but few mussalmans. therefore, the maulana wants me to declare this also that all such mussalmans whose hearts are pure and who are industrious had got their place in it. but they who want to come into it must obey its laws. hindus, mussalmans, christians, parsis, jews and all have their place in this a.i.s.a., if they believe in khadi. khadi pratishthan has some but they belong to the humbler walks of life. the abhoy ashram has one or two. there is not much money to be had for service. he has undertaken to examine every case personally and make his recommendation to the council. but i give due warning to all concerned whether mussalmans, christians, parsis or jews, that they must not blame the council if the khaddar service becomes a hindu preserve for want of efforts, ability or love for khaddar on the part of the others. (c) to women when hindu and muslim sisters have adopted the spinning-wheel and come to look upon khadi as their adornment, gandhiji shall feel that he has got all he wanted. he shall then certainly please my correspondent by wearing a dhoti and a long shirt with a collar, for he believe that, when the women have fallen in love with khadi, swaraj will have been won. meanwhile the correspondent should be kind to me and to those like me who wear a loin-cloth and, even if he regards the loin-cloth as indecent, should look upon people who wear it as his brethren, overlooking their indecency "gandhiji know hundreds of husbands who have been delighted to �nd their wives in khadi clothes. their household expenditure has been reduced and their love for their khadi-clad wives have grown. " he appeal to the sisters who think like her to take boldly to khadi and realize that beauty does not 'consist in dress but in purity of character, and clothes are not meant for adornment but for protecting the body from heat and cold." it was reserved for the modern women of india to tell me that khaddar is too coarse for them. but do you know that by your ceasing to wear khaddar millions of our sisters and brothers have been reduced to poverty? it is all very well for you who are fairly wellto-do, to attend functions and to go about in saris of 18 cubits. but remember that your sisters in the villages of india have not only no saris such as you have, but have not even enough food to eat. and gandhiji is telling god's truth when he says that he has seen hundreds, if not thousands, of women in india who have no clothes to wear but rags. even your money, your jeweler, your rings and your necklaces can be of no earthly use to me unless both men and women will wear khadi and nothing but that. this collecting of purses for the spinning-wheel is only a brief and intermediate interval. when every man and woman in india naturally takes to khadi as they all take to the grains that are grown on india's plains there will be as little use for these collections as there is for collection in order to carry on propaganda for cultivating rice and wheat in india. and if gandhiji could but induce you to understand the tremendous importance that khadi has to millions of starving people living in 7,00,000 villages in the whole of india. conclusion gandhi presented khadi as a symbol of nationalism, equality and self-reliance. according to mahatma gandhi there could be no swaraj without universal and voluntary acceptance of khadi. the spinning wheel was at one time the symbol of india's poverty and backwardness. gandhi turned it into a symbol of self-reliance and non-violence. "gandhi has given up all those things which were only a means for securing swaraj. you must, however, pursue that which helps the attainment of self-puri�cation — khadi, the abolition of untouchability and hindu-muslim unity. spinning is such an activity that both hindus and muslims can take equal part in it. "a woman is adorable, not for the jewellery she wears, but for the purity of her heart. gandhi therefore urge you, if you believe that khadi will solve all the distress of india, we have been feeling the necessity of boycotting foreign cloth. he ventures to suggest that, when khaddar comes universally in use, the boycott of foreign cloth will automatically follow. references 1. andrews, c.f., mahatma gandhi's ideas, including selections from his writings, london, george allen and unwin ltd., 1949. x 9gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 2. anil dutta mishra fundamentals of gandhism, mittal publications new delhi110059, 1995. 3. ansar harvani, gandi to gandhi guan publishing house new delhi, 1996. 4. m.k. gandhi cwmg vol. 17, publication division, new delhi, 1996 5. m.k. gandhi cwmg vol. 21, publication division, new delhi, 1966. 10 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 introduction perforation is one of the most important complications of a peptic ulcer (acid -peptic disease). in spite of modern management, it is still a life threatening catastrophe. the sudden release of gastric or peptic contents into the peritoneal cavity through a perforation leads to a devastating sequence of events which if not properly managed, is likely to cause death. perforation may occur in a patient with a known chronic peptic ulcer or it may happen without any preliminary symptoms at all (20%). recent statistics indicate that roughly 10% of the population develops a gastric or peptic ulcer in lifetime. about 13% of population above the age of 20 yrs have some degree of acid peptic disease during any annual period. acute perforation is one of the complications of chronic peptic ulcer (dc) and occurs in about 10-15% of all recognized [1]chronic peptic ulcers . a detailed history with regard to the symptomatology of the patient, a meticulous examination of the patient, radiological and biochemical investigations help to arrive at a correct diagnosis of perforation. operative method is still the treatment of choice and simple closure of perforation is the method followed in most of the surgical centers. conservative treatment is denitely unsuitable for routine use. but few of the patients who are brought to the hospital at a late stage, have major concurrent illness and preoperative shock, may improve with conservative treatment with herman taylor's regimen. immediate treatment for perforated peptic ulcer disease has been an established procedure for sometimes now. it can be stated that immediate denitive surgery like truncal vagotomy with a drainage procedure or proximal gastric vagotomy (pgv) after simple closure for perforated peptic ulcer offers the prospects of a permanent cure with a mortality and morbidity comparable to that of patients with elective surgery. the recent studies show that whenever a denitive surgery is deemed an appropriate addition to a simple closure of perforated du, pgv is the procedure of choice. if the condition is not diagnosed properly and not adequately treated, it progress in a denite manner with a typical course and may lead to the death of the patient due to bacterial peritonitis in about 7-8 days. the mortality increases with delay in operating: the mortality rate when operation is performed within 6 hours of onset of pain approaches zero, from 6-12 hours the rate is 510%, 12-24 hrs it is 25% or higher and in the course of 3rd day [2]after, operations are seldom successful . aims and objectives the present study has been undertaken to evaluate 1. the age and sex incidence, 2. associated clinical history. 3. risk factor involved, 4. time of surgical intervention done after the onset of illness, 5. postoperative complication, 6. total duration of hospital stay, 7. mortality and its relation with outcome of the patient. materials and methods: this study has been based on analysis 50 cases of peptic ulcer perforation (gastric and peptic) admitted in department of surgery, m.l.b. medical college, jhansi from december 2017 to august 2019. the cases were collected at random, which were admitted in emergency and treated in various surgical units. after admission a detailed history was taken and clinical examinat ion was done and poss ib le immediate investigations were done. all 50 cases admitted, and were subjected to emergency laparotomy . at the time of laparotomy, the site of perforation, size of perforation, nature of peritoneal uid, peritoneal uid culture and amount of peritoneal contamination were determined. all cases have been treated by simple closure with graham omental patch repair, peritoneal lavage, and ank drainage procedure. patients were followed up every day with continuous bedside monitoring of vital data in immediate post operative period. due attention was paid to note the development of any complication .suitable and appropriate treatment was instituted from time to time according to the needs of the patients. after satisfactory improvement patients were discharged from the hospital with advice regarding diet, rest, drug to be taken and need for periodic checkup. patients who came for regular checkup were examined in study of various clinical parameters in peptic ulcer perforation and its relation with outcome in bundelkhand region original research paper dr. surya prakash associate professor, department of surgery, m.l.b medical college jhansi x 27gjra global journal for research analysis general surgery background: in our study we aimed to provide a complete epidemiological, clinical and management description of peptic ulcer perforation in all age group patients materials and methods: this study has been based on analysis 50 cases of peptic ulcer perforation (gastric and peptic) admitted in department of surgery, m.l.b. medical college, jhansi from december 2017 to august 2019. results: all the patients who were undergoing exploratory laparotomy followed by graham's omentum patch repair for peptic ulcer perforation were taken. a detailed history, thorough clinical examination and necessary routine blood investigations and x-ray chest standing position were performed in each case. conclusion: peptic ulcer perforation shows increasing incidence in young adult males. the increased incidence shows association to smoking, alcoholism, irregular food habits, use of nsaids/steroids and overall stressed lifestyle. abstract keywords : peptic ulcer, perforation, laparoscopy, surgery, outcome volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. rajkumar rajpoot* associate professor, department of surgery, government medical college, orai (jalaun) *corresponding author adeel ahmad junior resident, department of surgery, m.l.b. medical college, jhansi 28 x gjra global journal for research analysis detail .a general physical examination and examination of the abdomen was carried out to note the condition of operative scar and for evidence of tenderness over the various regions of the abdomen and patients were advised necessary treatment. figure 1: x-ray abdomen ap erect view with both dome of diaphragm shows gas under right dome of diaphragm figure 2: gastric perforation results: all the patients who were undergoing exploratory laparotomy followed by graham's omentum patch repair for peptic ulcer perforation were taken. a detailed history, thorough clinical examination and necessary routine blood investigations and x-ray chest standing position were performed in each case. generally in per abdomen examinationtenderness ,guarding / rigidity were present . almost all the cases require resuscitation, urinary catheterization for urinary output monitoring / ryle tube insertion and aspiration for reduce peritoneal contamination/proper uid and electrolytes management with broad spectrum antimicrobial coverage include anaerobes. in preoperative investigation most of the patients have dehydration, anemia and hypernatremia. almost all patients have free gas under right dome of diaphragm in x-ray abdomen with both dome of diaphragm-ap erect.. all patients need surgical intervention for which we performed graham's omental patch repair with peritoneal lavage followed by morrison and pelvic drain insertion. in intraoperative ndingsmost of the patient have bilious / serosanguinous peritoneal uid and prepyloric (gastric) perforation of size perforation less than 10 mm. in the postoperative periodreturn of the bowel activity (day of passing atus) and rt removal usually done between 3-5 days followed by oral sips allow. morison drain usually removed between 3-5 days and pelvic drain removed within 6 –10 days of post-operative period. most common postoperative complication was surgical site wound infection which usually managed by lower skin stitch removal and proper cleaning and dressing. in my study -19 patient have respiratory infection either in preoperative or in postoperative period and most of managed by prophylactic nebulisation, chest physiotherapy and steam inhalation and early mobilization. most of the patient discharge from hospital within 6 -10 days. post operative mortality is only 6% and rest all survived. discussion peptic ulcer perforation is one of the commonest non traumatic abdominal surgical emergencies requiring hospitalization and management in our hospital. peptic ulcer disease, once so common 3-4 decades ago, has drastically decreased in incidence due to the advent of ppis and anti h. pylori therapy. although perforate peptic ulcer remains a dramatic surgical emergency, now-a-days it seldom results in death. the surgical mortality has decreased steadily and is now about [3]5% (sawyers et al., 1976 ). obviously, patient characteristics are crucial in choosing optimal surgical treatment. simple closure or even non-operative management is acknowledged to be most appropriate for patients who are markedly debilitated or in shock. simple closure is associated with an unacceptable high recurrence rate of peptic ulcer, as high as 92.50% (anantha [4]krishnan et al. 2013 ). but with increased knowledge about the signicance of h. pylori infection in perforated peptic ulcer, it has been shown that eradication of this organism has become imperative after patch closure. an aphorism 'once an ulcer, always an ulcer' which seemed infallible earlier is slowly becoming obsolete, since eradication of h. pylori seems to eliminate recurrences of peptic ulcer. 1. age: peptic ulcer perforation is common in age group of 50-60 years in our study, but the age is no bar for perforation to occur. in our study, youngest patient was 18 years old male and oldest was 80 years old. mean age in our study is 46.17+18.197 in years. 2. sex: in our study out of 50 patients 47 were male and only 3 females majority of the authors have reported that incidence is high in males when compared to females. in our study male to female ratio is 15:1 the male predominance can also be explained on the basis of smoking / alcoholism / more stress and strain of life style. 3. habits/risk factors: in our study 47 out of 50 patients were smokers and 26 out of 50 were both smoker and alcoholic. this point out to the synergism between both risk factor and people. our study [5]match with avijeet mukherjee et al . 4. chief / presenting complaints in our study most common symptom was sudden onset of upper abdominal / epigastric pain which was found in all 50 patients followed by abdominal distention which was found in 46 out of 50 patients. fever and vomiting had been seen in [6]some patients. our study match with andrew h. soll et al . 5. general examination most common general examination nding was dehydration. which was found in 44 out of 50 patients. followed by tachycardia which was found in 39 out of 50 patients. about 1/3rd of the patients presented with sirs / shock. 13 out of 50 patients were having anemia and 6 patients having renal impairment. [7] [8]tsugawa et al and boey john et al reviewed that preoperative shock and co morbidity led to increased morbidity and mortality in patients. in our study we report that early surgical intervention via exploratory laparatomy followed by graham's omental patch repair with peritoneal lavage and broad expectrum volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra antimicrobial including antianaerobes / proper uid and electrolyte management / prophylactic nebulization with chest physiotherapy/ early mobilization and early feeding favored good prognosis. 6. preoperative per-abdomen ndings in our study most reliably tenderness and guarding / rigidity were present in all cases indicating peritonitis obliteration of liver dullness and absent bowel sounds are common. our [9] [5]study matched with kuldeep m et al , avijeet mukerjee et al . 7. radiological investigation since peptic perforation is an emergency, time spent for unnecessary investigations is cut off and basic investigations like x ray erect abdomen for gas under diaphragm is enough in making a probable diagnosis of perforation peritonitis. in our study all cases were positive for free gas under right dome of diaphragm in plain xray abdomen ap erect view. [9]our study matched with kuldeep m et al , avijeet mukherjee et [5]al . 8. preoperative electrolyte imbalance: most of patients having hypernatremia or hyperkalemia can be explained by the late refer of the patients from lower centers. 9. intra operative ndings: in our study peritoneal uid was mostly bilious (26 out of 50) followed by serosanguinous uid (20 out of 50 patients), only 4 out of 50 patients had purulent peritoneal uid, who had poor outcome. in our study mostly patients with peptic ulcer perforations were pre pyloric and perforation of size less than 10mm had good prognosis. only 3 cases out of 50 were having perforation of size more than 10mm and were having higher morbidity. grahams omental patch repair with peritoneal lavage / morrison and pelvic drain insertion was done in all prepyloric perforation cases. 10. post operative care: in our study it is seen that return of the bowel activity usualy comes within 3-5 days in postoperative period. at the same time ryle tube was removed and oral sips were allowed. in our studymorrison drain was usually removed within 3-5 days in post operative period and pelvic drain was usually removed within 6 -10 days of postoperative period. 11. postoperative complication in our study most common post operative complicatin was surgical site wound infection which occurred in 28 out of 50 patients. this was probably due to peritoneal uid contamination, and was usually managed by removal of lowest stitch with regular cleaning and dressing. 19 out of 50 patients had respiratory infection either in preoperative / postoperative period. most of them were managed by nebulization and chest physiotherapy and a very few need icu care with ventilator support. 12. duration of hospital stay: in our study most of the patients were discharged within 6-10 days with prescription of anti-h-pylori regimen. 13. mortality: in our study mortality rate was very minimal and only 3 out of 50 patients were died. the mortality in these 3 patients can be attributed to elderly age, late presentation, shock at the time of presentation, bigger size of perforation and chronic smoking, alcoholism with other co-morbidities. [3]our study matched with sawyers et al and bharathi c [10]ramesh et al . conclusions 1. peptic ulcer perforation is one of the most common nontraumatic acute abdominal emergencies. 2. peak incidence 50-60 years. 3. male have higher incidences than female. 4. no perforation found in children. youngest was 18 year old male and oldest was 80 year old male. 5. most of patient of peptic perforation belong to middle class followed by upper lower and upper middle least is seen in upper class. 6. maximum number of patient of perforation belongs to rural area. 7. maximum number of patient are referred from some other lower centers. 8. most common risk factors are smoking followed by alcoholism and nsaid intake. 9. most common symptom is sudden onset upper abdominal / epigastric pain. 10. the general conditions of patients were usually poor with dehydration / sirs / shock. 11. generally in per abdomen examinationtenderness, guarding / rigidity were present. 12. almost all the cases require resuscitation, urinary catheterization for urine output monitoring / ryle tube insert ion and aspirat ion to reduce peri toneal contaminat ion / proper uid and electroly tes management along with broad spectrum antimicrobial coverage include anaerobes and proton pump inhibitors or hydrogen receptor blockers. 13. in preoperative investigation most of the patients have d e h y d r a t i o n , a n e m i a a n d h y p e r n a t r e m i a o r hyperkalemia. 14. almost all patients have free gas under right dome of diaphragm in x-ray abdomen with both dome of diaphragm-ap erect. 15. all patients need surgical intervention for which we performed graham's omental patch repair with peritoneal lavage followed by morrison and pelvic drain placement. 16. in intraoperative ndingsmost of the patient have bilious / serosanguinous peritoneal uid and prepyloric (gastric) perforation of size perforation less than 10 mm. 17. in the postoperative periodreturn of the bowel activity (day of passing atus) and rt removal usually done between 3-5 days followed by oral sips allow. 18. morison drain usually removed between 3-5 days and pelvic drain removed within 6 –10 days of post-operative period. 19. most common postoperative complication was surgical site wound infection which usually managed by lower skin stitch removal and proper cleaning and dressing. 20. in my study 19 patients have respiratory infection either in preoperative or in postoperative period and most of managed by prophylact ic nebul izat ion, chest physiotherapy, steam inhalation and early mobilization. 21. most of the patients discharge from hospital within 6 -10 days. 22. post operative mortality is only 6% and rest all survived. references: 1. khuroo ms, mahajan r, zargar sa, javid g, munshi s. prevalance of peptic ulcer in india: an endoscopic and epidemiological study in urban kashmir. gut. 1989; 30:930–4. https://doi.org/10.1136/gut.30.7.930 pmid:2788113 pmcid:pmc1434311. 2. baron jh. peptic ulcer. the mount sinai journal of medicine. 2000; 67(1):58–62. pmid:10677783. 3. sawyer pr, brogden rn, pinder rm, speight tm, avery gs. tinidazole: a review of its antiprotozoal activity and therapeutic efcacy. drugs. x 29gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 1976;11(6):423-40. pubmed pmid: 954609. 4. ananthakrishnan an, khalili h, pan a, higuchi lm, de silva p, richter jm, fuchs cs, chan at. association between depressive symptoms and incidence of crohn's disease and ulcerative colitis: results from the nurses' health study. clin gastroenterol hepatol. 2013 jan;11(1):57-62. doi: 10.1016/j.cgh.2012.08.032. epub 2012 aug 31. pubmed pmid: 22944733; pubmed central pmcid: pmc3587728. 5. avijeet mukherjee, debashis mondal.a randomized comparative study between omentopexy and omental plugging in treatment of duodenal perforation.international surgery journal mondal d et al. int surg j. 2 6. andrew h. soll md david y. graham md.peptic ulcer disease.first published: 14 november 2008.https://doi.org/10.1002/9781444303254.ch40. 7. tsugawa k, koyanagi n, hashizume m, tomikawa m, akahoshi k, ayukawa k, wada h, tanoue k, sugimachi k. the therapeutic strategies in performing emergency surgery for gastroduodenal ulcer perforation in 130 patients over 70 years of age. hepatogastroenterology. 2001 jan-feb;48(37):156-62. 8. boey j, lee nw, koo j, lam ph, wong j, ong gb. immediate denitive surgery for perforated duodenal ulcers: a prospective controlled trial. ann surg. 1982 sep;196(3):338-44. 9. kuldeep m, barkesiya b.l, barolia d, kuldeep p. a prospective study of clinical prole, management and outcome of surgical treatment of perforated peptic ulcer in northern india: a tertiary hospital experience. int j med res rev 2015;3(10):1140-1145. doi: 10.17511/ijmrr.2015.i10.206. 10. bharati c ramesh et al: immediate denitive surgery in perforated duodenal ulcer: a comparative study, between surgery and simple closure. indian j. surg,1996;257-279. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 30 x gjra global journal for research analysis 73.mr.vinod misra online.cdr introduction one of the greatest contributions of india to the world is the shrimad bhagavad gita. bhagavad gita is the song of the lord. when lord shri krishna observed that arjuna is refusing to ght because of materialistic attraction towards his dear ones, then shri krishna preached shrimad bhagavad gita to motivate arjuna and advised him to leave aside the weakness of the heart and to get ready to ght in the battleeld. vedvyasa created the greatest epic mahabharata. this epic which is also called pancham veda (the fth veda) contains various teachings. shrimad bhagavad geeta is the epitome of all such teachings. it is the gem of the complete mahabharata. it contains 18 chapters and 700 shlokas. krishna is a powerful teacher and arjun and sanjay are ideal students. people who apply the principles of gita in their lives become rich, courageous and able to face the challenges of their lives and bounce back. eminent personalities like mahatma gandhi, albert einstein, e.sreedharan (known as the metro man in india) read gita throughout their lives. the paper focuses on how to develop positive attitude in life through the teachings of the bhagavad gita. benefits of reading bhagavad gita four main benets of reading gita are money, victory, extraordinary power, morality. when there is no morality, character, ethics, values and principles everything will be destroyed. gita gives vision, mission, objective, strategy and action plan which can be mentioned in the abbreviation vmosa which means: v for vision m for mission o for objective s for strategy a for action plan morality makes you so powerful that you can face any difculty easily. jab tak tu lakshya ko dekh nahi sakta tab tak tu lakshya ko bhed nahi sakta (you cannot achieve the goal till you see it) jab tujhe lakshya nazar aane lagenge tab tere lakshya per nishane lagenge (when you start seeing your goals then you start targeting them) seven dangers to human virtue mahatma gandhi has mentioned the seven dangers to human virtue : 1) wealth without work (mehnat kiye bina dhan kamana) 2) pleasure without conscience (vichar kiye bina such) 3) knowledge without character (charitra ke bina gyan) 4) business without ethics (sanskar ke bina vyapar) 5) science without humanity (insaniyat ke bina gyan) 6) religion without sacrice (vairagya ke bina bhakti) 7) politics without principle (siddhant ke bina rajniti) mental diet plan all the discoveries and inventions in the world happened by asking questions. discovery is a learnt skill. you can learn to discover by asking a lot of questions. begin our day by asking empowering questions to yourself. what is your unlimited power signature strength which you have not used? how will you increase your energy and motivate others also? the quality of your questions will determine the quality of your answers. it's not only the question you have asked but also the questions you have failed to ask yourself will determine your future. some people ask empowering questions like why this happened to me? some ask empowering questions like what should i do so that i will bounce back. some questions will give you breakdown and some will give you breakthrough, some will give you hopeless end and some will give you endless hope. some will give you defect (you focus on difculty) and s ome w i l l ma ke you p er f ec t ( you w i l l f oc u s on determination/possibility/barrier-free thinking). mind is very powerful, it can break you or it can make you. you can become strongly mental or mentally strong. how to co nvert negative attitude into positive attitude attitude comes through the seed of ow of desire that we have developed. now the question is which seed pattern do you like to cultivate and the ow off desire you would like to focus on? you have multiple different types of possible seed pattern and ow of desires. role of attitude for growth and success it is said that higher you go in any department 90% of people are using attitude and only 10% are using their skill and lower you go in any department only 10% of people are using attitude and 90% are using their skill. for your growth it is very important that you have a lot of developing positive attitude through bhagavad gita original research paper mr. vinod misra assistant professor iet history one of the greatest contributions of india to the world is the srimad bhagavad gita. gita was spoken when there was deep crisis. the war was not with the words. it was a war where people were ready to kill each other. gita was preached by lord krishna to motivate arjuna in the battleeld of kurukshetra when arjuna got depressed when he saw his relatives with whom he has to ght. it is a divine book containing unlimited knowledge. it contains transformative powers at the human and society level. the verses (shlokas) and teachings of gita can act as life-changing lessons. in this conversation four characters are involved : krishna, arjuna, sanjay and dhritrashtra. the whole conversation is of 48 minutes (one muhurta). it contains 18 chapters and 700 shlokas. one thing which is common between all persons who have become successful in this world is their ability to overcome challenges in life. by applying the principles of bhagavad gita we can overcome challenges of our life and become successful. anyone can apply the principles of gita in his/her life and overcome challenges and become successful. the paper focuses on how to develop positive attitude in life through the teachings of the bhagavad gita. abstract keywords : bhagavad gita, positive attitude dr. ritu tyagi* principal iet *corresponding author 6 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra positive attitude. it will help you to grow a lot. if you try to be the “best” you will be “number one” if you try to be “unique” you will be the “only one” main kabhi harta nahi ya to jeeta hoon ya seekhta hoon (i never loose whether i win or learn) how to increase your conscious level and give new interpretation? whether you want to make it +10/10 or -10/10 on a scale of 10. from passion to profitable profession lack of clarity is the biggest problem in education in student life (which subject to choose? which carrier to choose?). give a shape or direction to your passion. make it a problem solving purpose. is your passion solving any problem in the society? convert it into a protable profession. following three steps will help in making a protable profession : step 1 : passion step 2 : problem solving step 3 : protable profession bill gates, mark zuckerberg, michael jordan, sanjeev kapoor, kansan bhai patel and many other famous people have turned their passion into a successful protable profession and made their name in the world. all the success stories in the world are all stories of great failures but it was their ability to bounce back in tough times that made them successful. you don't lead your life your patterns are leading your life. you don't take any decision your patterns are inuencing your decisions. motivation should not be outside in it should be inside out. whenever motivation depends on external sources, it cannot last for longer time because once you loose the source the motivation went away. importance of values when you value the valuables, you neither get the valuables nor the values. when you value somebody's value system his value system becomes your value system. when you value the values of the right people, valuables come so fast that you can't even manage. strong value system will lead to massive behavior which will ultimately lead to massive productivity. have the genius around you to attract the genius within you. conclusion gita can act as a powerful catalyst for transformation. when the thinking of man is improved it will surely improve the quality of his actions and the results. all the success stories in the world are all stories of great failures but it was their ability to bounce back in tough times that made them successful. you don't lead your life your patterns are leading your life. you don't take any decision your patterns are inuencing your decisions. motivation should not be outside in it should be inside out. whenever motivation depends on external sources, it cannot last for longer time because once you loose the source the motivation went away. anyone can apply the principles of gita in his/her life and develop positive attitude and become successful. references 1. bhaktivedanta, a.c and prabhupada swami. (2013) bhagavad-gita as it is. the bhaktivedanta book trust : mumbai. 2. mahadevan, c.s. (2001). the glories of the gita: stories from the padma purana. sterling publishers : new delhi. dis-empowering questions (why i have failed again & again?) empowering questions (what i have learnt from this failure?) strongly mental mentally strong break down break through defect perfect difculty possibility/opportunity/barrie r-free thinking hopless end endless hope x 7gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction clinicians traditionally have perceived pathologists as having all the answers, but always too late. the use of modern exible gastroduodenoscopes and the acquisition of mucosal 1biopsy specimens have opened a window to the living tissues. introduction of bre-optic endoscope in 1960s greatly improved the diagnostic facility for gastrointestinal lesions. therefore, gastroduodenoscopy is now a routine procedure and has superseded the barium meal as the primary diagnostic tool. in addition, tissue specimen can be removed from the lesions under direct vision, using biopsy forceps. histopathological study of biopsy specimen will conrm endoscopic diagnosis in most of the cases. the gross ndings on endoscopy are not disease specic and may be seen in various other upper gastrointestinal pathologies. the literature on role of endoscopy in the diagnosis and follow up of patients with gastro duodenal diseases is extensive. there are only few studies reporting the correlation of endoscopic diagnosis and histopathological diagnosis. an attempt was made to study the various gastroduodenal lesions by endoscopic biopsies to throw more light on the correlation of endoscopic diagnosis with histopathological diagnosis. materials and methods the present study was a prospective study carried out on patients attending endoscopic unit for the evaluation of upper gastro intestinal symptoms. hundred cases of endoscopic biopsies from december 2014 to june 2016 were included in the study. all biopsies done for various upper abdominal symptoms with or without systemic symptoms were included in our study. gastroduodenoscopies for therapeutic purposes, emergency setting and endoscopy cases where biopsies cannot be done were excluded from our study. the endoscopic procedure was done in a patient with symptoms of gastroduodenal disease after six hours fasting. after endoscopic evaluation, biopsy forceps composed of two cups of varying shape, the edges of which may be smooth or dentate. the size of the cups may vary from 2-3mm. the forceps are often designed with a central bayonet that permits tissue to be pinned down so that an accurate biopsy can be taken. once the cups are brought together, the tissue is torn off and retrieved by bringing the biopsy forceps out through the channel. the biopsy tissue placed on the lter paper is transferred in the bottle containing 10% neutral formalin. after xation the biopsy specimen was wrapped in a piece of lter paper and processed in a perforated capsule. the tissue is processed as 10% formalin for 1 hour, 60% alcohol for 1 hour, 70% alcohol for 1 hour, 80% alcohol for 1 hour, 90% alcohol for 1 hour, 95% alcohol for 1 hour, absolute alcohol for 4 hours, absolute alcohol for 4 hours, xylene for 1 hour, xylene for 1 hour, wax for 4 hours, wax for 4 hours. unwrapped and embedded in parafn with surface uppermost 3 to 5 microns thick, 3-4 sections were taken perpendicular to surface. routine haematoxylin and eosin, special stains like pas, giemsa were done. histological diagnosis made. results in this study, 81 gastric biopsies and 19 duodenal biopsies were examined. 76% were males and 24% were females. majority were in the more than 58 years range 18-80 years. the mean age of male and female in the study were 49.2 and 45.8 years respectively. the predominant presenting symptom of the patient presented pain abdomen (71%) followed by dyspepsia (34%), weight loss (15%), vomiting (9%), and hematemesis (6%).the most common site involved in gastroduodenal biopsies of our study is pylorus 37%, followed by body 19%, antrum and duodenum 17% each. in the study most of the patients were of lower socioeconomic status (50%). among 100 patients, 60% are smokers and 62% are alcoholics. the most common endoscopic presentation is gastric erythema (42%) followed by benign gastric ulcer (19%); ulceroproliferative growth (15%), 13 of which were in stomach and 2 duodenum, duodenal erythema(13%), malignant gastric ulcer and inltrative growth (3% each),gj stomal ulcer and antral polyp(1% each), as depicted in table 1. out of 81 gastric biopsies 56 were non-neoplastic and 18 were nonneoplastic. the most common histological diagnosis is chronic gastritis (44%), followed by adenocarcinoma (15%) and chronic duodenitis (15%), benign gastric ulcer (11%) which included one case of gastric erosion ad intestinal metaplasia each and followed by gastric dysplasia (3%), duodenal ulcer (2%) and antral inammatory polyp in 1%, as depicted in table 2. 5% cases are histologically normal as compared to endoscopic presentation. table 1: distribution of study subjects based on endoscopic presentations does endoscopy always predict microscopic picture in gastroduodenal biopsies? original research paper dr. sushma cherukuru consultant pathologist cloud nine hospitals jayanagar bengaluru x 57gjra global journal for research analysis pathology background: the gastroduodenoscopy and biopsy is the diagnostic tool of choice to detect gastroduodenal diseases. however, endoscopic diagnosis is not always predictive of microscopic ndings. objective: to study varied spectrum of histopathological lesions both non-neoplastic and neoplastic in patients undergoing gastroduodenal biopsy. materials and methods: this is a prospective study of 100 patients with gastroduodenal diseases who underwent gastroduodenoscopy from december 2014 to june 2016. results: in our study, the majority of patients were between 34 to 62 years, with male predominance (49.28%). chronic gastritis (44%) was most common followed by gastric adenocarcinoma (15%) (intestinal type-80%); diffuse type-20%), and chronic duodenitis (15%). a rare case of granulomatous gastritis and ampullary carcinoma was found. conclusion: non neoplastic lesions were more common than the neoplastic lesions. the gross ndings on endoscopy are not disease specic. histopathological study of biopsy specimen will conrm endoscopic diagnosis in most of the cases. abstract keywords : gastroduodenal; histopathology; granulomatous; ampullary; adenocarcinoma. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra endoscopic presentation frequency percentage gastric erythema 42 42% 58 x gjra global journal for research analysis table 2: distribution of study subjects based on histological diagnosis the most common lesion with respect to site were chronic gastritis 3% in the cardia; adenocarcinoma, benign gastric ulcer, chronic gastritis (1% each) in the fundus; chronic gastritis in body (13%), antrum (6%) and pylorus (21%). the most common site for chronic gastritis was pylorus (47.72%) followed by body (29.54%), antrum (13.63%), cardia (6.8%) and fundus (2.27%). pylori was positive in 15 helicobacter cases. the most common lesion found in the duodenum is chronic duodenitis (15%) followed by duodenal ulcer and adenocarcinoma (2%each). in chronic duodenitis, the patient's age ranged from 20 to 70 years. in duodenal adenocarcinoma patient's age is 54 years and in ampullary carcinoma it is 48 years. majority of gastric cancers were elderly males. the most common type of gastric adenocarcinoma was intestinal type (80%) and 20% being diffuse type. all the 3 cases of diffuse type of adenocarcinoma were of signet ring type. the sensitivity of endoscopy in correlating endoscopic picture of ulceroproliferative growth, ulcer, inammation and erosion are 86.4%, 91.7%, 82.8%, and 100% respectively. discussion the present study was an analysis of 100 gastroduodenal biopsied lesions, which included 81 gastric biopsies and 19 duodenal biopsies, which showed that non neoplastic diagnosis outnumbered neoplastic diagnosis. in the present study the numbers of males undergoing upper gi endoscopy were more than the number of females. similar ndings were 2found in the previous study by david a liberman et al and 3florian froehlich et al .in all the three studies, the men out numbered women due to more prevalence of smoking alcoholism and stressful life.it was found that the majority of patients presenting with gastro duodenal symptoms were more than 58 years of age which was similar to study done by 3florian froehlich et al . the commonest symptom the patient presented with was pain abdomen (71%) followed by dyspepsia (34%) which correlates 4with the study done by heading r.c et al revealing 54% 5presented with pain abdomen and in study usman et al 46% presented with pain abdomen. the most common histological pattern noted in gastro duodenal biopsies of our study was gastritis (44%), which is 6similar to the study done by sultana et al , followed by gastric adenocarcinoma (15%). in the present study, it was found that alcoholism and smoking were primary habitual factors in patients undergoing endoscopy for gastro duodenal 7symptoms, similar to study done by william k.hirota et al . the most common histological pattern noted in gastro duodenal biopsies noted was gastritis (44%), which is similar to the 6study done by sultana et al . the prevalence of helicobacter pylori was noted in 34.09% cases of chronic gastritis which is less than that noticed in 8 9other studies by caromona et al ., jenilohun et al . in the present study, the most common site affected by gastritis was pylorus (47.72%) whereas antrum was observed to be 10,11 common in other studies which could be reason for discrepancy. off 81 gastric biopsies, 18 were neoplastic, which include 15 cases of adenocarcinoma and three cases of dysplasia. gastric carcinoma was more common in males than females (2.8:1) in the present study, which correlates with the study 12done by david et al with male: female ratio of 2.5:1. various studies have noted that adenocarcinoma account for 90 – 95% 13-15of gastric cancer . this correlated with o-iour study where adenocarcinoma constituted 91.3% of all gastric cancer. the commonest site of presentation of gastric adenocarcinoma was the pylorus (10%) antrum (4%) i.e., distal third of stomach followed by fundus (1%). the types of growth encountered were ulcerative in 80% and inltrative in 20%. when the histopathological types of gastric adenocarcinoma were considered 80% were of intestinal adenocarcinoma type and 20% were of diffuse carcinoma type. similar ndings were noted in other studies with the 16commonest site being the antrum (distal third) , the commonest type of presentation being ulceration and the commonest histopathological type being intestinal type of 17adenocarcinoma . off 19 duodenal biopsies of which 17 were non-neoplastic and 2 neoplastic. benign lesions (89.5%) were more common than the malignant lesions which are similar to the study done by 18 19tadashi et al and ravi et al . in our study and the one by 18tadashi et al the commonest lesion in duodenum was duodenitis. the neoplastic lesions included in this study were one adenocarcinoma and one ampullary carcinoma. our s tudy has l imi tat ions. in our s tudy, modern gas t roduodenoscop ic techn iques which inc lude chromoendoscopy or other techniques were not used. second, there are a smaller number of malignancies to draw conclusion. however, our study provides insights into correlation of endoscopic and histopathological ndings which are important in tailoring the management. conclusion non neoplastic lesions were more common than the neoplastic lesions. the most common type of gastric adenocarcinoma was intestinal type. the gross ndings on endoscopy are not disease specic and may be seen in various other upper gastrointestinal pathologies. histopathological study of biopsy specimen will conrm endoscopic diagnosis in most of the cases. references: 1. lawrence j. brandt. clinical practice of gastroenterology stomach and duodenum. churchill livingstone . vol. 1: 151415. 2. david a. liberman patterns of endoscopy use in the united states .j gastroenterol 2000: 118 (3) : 619-24. 3. florian froehlich under utilization of upper gastrointestinal endoscopy. j gastroenterol, 1997: 112 (3) : 690 — 97. 4. heading, r.c., prevalance of upper gastrointestinal symptoms in the general volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra benign gastric ulcer 19 19% malignant gastric ulcer 3 3% ulceroproliferative growth 15 15% inltrative growth 3 3% duodenal erythema 13 13% duodenal ulcer 3 3% gastrojejunal stomal ulcer 1 1% antral polyp 1 1% total 100 endoscopic presentation frequency percentage chronic gastritis 44 44% gastric adenocarcinoma 15 15% chronic duodenitis 15 15% benign gastric ulcer 11 11% gastric dysplasia 3 3% duodenal ulcer 2 2% inadequate 2 2% inammatory antral polyp 1 1% duodenal adenocarcinoma 1 1% ampullary adenocarcinoma 1 1% normal 5 5% total 100 population — a systematic review; scand j of gastroenterolog. 1999; vol 34: 3-8. 5. mohd. usman, farrukh saeed, haz mohd; the diagnostic yield of upper gastrointestinal endoscopy in patients with iron deciency anemia. pak armed forces med j. 2008; vol 4 : 3438. 6. a sultana. sm badruddoza. f rahman; correlation between endoscopic and histological ndings in different gastroduodenal lesion and its association with helicobacter pylori. anwar khan modern medical college journal. 2011: vol 2 no. 2 : 610. 7. william k. hirota specialized intestinal metaplasia dysplasia and cancer of the esophagogastric junction and stomach : prevalence and clinical data j gastroenterol. 1999 ;116 (2) 277-85. 8. carmona saez tj, munoz torres e, paz bouza ji; correlation among endoscopic, histological and microbiological ndings in gastroduodenal pathology associated with helicobacter pylori; an med imam 1996 jun: 13 (6): 26973. 9. ac jemilohun, ja otegbayo, so ola, oa oluwasola: prevalance of helicobacter pylori among nigerian patients with dyspepsia in ibadan. pan african medical journal; vol 6. no.1; 2010. 10. jonsson, r. golthard, g. bodemar, u. brodin; the clinical relavance of endoscopic and histologic inammation of gastroduodenal mucosa in dyspepsia of unknown origin; scand journal of gastroenterology: 1989. vol. no. 4, 385395. 11. de mello es, melo cr; prevalence of various types of gastritis in patients with upper dyspeptic symptoms. arg gastroenterol 1992 aprjun: 29(2): 43-50. 12. david m. roder. the epidemiology of gastric cancer. gastric cancer journal 2002 dec; vol. 5. issue 1: 511. 13. dicken bj, bigam dl. cass c. mackey jr; gastric adenocarcinoma review and consideration for future directions . ann surg 2005; 241(1) : 2739. 14. kelly jr, duggan jm. gastric cancer: epidemiology . journal of clinical epidemiology 2003; 56 : 19. 15. fuchs cs, mayer rj. gastric ca. n engl j med 1995; 333(1) : 32 — 36. 16. mohandas km. nagral a. epidemiology of digestive tract cancers in india. stomach and gastrointestinal lymphomas. indian j gastroenterol 1998: 17: 24-7. 17. preiser f, carneiro f, correa p, lambert p, megrawd f et al. gastric carcinoma. in hamilton sr, altonen la (editors). pathology and genetics of tumours of the digestive system — who classication of tumours; lyon. france: iarc press; 2000: 3852. 18. tadashi terada. pathologic observations of' the duodenum in 615 consecutive duodenal specimens: benign lesions. lnt clin exp pathol 2012: 5 (1): 4651. 19. ravi kanthan. daniel gomez. endoscopic biopsies of duodenal polyp or mass lesions: a surgical pathology review. j clin pathol 2010: 63: 921925. x 59gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: the risk of cardiovascular diseases are increasing day by day in developing countries. out of which hypertension being one of the most common problem. there are many risk factors for hypertension as well as many researches says that lack of sleep is one of the cause. night shift worker mostly tend to have hypertension due to disturbance in sleep. to prevent further complications and to nd out the modied risk factor for hypertension in subjects having lack of sleep due to working in shifts so this study was conducted working mostly at night is mostly associated with consequences of general health, because of disturbance in chronobiological rhythms, disturbances of the circadian sleep rhythm could disturb the blood pressure and increases the incidence of hypertension. studies with short duration have found higher risk of blood pressure among shift workers .2 shorter period of sleep can lead to various complications depriving the quality of life of the persons. there are many risk factors such as anxiety, obesity, diabetes. some evidences say that there are acute changes in blood pressure mostly having shorter period of sleep. despite of lack of evidence from short term studies, there is very few evidences that acute changes in blood pressure regulation in shift worker lead to chronic hypertension. people want and able to do everything at any hour of the day and night. various type of work schedules has been adopted by organizations and companies in which working hours are 2extended to evenings and night hours, as well as to weekend . shift work is associated with an increased risk of coronary heart disease with a direct association between time of exposure to work in shifts. several studies have also reported a higher prevalence of coronary risk factors among rotating shift workers, due to increased cigarette consumption, higher blood pressure, and increased serum cholesterol, glucose, and uric acid level and urinary adrenaline excretion. working in shifts extends the period of production beyond the conventional eighthour working day. although the shift workers of fty years ago were likely to be factorybased workers, increasing demand for services has extended shift work practice to those employed in what are traditionally known as white collar occupations, such as doctors and 1.nurses disturbance of worker's normal biological rhythm cause 4health problems in shift workers . most human functions have a rhythm, of approximately a 24-hours period, known as circadian rhythm. these rhythms are determined partly by endogenous factors, the internal body clock, and partly by environmental factors such as daylight, noise, and the social 5habits of the individual . mult iple physiological , psychological, and behavioral parameter such as body temperature, serum and urinary corticosteroids and electrolytes, cardiovascular functions, gastric enzyme secretion, blood leukocyte count, muscle strength, alertness, 6mood, and long-term memory follow circadian rhythms . these circadian rhythms, which are related to activities during the day and rest at night, are persistent and rigid and 7therefore do not adapt immediately to new working patterns . researchers found that persons between 25 and 35 year of age with 5 or fewer hours of sleep per night were twice as likely 8to have hypertension over an 8 to 10 year follow up period .so this study was conducted to nd out the prevalence modiable risk factors of hypertension in night shift workers. prevalence of modifiable risk factors of hypertension in night shift workers original research paper riddhi hemant shetye department of musculoskeletal sciences, faculty of physiotherapy, kims “deemed to be” university, karad, maharashtra, india. x 89gjra global journal for research analysis physiotherapy background: working at night leads to various health problems. shift workers mostly working in night shifts usually have shorter period of sleep which can lead to various complications depriving the quality of life of these persons. there are many risk factors such as anxiety, obesity, diabetes. some evidences say that there are acute changes in blood pressure in subjects mostly having shorter period of sleep so there is need to nd out the modied risk factors of hypertension in night shift workers. so this study was intended to out the prevalence of risk factors of blood pressure in night shift workers objectives: objectives of the study were to nd out and determine the prevalence of modiable risk factors of hypertension in night shift workers. methods: this was an observational study with 100 subjects as a sample. subjects were selected as per inclusion and exclusion criteria. inclusion criteria included male subjects working for ve years or more in night shift in between age group 25-35 years. subjects having an known history of hypertension, diabetes mellitus and habit of tobacco chewing were excluded from study. later questionnaire of hypertension group were distributed and survey was conducted among the subjects. statistical analysis was done and results were interpreted. results: statistical analysis of questionnaire of hypertension group stated that there is higher risk of hypertension due to modiable risk factors in subjects working in night shifts. conclusion: the study concluded that there are high chances of risk factor of hypertension in night shift workers. abstract keywords : hypertension, night shift workers, modiable risk for hypertension dr. sandeep babasaheb shinde* department of musculoskeletal sciences, krishna college of physiotherapy, kims “deemed to be” university, karad, maharashtra, india. *corresponding author sonali tukaram kadam department of musculoskeletal sciences, faculty of physiotherapy, kims “deemed to be” university, karad, maharashtra, india volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 90 x gjra global journal for research analysis methods: this observational study was carried out in krishna college of physiotherapy, kims deemed to be university, karad after obtaining the ethical permission from institutional ethical committee. the study included 100 individuals working in night shift. patients were selected as per the inclusion and exclusion criteria. inclusion criteria included male subjects working for ve years or more in night shift in age group between 25-35 years. subjects having an known history of hypertension, diabetes mellitus and habit of tobacco chewing were excluded from study. the patients were given all the information about what we are going to do. later the demographic data such as name, age, gender what time is the shift, height &weight was taken. with the help of consent form, patients consent was taken and study was explained to subjects. with the help of questionnaire of hypertension, patients were assessed and survey was conducted. with the help of statistical analysis results were drawn and interpreted. results: results was done manually and by using the statistics software instat so as to verify the results derived. question no 1 work duration graph 1 this graph represents the working duration of night shifts of the subjects. out of 100 % 43% subjects worked for 2 years, 29 subjects worked for 3 years ,21 subjects worked for more than 4 years while 7% subjects worked for 1 year. question no 2 when were, you diagnosed to have hypertension graph 2 the graph represents that subject diagnosed with hypertension out of 100%, 68% subject were diagnosed with hypertension in one month to one year, 19% subject were diagnosed with more than one year age, 13% subject were diagnosed with hypertension less than one month question no 3 have you ever suffering from any of the following condition? graph 3 the graph states that 42% subjects suffer from high cholesterol,15% subject are suffering from diabetes mellitus,15% subject are suffering from angina,10% subject suffering from tia/stroke, 9% subject are suffering from intermittent claudication, while 9% of subject are suffering from poor vision. question no 4 have you ever smoking cigarette? graph 4 the graph represents that out of 100% .59% subject were cigarette smoker and 41% subject were not. question no 5 are you taking alcohol graph 5 the graph tells us the percentage of subjects addicted to alcohol. 61% subject were alcoholic and 39% subject were not. question no 6 what level of physical activities do you have while at work graph 6 level of physical activities at work done by the subject out of 100% is represented in graph.65% subject are doing moderate activities at work, 20% subject are doing active activities at work 15% subject are doing light activities at work. question no 7 what level of physical activities do you have while coming to and from work. graph 7 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra the graph represents the level of physical activities the subjects do while going to and from work out of 100% subject,50% subject are walking or cycling in 1mins or 29mins,29% subject are using motorized transport and 21% subject are walking or cycling more than 30 mins. question no 8 what level of activities do you have during your leisure time? graph 8 the graph shows us the level of physical activity subjects do during there leisure time. 60% subject are having moderate activities during their leisure time, 21% subject are having high activities during their leisure time, 19% subject are having low activities during their leisure time. question no 9 how often do you consume fruit and vegetable of all kind? graph 9 the graph represents the consumption of fruits and vegetables by the subjects. out of 100%.43% of subjects consume fruit and vegetables once in a day, 29% consume twice per day ,19% do not consume fruits and vegetables and 9% consume fruits and vegetables more than 3 times a day. this concludes that few no of subjects consume fruits and vegetables in appropriate proportion. question no 10 do you have any close relative who is suffering from hypertension? graph 10 this graph signies the relation of family history and hypertension. out of 100 % this graph states that 43 %of subjects are having a family history of hypertension and 57% are not having the family history of hypertension. question no 11 measure the blood pressure three day in average graph 11 out of 100% measure of blood pressure the graph shows 55% of average blood pressure that is between 120/80-130/90 and 45% of blood pressure i.e. blood pressure above 130/90. discussion: this study was done to nd out the prevalence of modiable risk factor of hypertension in night shift workers. the study included 100 subjects between the age group 25 to 35 year having hypertension. a survey was conducted using the questionnaire to nd out the modied risk factors for hypertension in night shift workers. night shift workers due to lack of sleep are prone to many conditions such as diabetes, anxiety, obesity and hypertension this study showed that habits such as tobacco chewing, consuming alcohol, reduced physical activity in leisure hours can be the modied risk factors for hypertension in subjects working in night shifts. this study was done by reviewing other studies with the aim of this study was to nd out the prevalence of modied risk factors of hypertension in night shift workers. in previous study conducted by m shafei, t tengku, t winn on the association of shift work and hypertension among male factory workers in kota bharu, kelantan ,malaysia stated that the prevalence of hypertension was signicantly higher among shift workers (22.4%) compared to day workers (4. 2%) previous study conducted by j yeom etall on effect of shift work on hypertension. this was a cross-sectional study. this study concluded that shift workers had a higher chance of hypertension than day workers. particularly, the longer the working work continuously, the risk of hypertension getting higher. so, this study was conducted to nd out the risk factors for hypertension in subjects working in night shift. this survey was conducted using questionnaire which consisted to 11 questions such as 1) work duration.2)when were, you diagnosed to have hypertension 3)have you ever suffering from any of the following condition.4) have you ever smoking cigarette.5) are you taking alcohol.6) what level of physical activities do you have while at work.7) what level of physical activities do you have while coming to and from work..8)what level of activities do you have during your leisure time.9) how often do you consume fruit and vegetable of all kind.10)do you have any close relative who is suffering from hypertension.11) measure the blood pressure three day in average . according to questionnaire this study the results of selected subjects stated that out of 100% 43% subjects worked for 2 years, 29 subjects worked for 3 years,21 subjects worked for more than 4 years while 7% subjects worked for 1 year. 68% subject were diagnosed with hypertension in one month to one year, 19% subject were diagnosed with more than one year age, 13% subject were diagnosed with hypertension less than x 91gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra one month .42% subjects suffer from high cholesterol,15% subject are suffering from diabetes mellitus,15% subject are suffering from angina,10% subject suffering from tia/stroke, 9% subject are suffering from intermittent claudication, while 9% of subject are suffering from poor vision. 59% subject were cigarette smoker and 41% subject were not. 61% subject were alcoholic and 39% subject were not. 65% subject are doing moderate activities at work, 20% subject are doing active activities at work 15% subject are doing light activities at work. 50% subject are walking or cycling in 1mins or 29mins,29% subject is using motorized transport and 21% subject are walking or cycling more than 30 mins. 60% subject are having moderate activities during their leisure time, 21% subject are having high activities during their leisure time, 19% subject are having low activities during their leisure time. 43% of subjects consume fruit and vegetables once in a day, 29% consume twice per day ,19% do not consume fruits and vegetables and 9% consume fruits and vegetables more than 3 times a day. 43 %of subjects are having a family history of hypertension and 57% are not having the family history of hypertension. 55% of average blood pressure that is between 120/80-130/90 and 45% of blood pressure i.e. blood pressure above 130/90. this results concluded that tobacco chewing, alcohol consumption, reduced physical activity and long working duration in night shifts are the risk factors for hypertension in night shift workers. this study will help the further researcher to diagnose hypertension as early as possible. it will also help in nding the management strategies in hypertensive subjects to lead a quality life. this study will also help in preventing hypertension by modifying the modiable risk factors such as tobacco chewing, alcohol consumption which are used by night shift workers to avoid sleep and are the leading cause of hypertension in subjects working in night shifts and having deprived sleep. this study will help in bridging gap in knowledge regarding hypertension by carrying out further researches. conclusion: this study concluded that there are high risk of hypertension due to modiable risk factors in night shift workers acknowledgment: we acknowledge the guidance and constant support of dr. varadharajulu g, dean, faculty of physiotherapy, karad, dr. sandeep shinde, and dr. kakade sv, for the help in statistical analysis. conflict of interest: there is no conict of interest concerning the content of the study. references: 1. s mohd nazri, ma tengku and t winn the association of shift work and hypertension among male factory workers in kota bharu, kelantan malaysia. southeast asian journal of tropical medicine and public health, vol 39 no 1 january 2008. 2. carla sfreddo, sandra costa fuchs shift work is not association with high blood pressure of prevalence of hypertension. plos one 5(12)e 15250.doi: 10.1371/ journal. pone. 0015250 vol 5 issue 12 december 2010 3. henok asresahegn asfaw, ephrem mamo gebrehiwot, solomon shiferaw effect of shift-work on hypertension among factory workers in ethiopia. american journal of clinical and experimental medicine. vol 3, no 4 june 2015, 3(4): 142-148. 4. akerstedt t. shift work and disturbed sleep/wakefulness. occup med 2003: 53: 89-94 5. suprgeon a. working time its impact on safety and health, geneva: international lab our organization. 2003: 145 pp. 6. scott aj, ladou j health and safety in shift workers in zenz c, ed. occupational medicine. mosby, 1994: 50641. 7. taylor e, briner rb, folkard s. models of shiftwork and health: an examination of the inuence of stress on shiftwork theory. human factors.1997: 39: 6782 8. james a. mccubbin, june j. pilcher, d dewayne moore blood pressure increases during a simulated night shift in persons at risk for hypertension. international journal of behavioral medicine, 17,314-20, 2010 9. pati ak, chandrawanshi a, reinberg a. shift work consequences and management. current science, vol 81, no 1,july 2001. 10. moore-ede m, richardson g medical implication of shift work. annu rev med 1985, 36:607-617. 11. coffey l, skipper j, jung f nurses and shift work effects on job performance and job-related stress. j adv. nursing 1988, 13:245-54 92 x gjra global journal for research analysis introduction filariasis is an infectious parasitic disease and is regarded as a major public health problem in the tropical countries of 1 africa, southern america, and asia . in india it is endemic in orissa, uttar pradesh, bihar, andhra pradesh, tamil nadu and gujarat. the nematode wuchereria bancrofti accounts for 90 % of cases worldover followed by brugia malayi and 2 brugia timori . infected mosquitoes serve as vectors and humans are the denitive host. the commonest presentation is lymphatic lariasis which usually involves lower extremities, scrotum, retroperitoneal tissue and axilla causing lymphoedema, elephantiasis, hydrocele, ram horn penis and rarely in breast. usually it presents as a generalized lymphoedema of affected parts. case report a 51 year old male, resident of kanyakumari district, presented with swelling in the penile shaft since 2 weeks, associated with itching. there was no history of fever with chills or trauma. no signicant treatment or drug history, no other similar swellings in the body. on examination 2cm x 1.5cm size, non tender, rm, mobile swelling in the penile shaft. there was no inguinal lumphadenopathy, provisionally diagnosis of fibroma was made and posted for excision biopsy. post excision the lesion was bisected and found to have live worm (gure: 1 and 2) provisionally diagnosis made as? cysticercosis and sent for hpe. oral albendazole and ivermectin, tablets were given. biopsy report came as larial worms within the cyst and cyst contains heavy lymphoplasma cells and eosinophils inltration. patient came for rst follow up; wound is clean and healthy, no edema noted. fig 1: worm with in cyst fig 2: live worm fig 3: biopsy report discussion filariasis is a parasitic infection caused by a round worm of filarioideae super family. humans are denitive hosts in larial nematodes. the disease manifests as two distinct clinical types1) lymphatic lariasis caused by parasite in lymphatic system and, 2) occult lariasis caused by immune hyper responsiveness of the human host as tropical pulmonary eosinophilia. the global burden of is not well dened, lymphatic lariasis but it is known to be endemic in over 80 countries, placing 1 billion persons at risk. the world health organization (who) most recently estimated 120 million people to be currently infected—2% of the world's population. of these, 44 million have clinical manifestations such as lymphoedema, elephantiasis, hydrocele, lymphangitis, chyluria and renal disease. lymphatic lariasis is a major health problem in india with most infections caused by wuchereria bancrofti (90%), brugia malai and brugia timori. heavily infected areas are tamil nadu, uttar pradesh, bihar, jharkhand, andhra 3 pradesh, orissa, kerala and gujarat . an uncommon presentation of the filarial worm as a penile nodulea rare case report original research paper dr. devaprasath jeyasekharan m.s (gen),f.a.ms, urology x 41gjra global journal for research analysis general surgery filariasis is a tropical infectious disease and a major global health problem with high incidence in indian subcontinent. presenting with lymphatic dysfunction in the form of hydrocele, lymphocele, chyluria and groin lymphadenovarix. we report a rare presentation of lariasis as penile nodule. abstract keywords : volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. sabu jeyasekharan* m.s general surgery *corresponding author dr. bala v sagar m.s general surgery dr. deepak david m.s mch, urology dr. nithila dnb gen surgery dr. scott m.s general surgery dr. rangaswami dnb resident, general surgery 42 x gjra global journal for research analysis adult worms usually stay in the lymphatic tissue and release early larval forms in blood stream known as microlaria into the host bloodstream. circulating microlaria are picked up along with a blood meal by the arthropod vector and 4 transmitted to a new host . depending on whether microlaria can be detected in the peripheral blood, patients are described as microlaraemic or amicrolareamic. man is a natural host. all ages are susceptible. in endemic areas, the microlaria rate is higher in men. culex , anopheles and aedes species of mosquito are vectors for wuchereria bancrofti. the disease may be asymptomatic or there can be acute episodes of local inammation involving skin, lymph nodes and lymphatic vessels. chronic disease in endemic communities can manifest in men in the form of genital damage, especially hydrocele, funiculitis, epididymitis and elephantiasis of the penis and scrotum. in women, the vulva or breast may be 4 involved. an entire arm or leg maybe affected in both sexes . microlaria of w.bancrofti circulates in the peripheral blood with regular nocturnal periodicity and maximum density had 5 been reported between 10 pm and 2 am . tests used for diagnosis include demonstration of microlaria in the peripheral blood or skin and detection of larial antigens and antibody. for detection of microlaria, thick and thin blood smears are made and stained with haematoxylin or giemsa stains. ultrasound is a valuable tool in the diagnosis of cases of 7 lymphatic lariasis. amaral et al had rst reported the use of ultrasound to visualize adult worms of wuchereria bancrofti in the scrotal area of infected men. they described a continuous, distinctive and specic pattern of worm movement called the 6 "filarial dance" sign . there is continual development of new control strategies and treatment programs for lariasis. four drugs are now used s i n g l y o r i n v a r i o u s c o m b i n a t i o n s a n d d o s e s diethylcarbamazine,(dec), ivermectin, albendazole, and doxycycline. the dec recommended dose is 6mg/kg body weight per day in divided doses given orally for 12 days. it may be combined with either albendazole or ivermectin (a single dose of 200 to 400 µg/kg) for mass therapy in endemic areas. vectors can be controlled by anti-larval measures and minor environmental measures. conclusion the uniqueness of this case is its presentation as isolated penile shaft nontender mobile lesion with atypical morphology, without concomitant involvement of scrotum. though the larial cyst was completely removed this patient will be followed up periodically. references 1. chakrabarti i, das v, halder b, giri a. adult larial worm in the aspirate from a breast lump mimicking broadenosis. trop parasitol 2011;1:129-31. 2. bhattacharjee pk, ray rp, halder s. filariasis of breast: an unusual presentation. ann trop med public health 2012;5:376-8 3. park k. park’s textbook of preventive and social medicine. 23rd edition. jabalpur: bhanot;2015. 4. upadhyaya v, upadhyaya dn, sarkar s. an interesting case of breast lariasis. indian j radiol imaging 2006;16:915-7. 5. paniker jayaram ck, ghosh sougata. paniker’s textbook of medical parasitology. 7th ed. new delhi: jaypee brothers medical publishers (p) ltd; 2013. 6. upadhyaya v, upadhyaya dn, sarkar s. an interesting case of breast lariasis. indian j radiol imaging 2006;16:915-7. 7. amaral f, dreyer g, figueredo-silva j, et al. adult worms detected by ultrasonography in human bancroftian lariasis. am j trop med hyg 1994; 50: 753. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra this article endeavours to study the place of women awakening in current indian ction in english throughout 1950-1980 as portrayed in the books of indian diasporic writer kamala markandaya.in this novel likewise, as in some prior books, kamala markandaya has celebrated the life of a woman mohini who is displayed in a light superior to that of other female gures in the novel. hence, kamala markandaya, one of the nest and most recognized indian authors in english of the post colonial period and an indian diaspora, delineates women's issues and problems profoundly in her books. indian women authors in english have been introducing woman as the central role in their books as woman's quest for personality is an intermittent subject in their ction. female protagonists who appear to be the fanciful models of a markandaya demonstrate that the situation of the woman in country india has a serious part in the changing situation of indian culture, boasting the rst indian journalist and author who deeply explore women's problems and mind. markandaya presents love and closeness between another female protagonist mira, an indian young woman and richard, an englishman out of sight of india's autonomy development. on making a profound scrutiny of kamala markandaya's books, it can be viewed that her extraordinary familiarity with her way of life as a woman and her thoughtfulness regarding female issues. a few profoundly skilled and productive women authors counting kamala markandaya, anita desai, attiahosain, santha ram rau and shashi despande have advanced indian ction in english.as per the literary exploration in her novels, kamala markandaya has demonstrated that indian women are made to embrace two opposing parts-the sustaining consideration taking and the latent powerless part.simone de beauvoir investigates in the second sex the quest for feminine awakening a brief survey of kamala markandaya's novels, which examines relationship between men and women and contends that man's subjectivityhis insistence toward oneself as a free, self-ruling and autonomous beingis created just through restriction to and in reliance upon women's total and inside otherness and the irregularity in the male/female relationship could be cured just by women' suspicion of the position of subject, against an object.especially, indian diasporic woman writers are effectively portraying feministic characters in their novels because they want to infuse the mindset of woman's liberation into indian social life.premala, an alternate female hero heads an alternate sort of life, is a gloried stereotyped young woman who symbolizes indian customs and society and denied of affection even inside wedded life, showing incredible persistence, the soul of tribute and adoration.gupta, she is removed from her home and town and turns into a no place woman, losing her character a.k. bhatnagar apropos watches: lalitha's life is a living example of the tragedy of the modern woman particularly in india (bhatnagar: 89). the up to date western qualities of urban life decimate lalitha's self and destroy her identity totally. the indian diasporic women authors, for example, bharati mukherji, chitra banerjee, jhumpa lahiri and kiran desai have disclosed the complexities of separation, absorption, social and demographic change, which inuenced the general public itself as well as the lives of the different ethnic gatherings and the outsiders.all these writers, like kamala markandaya, create the prelude of a crisp arousing if there should be an occurrence of indian women.in some inner fury, kamala markandaya presents premala as the delegate of her women's activist perspective of life. conclusion since autonomy, numerous indian women writers in english have exhibited woman as the focal concerns in their books as most of them have diasporic views. with diasporic mindset of writer, markandaya's women are looking for something positive and effective because she portrays woman characters as per the willpower of european women. about the majority of markandaya's women characters show a positive and hopeful point of view and rise signicantly stronger than their male partners develop. the story strategies that markandaya utilizes within her books are adapted towards uncovering social bad form in india, consequently the utilization of the more particular term 'social authenticity' by various faultnders to depict markandaya's books. indeed, in books, where male characters are the heroes, the women are demonstrated quiet and mitigating as though to balance the aggressive nature of male characters. kamala markandaya, one of the nest and most recognized indian writers in english of the post–colonial time, has taken the activity of holding the banner for women.her male characters understand their own particular lack of ability and later on get tame and meek to the women who make them mindful and comprehend that they are not items that might be obtained, utilized, and tossed. in each of her books she has depicted solid women characters that are ready to meet the tests of life come hell or high water. it is through the system of delineating women however male perspective, which is feminine awakening in the novels of kamala markandaya original research paper patel veenakumari motibhai ph.d. scholar in english (vnsgu surat) english since autonomy, numerous indian women writers in english have exhibited woman as the focal concerns in their books as most of them have diasporic views.with diasporic mindset of writer, markandaya's women are looking for something positive and effective because she portrays woman characters as per the willpower of european women.about the majority of markandaya's women characters show a positive and hopeful point of view and rise signicantly stronger than their male partners develop.the story strategies that markandaya utilizes within her books are adapted towards uncovering social bad form in india, consequently the utilization of the more particular term 'social authenticity' by various faultnders to depict markandaya's books.indeed, in books, where male characters are the heroes, the women are demonstrated quiet and mitigating as though to balance the aggressive nature of male characters. abstract keywords : volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 50 x gjra global journal for research analysis creative, that kamala markandaya has utilized. markandaya demonstrates that the predicament of the woman in country india has a genuine part in the changing situation of indian culture. conclusion in perspective of the above, it could be abridged that referred to books and reactions brood us the state of women in india has been pretty much same, whether we discuss about pre-independence times or post-independence times. most likely in a few cases, her male characters understand their strength yet her women character who puncture the needle into the inatable of their sense of self. references works cited 1. banet-weiser, s.“girls rule! gender, feminism, and nickelodeon.” critical studies in a. media communication. 21.2(2004): 119-139. 2. bartky, sandra lee. “body politics” in a companion to feminist philosophy. oxford: blackwell, 1998. 3. bhatnagar, a.k. kamala markandaya : a thematic study. new delhi: sarup and sons, 1995. 4. chatterjee, arudhate. “rukmani: the mother gure in nectar in a sieve" studies in indian fiction in english. ed. 5. durham, m. “articulating adolescent girls’ resistance to patriarchal discourse in popular media.” women’s studies in communication. 22.2 (1999): 210-229. 6. dyson, tim and mick moore, kinship structure, female autonomy and demographic behavior in india, population and development review, 9(1): 35-60, 1983. 7. jeanes, r. “i’m into high heels and make up but i still love football’: exploring gender a. identity and football participation with preadolescent girls.” soccer & society. 12.3(2011): 402-420. 8. joseph, margaret. kamala markandaya. new delhi: arnold heinemann, 1980. rao. a.v. krishna. “continuity and change in the novels of kamala markandaya”. perspectives on kamala markandaya. ed. madhusudan prasad. ghaziabad: vimal prakashan, 1984. 9. korobov, n., and a. thorne. “the negotiation of compulsory romance in young women friends’ stories about romantic heterosexual experiences.” feminism and psychology. 19(2009):49-70. 10. levant, r., richmond, k., cook, s., house, a.t., & aupont, m. “the femininity ideology scale: factor structure reliability, convergent and discriminant validity, and social contextual variation.” sex roles. 57(2007): 373-383. 11. lotz, a. redesigning women. urbana and chicago: university of illinois press.2006. 12. markandaya, kamala. a silence of desire. new delhi: sagar publications, 1968. 13. ---.pleasure city. london: chatto and windus, 1982. 14. ---. possession. london: putnam & co., 1963. 15. ---. some inner fury. london: putnam & co., 1955. 16. ---. the coffer dams. new delhi: penguin, 2008. 17. ---. the golden honeycomb. new delhi: b.i. publication, 1977. 18. --. the nowhere man. new delhi: penguin, 2012. 19. mukherjee, bharati. jasmine. new delhi; penguin books (india), 1990. 20. painter, c., & ferrucci, p. “unprofessional, ineffective, and weak: a textual analysis of the portrayal of female journalists on sports night.” journal of mass media ethics. 27.4(2012): 248-262. 21. snyder, r.c. “what is third-wave feminism? a new directions essay.” journal of women in culture and society. 34.1(2008): 175-196 22. srivastava, r.k. the novels of kamala markandaya. amritsar: guru nanak dev university. 1988. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 51gjra global journal for research analysis introduction the word ozone comes from the greek “ozein” meaning odorant. ozone (also known as triatomic oxygen and trioxygen) is an allotropic form of oxygen occurring naturally in the earth's atmosphere. it surrounds the earth at an altitude of between 50,000 and 100,000 feet. [1] it is created, when ultraviolet rays cause oxygen atoms to disassociate and temporarily recombine in groups of three. it is also formed by the action of electrical discharges on oxygen, so it is often created by thunder and lightning. chemistry: ozone (o ) concists of three oxygen atoms, with molecular 3 weight is 47, 98 g/mol and thermodynamically highly unstable compound.[11] when compared to oxygen ozone is 1.6-fold more denser and 10-fold more soluble in water .ozone is an unstable gas and which gives up nascent oxygen molecule to form oxygen gas.as it releases nascent oxygen, it has been used in medical eld to kill bacteria, fungi, to inactivate viruses and to control hemorrhages. [2] medical grade ozone is made from pure medical oxygen. it is produced commercially in ozone generators, which involves sending an electrical discharge through a specially-built condenser containing oxygen. history first discovered in 1840 by the german chemist christian frederick schonbein at the university of basil in switzerland, ozone was rst used in medicine by landlerin the year 1870. it was not studied or used until 1932 by the scientic community. ozonated water was rst used as a disinfectant by dr. e. a. fisch, a swiss dentist. by a twist of fate, a surgeon, dr. e payr (1871–1946) had to be treated for a gangrenous pulpite and remained astonished by the result achieved with local ozone treatment. he enthusiastically extended its application to general surgery. at the time, ozone therapy was difcult and limited due to the lack of ozone-resistant materials, such as nylon, dacron, and teon, until 1950 when ozone-resistant materials were manufactured. at that time joachim hänsler, a german physicist and physician, joined another german physician, hans wolff, to develop the rst ozone generator for medical use. their design continues to be the basis for modern equipment. ozone generators there are three different systems for generating ozone gas: [4] ultraviolet system: produces low concentrations of ozone, used in esthetics, saunas, and for air purication. cold plasma system: used in air and water purication. corona discharge system: produces high concentrations of ozone. it is the most common system used in the medical/ dental eld. it is easy to handle and it has a controlled ozone production rate. medical grade ozone is a mixture of pure oxygen and pure ozone in the ratio of 0.05% to 5% of ₃ and 95% to 99.95% of o₂. use of ozone in dentistry the use of ozone in dentistry is gaining its place in every day's dental practice and is used in almost all dental applications. the undisputed disinfection power of ozone over other antiseptics makes the use of ozone in dentistry a very good alternative and/or an additional disinfectant to standard antiseptics. due to safety concerns, ₃ gas was not recommended for intraoral use. only dissolved ozone in water and ozonated oils were and are still commonly used in different elds of dentistry. with the development of a foot pedal-activated dental handpiece with a suction feature, ₃ gas can now be used safely in situations where diffusion is an important factor, i.e. dental hard tissues. according to fritz kramer, ozone, such as in the form of ozonated water, can be used in the following ways. 1. as a powerful disinfectant 2. in its ability to control bleeding 3. in its ability to cleanse wounds in bones and soft tissues. 4. by increasing the local supply of oxygen to the wound area, ozone can improve healing. 5. ozonated water can increase temperature in the area of the wound, and this increase the metabolic processes related to wound healing. ozone therapy in periodontics (review) original research paper dr. mrs.veena. a. patil mds periodontics, hod and professor, department of periodontia, h.k.e.s. s.n dental college, kalaburagi. x 19gjra global journal for research analysis dental science the usage of ozone in dentistry has been proposed because of its various biological properties like disinfection, antimicrobial activity, biocompatibility and healing properties. in the last few years, various therapeutic protocols with ozone have been developed in various elds of dentistry. inspite of many advantages, therapeutic ozone's application in dentistry is limited because of its possible side effects. hence, dentists has to know the appropriate usage of ozone therapy which can provide better patient care and considerably cut down the time and cost of the treatment. abstract keywords : volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. ayesha mds-postgraduate studying in hkes s.n dental collage,kalaburagi dr. sobia tahseen ansari* mds-postgraduate studying in hkes s.n dental collage,kalaburagi *corresponding author 20 x gjra global journal for research analysis biological actions the application of ozone in dentistry comes as a result of physico-chemical properties: there are several known actions of ozone on human body, such as immunostimulating and analgesic, antihypoxic and detoxicating, antimicrobial, bioenergetic and biosynthetic (activation of the metabolism of carbohydrates, proteins, lipids) etc. 1. antimicrobial effectozone works destructively against bacteria, fungi, and viruses. the antimicrobial effect of ozone is a result of its action on cells by damaging its cytoplasmic membrane due to ozonolysis of dual bonds and also ozoneinduced modication of intracellular contents (oxidation of proteins loss of organelle function) because of secondary oxidants effects. this action is non-specic and selective to microbial cells; it does not damage human body cells because of their major antioxidative ability. ozone is very efcient in antibiotics resistant strains. its antimicrobial activity increases in liquid environment of the acidic ph. in viral infections the ozone action lies in the intolerance of infected cells to peroxides and change of activity of reverse transcriptase, which takes part in synthesis of viral proteins. [6] 2. immunostimulating effectozone inuences cellular and humoral immune system. it stimulates proliferation of immunocompetent cells and synthesis of immunoglobulins. it also activates function of macrophages and increases sensitivity of micro-organisms to phagocytosis. [6] as a response to this activation through ozone, the body's immune cells produce special messengers called cytokines. these molecules in turn activate other immune cells, setting off a cascade of positive change throughout the immune system, which is stimulated to resist diseases. this means that the application of medical ozone is extremely useful for immune activation in patients with a low immune status and/or immune decit. [8] ozone causes the synthesis of biologically active substances such as interleukins, leukotrienes and prostaglandins which is benecial in reducing inammation and wound healing. [6] ozone in high concentration causes immunodepressive effect whereas in its low concentration immunostimulating effect. [7] 3. antihypoxic effectozone brings about the rise of po2 in tissues and improves transportation of oxygen in blood, which results in change of cellular metabolism – activation of aerobic processes (glycolysis, krebs cycle, �-oxidation of fatty acids) and use of energetic resources. repeating low doses of ozone activate enzymes: super-oxide dismutases, catalases, dehydrogenase, and glutatione peroxidases. they are part of complex enzymatic systems which protect organisms against the action of oxygen-free radicals. it also prevents formation of erythrocytes aggregates and increases their contact surface for oxygen transportation. its ability to stimulate the circulation is used in the treatment of circulatory disorders and makes it valuable in the revitalizing organic functions. [6] 4. biosynthetic effectit activates mechanisms of protein synthesis, increases amount of ribosomes and mitochondria in cells. these changes on the cellular level explain elevation of functional activity and regeneration potential of tissues and organs. [6] 5. ozone causes secretion of vasodilators such as no, which is responsible for dilatation of arterioles and venules. [6] it also activates angiogenesis. [7] 6. ozone, when acting on the organic substance of mineralized tooth tissues intensies their remineralization potential. at the same time, it is capable of “opening” dentinal tubules, which enables the diffusion of calcium and phosphorus ions to the deeper layers of carious cavities. [9] a high concentration of ozone kills bacteria very quickly and is thousand times more powerful than other bacterial killing agents. the average concentration of ozone used in treatments is 25 gm of ozone per milliliter of oxygen/ozone gas mixture that translates into 0.25 parts of ozone to 99.75 parts of oxygen. evidence-based research has shown that at this concentration, ozone effectively kills bacteria, fungi, viruses and parasites. [10] as an antimicrobial agent, it is a powerful oxidizer at a dramatically lower concentration than chlorine with none of the toxic side effects. [10] studies have revealed that it only takes 10 sec to kill 99 % of bacteria, fungi and viruses. [11] it can oxidize many organic compounds and it is a powerful germicide. [12] some of the other effects are circulatory enhancement, disruption of tumor metabolism and stimulation of oxygen metabolism. [13] according to most authors, a 10-sec-application of ozone causes the destruction of 99% of bacteria, and a 20-secapplication even of 99.9%. in this way, so-called ecological niche appears. however, it is not conducive to their repeated colonization within 4 to 6 weeks. [14,15] ozone is not toxic when it is given in the amount of 0.05 ppm for 8 hours. during ozone therapy a maximum concentration of ozone in oral cavity amounts to 0.01 ppm. goals of ozone therapy setting the standard-of-care and therapeutic goals are based on sound evidence-based science is critical. therapeutic goals are inclusive and not exclusive of standard of care. the goals of oxygen/ozone therapy are: [10] 1. elimination of pathogens. 2. restoration of proper oxygen metabolism. 3. induction of a friendly ecologic environment. 4. increased circulation. 5. immune activation. 6. simulation of the humoral anti-oxidant system. ozone in the treatment of periodontal diseases periodontal disease is a multifactorial disease process in the mouth. the role of microorganisms, hostresponse, in the etiology of periodontal disease is well established. the undisputed disinfection power of ozone over other antiseptics makes the use of ozone in treatment of volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra periodontitis a very good alternative and/or an additional disinfectant to standard antiseptics. ozonated water (4 mg/l) was found effective for killing grampositive and gram-negative oral microorganisms and oral candida albicans in pure culture as well as bacteria in plaque biolm and therefore might be useful as a mouth rinse to control oral infectious microorganisms in dental plaque. in implant dentistry, the use of ozone is currently being investigated for the decontamination of the implant surface in peri-implant therapy. thanomsub et al. 2002 tested the effects of ozone treatment on cell growth and ultra-structural changes in bacteria (escherichia coli, salmonella sp., staphylococcus aureus and bacillus subtilis). it was discovered that ozone at 0.167 mg/min/l can be used to sterilize water, which is contaminated with up to 105 cfu/ml bacteria within 30 min. destroying of bacterial cell membrane was observed, subsequently producing intercellular leakage and eventually causing cell lysis. nevertheless, these ozone concentrations have no signicant effect on the cell viability in bacterial cultures at higher concentrations of 106 and 107 cfu/ml.[18] ebensberger et al. in 2002 evaluated the effect of irrigation with ozonated water on the proliferation of cells in the periodontal ligament adhering to the root surfaces of 23 freshly extracted completely erupted third molars. the teeth were randomly treated by b intensive irrigation with ozonated water for 2 min or irrigation with a sterile isotonic saline solution, serving as a control group. the periodontal cells of these teeth were studied immunohistochemically to mark proliferating cell nuclear antigen. it was observed that the labeling index (the number of positive cells compared to the total number of cells suggesting enhancement of metabolism) was higher among the teeth irrigated with ozone (7.8% vs. 6.6%); however, the difference was not statistically signicant (p = 0.24). they concluded that the 2 min irrigation of the avulsed teeth with non-isotonic ozonated water might lead not only to a mechanical cleansing, but also decontaminate the root surface, with no negative effect on periodontal cells remaining on the tooth surface.[19] holmes in 2003, observed effect of kavo healozone device on pr imary root car ious lesions (prcl) fo l lowed-by professionally-applied remineralizing solution containing xylitol, uoride, calcium, phosphate and zinc. this treatment modality was applied to 89 patients, aged from 60 to 82 years. after 18 months, 100% of ozone-treated prcl�s had improved. in control group, where lesions were left without treatment, only 1 prcl had improved. in 62% of cases the status remained leathery, while in 37% of prcl�s had worsened from leathery to soft.[5] nagayoshi et al. 2004 tested the efcacy of ozonated water on survival and permeability of oral micro-organisms. gram negative bacteria, such as porphyromonas endodontalis and porphyromonas gingivalis were substantially more sensitive to ozonated water than gram positive oral streptococci and c. albicans in pure culture. furthermore ozonated water had strong bactericidal activity against bacteria in plaque biolm. in addition, ozonated water inhibited the accumulation of experimental dental plaque in vitro.[20] hems and gulabivala, 2005 evaluated the potential of ozone as an anti-bacterial agent using enterococcus faecalis as a test species. ozone was used both gasiform (produced by purezone device), and aqueous (optimal concentrations 0.68 mg/l). it was concluded that ozone in solutions was antibacterial against planctonic enterococcus faecalis after 240 s treatment. however it was not effective against enterococcus faecalis cells in a biolm unless they were displaced into the surrounding medium by agitation. gaseous ozone was not effective on the enterococcus faecalis biolm.[21] ramzy et al. in 2005 irrigated the periodontal pockets by ozonized water in 22 patients suffering from aggressive periodontitis. periodontal pockets were irrigated with 150 ml of ozonized water over 5-10 min once weekly for a clinical 4 weeks study using a blunt tipped sterile plastic syringe. high signicant improvement regarding pocket depth plaque index gingival index and bacterial count was recorded related to quadrants treated by scaling and rootplaning together with ozone application. they also reported signicant reduction in bacterial count in sites treated with ozonized water.[22] huth et al. in 2006, in their study declared that the aqueous form of ozone, as a potential antiseptic agent, showed less cytotoxicity than gaseous ozone or established anti microbials (chlorhexidine digluconate [chx]: 2%, 0.2%; sodium hypochlorite 5.25%, 2.25%; hydrogen peroxide-h o 2 2 3%) under most conditions. therefore, aqueous ozone fullls optimal cell biological characteristics in terms of biocompatibility for oral application.[23] muller et al. in 2007 compared the inuence of ozone gas with photodynamic therapy (pdt) and known antiseptic agents (2% chlorhexidine, 0.5 and 5% hypocholrate solutions) on a multispecies oral biolm in vitro. actinomyces naeslundii, veillonella dispar, fusobacterium nucleatum, streptococcus sobrinus, streptococcus oralis and c. albicans were studied. gasiform ozone was produced by vacuum ozone delivery system kavo healozone. they concluded that the matrixembedded microbial populations in biolm are well protected towards antimicrobial agents. only 5% hypochlorate solution was able to eliminate all bacteria effectively. usage of gasiform ozone or pdt was not able to reduce bacteria in the biolm.[24] kronusova 2007 used ozone in following cases: prevention of dental caries in ssures of the rst permanent molars in children, application of ozone in prepared cavity, after tooth extraction, in case of post extractional complications, in patients with chronic gingivitis, periodontitis and periodontal abscesses, herpes labialis, purulent periodontitis, dentition difcilis, etc., almost all patients with gingivitis showed subjective and objective improvement of their status, as well as patients with periodontal abscess, where no exudation was observed. application of ozone after tooth extraction was found also quite useful only 10% of patients suffered from such complication as alveolitis sicca, but even in these cases the clinical course was shorter and more moderate.[25] karapetian et al. in a study of peri-implantitis, treatment with conventional, surgical and ozone therapy methods was investigate and it was found that the most effective bacteria reduction was in the ozone-treated group.[26] kshitish and laxman in 2010 conducted a randomized, double-blind, crossover split-mouth study on 16 patients suffering from generalized chronic periodontitis. the study period of 18 days was divided into two time-intervals, i.e., thbaseline (0 days) to the 7 day, with a wash out period of 4 days followed by a second time-interval of 7 days. subgingival irrigation of each half of the mouth with either ozone or chlorhexidine was done at different time intervals. they observed a higher percentage of reduction in plaque index (12%), gingival index (29%), and bleeding index (26%) using ozone irrigation as compared to chlorhexidine. the percentile reduction of aa (25%) using ozone was appreciable as compared to no change in aa occurrence using chlorhexidine. by using o and chlorhexidine, there was no anti-bacterial 3 effect on porphyromonas gingivalis (pg) and tannerella x 21gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra forsythensis. the anti-fungal effect of ozone from baseline th(37%) to 7 day (12.5%) was pronounced during the study period, unlike chx, which did not demonstrate any antifungal effect. no anti-viral property of ozone was observed. the anti-viral efcacy of chlorhexidine was better than that of ozone. they concluded that despite the substantivity of chlorhexidine, the single irrigation of ozone is quite effective to inactivate microorganisms.[27] fillippi. a observed the inuence of ozonized water on the epithelial wound healing process in the oral cavity. it was found that ozonized water applied on daily basis can accelerate the healing rate in oral mucosa.[28] conclusion since its introduction in 1840, ozone therapy is proving to be a new therapeutic modality with great benets to the patients. ozone with its potent antimicrobial power and competency to stimulate the circulatory system and modulate the immune response, accomplish a therapeutic agent of choice in the treatment of medical pathologies and infectious oral diseases.there is good evidence of in vitro biocompatibility of aqueous ozone with human oral epithelial cells, gingival broblast cells and periodontal cells. further, the use of ozone is an easy and painless treatment modality. the clinical application of ozone has not achieved strong level of efcacy and cost effectiveness. this divergence of the study outcomes may be related to the methodological differences linked to the lack of in vitro and in vivo, long term randomized controlled trials and double blind studies. there is still a need for the highest level of evidence, i.e., well designed; doubleblind randomized clinical trials to justify the routine use of ozone as a treatment modality in dentistry. references 1. chemical technology an encyclopedic treatment, vol 1, new york: barnes &amp; noble, inc. 1968; 79. 2. garg r, tandon s. ozone: a new face of dentistry. the internet journal of dental science. 2009;7:2. 3. fish e. apparatus for the production and use of ozone in therapeutics. united states patent 2,054,367. september 15, 1936. 4. nogales cg, ferrari pa, kantorovich eo, lage-marques jl. ozone therapy in medicine and dentistry. j contemp dent pract. 2008 may; (9)4:075-084. 5. krammer f. ozone in the dental practice. medical applications of ozone. norwalk, ct: international ozone association, pan american committee. 1983; 258-65. 6. seidler v, linetskiy i, hubalkova h, staňkova h, šmucler r, mazanek j. ozone and its usage in general medicine and dentistry. a review article. prague medical report. 2008; 109(1): 5–13. 7. teresa b, wolanska e, cieszkobuk m, orlowski m, chalas r. practical use of ozone in dentistry – comments. annales universitatis maria curie sklodowska lubinpolonia. 2008; vol. lxiii, n 1, 28 sect io d 8. seaverson k, tschetter d, kaur t. patient guide to oxygen/ozone therapy. health centered cosmetic dentistry. [online]. [cited 2010 january 13] 9. lynch e. leczenie próchnicy z wykorzystaniem system healozon. edentico. 2004;134,3. 10. mollica p, harris r. integrating oxygen/ ozone therapy into your practice. [online]. [cited 2010 january 13];[4 screens]. 11. ozone dental therapy. [online]. [cited 2010 january 13] [1 screen].safe dentistry. co. uk / ozone –dental therapy. 12. gum gp and bone regeneration procedures. australian institute of implant dentistry [online]. [cited 2010 january 13]. 13. ozone therapy oxygen therapies.applied ozone systems. [online].[cited 2010 january 13]. 14. baysan a, whiley ra, lynch e. antimicrobial effect of novel ozone generating device on microorganisms associated with primary root carious lesions in vitro. caries research. 2000; 498,6,34. 15. holmes j. zastosowanie ozonu do leczenia pierwotnych zmian próchnicowych bruzd. por. stomat.,39, 4 baysan a, whiley ra, lynch e. antimicrobial effect of novel ozone generating device, 2004. 16. azarpazhooh a, limeback h. the application of ozone in dentistry: a systematic review of literature. j dentist. 2008;36:104-116. 17. huth kc, jakob fm, saugel b, cappello c, paschos e, hollweck r, et al. effect of ozone on oral cells compared with established antimicrobials. eur j oral sci. 2006;114:435-440. 18. nagayoshi m, kitamura c, fukuizumi t, nishihara t, terashita m. antimicrobial effect of ozonated water on bacteria invading dentinal tubules. j endod. 2004;30:778-781. 19. huth kc, jakob fm, saugel b, cappello c, paschos e, hollweck r, et al. effect of ozone on oral cells compared with established antimicrobials. eur j oral sci. 2006;114:435-440. 20. kronusova m. aplikace atomarniho kysliku v ordinaci praktickeho zubniho lekaře. progresdent 3. 2007; 34–36. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 22 x gjra global journal for research analysis 84.latifah susilowati online.cdr introduction toddler enter the stages of golden age, window of opportunity, and a critical period because that age a child experiences development and growth that will affect the child's subsequent development. at this time children also experience periods that are vulnerable to negative inuences. the quality of growth and development of children must get serious attention for families and countries because children are the nation's next generation (the indonesian ministry of health, 2016). the global burden of disease study said that 52.9 million children under the age of 5 had developmental problems (global research on developmental disabilities collaborators, 2018). the indonesian ministry of health reports that in 2010 11.5% of children experienced development and growth disorders. the indonesian pediatrician association (idai) (2013) estimates that 5-10% of children experience developmental delays and 1-3% experience general developmental delays. therefore it is important for parents to know the stages of child development and the factors that inuence it so that parents can avoid factors that can cause children to experience developmental delays. material and methods this was observational analytic study with the cross sectional approach, conducted from april to september 2019 in public health region depok 1, sleman, indonesia. the study subject were mothers and toddler (12 months 36 months). accidental samplings was used to select the 60 respodent with inclusion criteria: child lived with the mother, the child did not have a physical disability and the exclusion criteria: the child was sick when the data collected. information related characteristics and factors that inuence child development (nutritional status, maternal employment status, maternal education level, birth weight and history of prematurity, the role of mothers in meeting the basic needs of children) recordered in semi-stuctured self administrated questionare. kpsp questionnaire (pre-screening devel o pment) as a guideline for assessing child development for ages 0-72 months issued by the indonesian ministry of health as well as questionnaires for the role of mothers in meeting the basic needs of children who have been tested for validity and reliability are carried out in ringinsari hamlet, depok, sleman. validity test uses the product moment formula with the results of r count more than 0.361 and the validity test uses alpha cronbach with 0.912 results. statistics data were analyzed and interpreted using descriptive statistics and bivariate analysis used the fisher test. while multivariate analysis used logistic regression. the level of signicance determined in this study was p <0.05. ethics this study has obtained information on research ethics approval issued by the health research ethics commission of the faculty of health, jenderal ahmad yani university, yogyakarta, number: skep /066/kepkv /2019. result table 1 shows the sociodemographic of the study subjects. it was seen that maximum (51.7%) mother belonged to the age group of 26-35 years and child 12-24 month. about half (51.7%) subjects from male. table 1: sociodemographic information analysis factors related to the development of toddler original research paper latifah susilowati department of pediatric nursing, nursing study program, faculty of health, jenderal achmad yani university, yogyakarta health science background: toddler age entered in the golden age stage because the development and growth at that stage affect the subsequent development. early childhood development is one of the programs in the sustainable development goals to be a priority to be achieved in 2030. many factors can inuence children's development. health professionals and parents need to understand this to avoid factors that can cause children to experience developmental delays. objectives: to nd factors related to the development in toodler. methods: a present cross sectional study was conducted from april to september 2019 in public health depok 1 sleman, indonesia. sampling method employed was acidental sampling with 60 respondent. factors the inuence development in toddler colleted by questionnaire and tooddler development was assessed using the pre development screening questionnaire from the ministry of health. multivariate analysis used logistic regression tests and bivariate analysis used the sher test. results: the logistic regression test results showed that the education level of the mother had a value of p = 0.017 and or 0.077. the nutritional status of children shows the value of p = 0.032 and or 0.98. conclusion: there is a relationship between the level of mother's education and the nutritional status with the development in toodlers. children with low-educated mothers have a 0.077 fold risk of developing developmental problems and children who have less nutritional status have a 0.098 fold risk of developing developmental problems. health workers need to educate the factors that can inuence children's development to parents. abstract keywords : toodler; development; factors yanita trisetiyaningsih department of maternity nursing, nursing study program, faculty of health, jenderal achmad yani university, yogyakarta dwi yati * department of maternity nursing, nursing study program, faculty of health, jenderal achmad yani university, yogyakarta *corresponding author demographic variables frequency percentage(%) age of mother 17-25 years 26-35 years 36-45 years 7 31 22 11,7 51,7 36,6 36 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 2 shows factors related to the development of toddler in the study. it known that the role of mothers in meeting the basic needs of children between good and less categories has the same percentage of 50%. most of the mothers do not work 31 people (51.7%), mothers have high education level of 49 people (81.7%), the nutritional status of children in the good nutrition category are 47 people (78.3%). most children were born with normal body weight of 56 people (93.3%) and most did not have a preterm history of 59 people (98.3%). table 2: frequency distribution of factors related to the development of toddler table 3 shows that the majority of toddler-age children have a corresponding development of 95%. only 5% of children have doubtful child development. table 3: frequency distribution of development of children under ve bivariate analysis factors associated with the development of toddler shown the results of each development factor using the sher test, there are 3 child development factors that have a value of p <0.25, namely the role of the mother in meeting the child's basic needs (p = 0.119), the level of education of the mother (p = 0.084), and the nutritional status of children (p = 0.115). furthermore, 3 factors entered into multivariate analysis using logistic regression tests. table 4: bivariate analysis of factors related to the development of toddler the results of multivariate analysis showed that the level of maternal education and nutritional status of each related to child development was indicated p> 0.05. the or (odd ratio) variable of mother's education level is 0.77. these results indicate that toddlers with low-educated mothers have a 0.077-fold risk of developing developmental problems. while the or (odd ratio) variable of the nutritional status level of children is 0.98. these results indicate that toddlers who have undernourished nutritional status have a 0.098-fold risk of developing developmental problems table 5: multivariate analysis of factors associated with the development of toddler discussion relationship of mother's education level with toddler's development the results showed that the majority of maternal education was high. the bivariate analysis showed that the mother's educational level was related to the development of toddler. the results of multivariate analysis showed that maternal education level was related to the development of toddler (p <0.05). toddlers with low-educated mothers have a 0.077-fold risk of developing developmental problems. previous research conducted by santri, indriansari, girsang (2014) concluded that parental education is related to toddler age (13 years). there is a relationship between maternal education and children's ne motor development (kusumaningtyas and wayanti, 2016). when mothers stimulate development, there is a need for knowledge that must be possessed by mothers. research by herlina (2014) concludes that there is a relationship between the level of mother's education and knowledge of children's motor development. the role of mothers in the development of children is needed to achieve optimal development so that good knowledge must be owned by a mother. this knowledge is obtained from the mother of information that has been obtained both from formal education and from other information media. the higher level of education the mother will be easier to receive and process information from outside including how to care for children well and how to provide stimulation or stimulation so that optimal child development (kusumaningtyas and wayanti, 2016). mother's education is the strongest factor related to children's health, behavioral and cognitive development (harding, morris, and hughes, 2015). education is an important predictor of developmental resources in the family because education can shape a child's cognitive development by building a good family life, including income, family structure age of child 12 – 24 months 25 – 36 months 37 23 61,7 38,3 gender of child male female 31 29 51,7 48,3 total 60 100 variable frequency percentage(%) the role of mother in meeting the needs of children good not good 30 30 50 50 mother's employment status not working working 31 29 51,7 48,3 mother's education level high education basic education 49 11 81,7 18,3 children's nutrition status good not good 47 13 78,3 21,7 birth weight normally birth weight under normally birth weight 56 4 93,3 6,7 prematurity history not prematur prematur total 59 1 60 98,3 1,7 100 child development frequency percentage(%) normal 57 95 suspect 3 5 jumlah 60 100 mother's employment status not working working 29(93,5) 28(96,6) 2(6,5) 1(3,4) 0,525 mother's education level high education basic education 48(98) 9(81,8) 1(2) 2(18,2) 0,084* children's nutrition status good not good 46(97,9) 11(84,6) 1(2,1) 2(15,4) 0,115* birth weight normally birth weight under normally birth weight 53(94,6) 4(100) 3(5,4) 0(0) 0,810 prematurity history not prematur prematur 56(94,9) 1(100) 3(5,1) 0(0) 0,950 dependent variables developmentof child p value normal f (%) suspect f (%) the role of mother in mee ting the needs of children good not good 30(100) 27(90) 0(0) 3(10) 0,119* variables p value exp(b) ik 95% min max mother's education level 0,017 0,077 0,009 0,643 children's nutrition status 0,032 0,098 0,012 0,820 x 37gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra and mental health of parents (jackson, kiernan, mclanahan, 2019). relationship of nutritional status with toddl er's development nutritional status assessment in this study uses the z score calculation and is classied into 2 categories, good nutrition if the value is in the range of -2 to +2 while malnutrition if the value is in the range of -3 to -2. the results of univariate analysis showed that most children had good nutritional status (78.3%). most of the children who have good nutritional status have development in accordance with the stages of age (normal) (97.6%). previous studies conducted by agarwal et al (2018) reported that most children who had good nutritional status did not experience developmental delays. other research that is in line with this research conducted by suharyanti, hastuti & triredjeki (2017) shows that most children with good nutritional status, most have appropriate development. multivariate analysis results showed that the nutritional status of children associated with child development (p < 0.05). toddlers who have less nutritional status have a 0.098-fold risk of developing developmental problems. previous studies have reported a positive relationship between the nutritional status of children with the status of child development. malnourished children have a 2.508-fold risk of delayed development (agarwal et al., 2018). nutritional status of children has an impact on certain domains of child development, namely hearing ability, language and social interaction. children with malnutrition are three times more likely to experience hearing delays and language skills and ve times the risk of experiencing delays in the domain of social interaction compared to children with good nutritional status (jimoh, anyiam, yakubu ,2018) good nutrition shows that the nutrients needed by children are fullled. nutrition is very important for child development. nutrition plays an important role in children's brain development from conception to age 3 years (cusick & georgieff, 2017). adequate nutrition during pregnancy and the two years of early life of a child is needed for brain development as a basis for cognitive development, emotional motor skills and social throughout the childhood to adulthood. children with impaired or late development of skills during early life are at risk of causing neuropsychological disorders in the future, dropping out of school and low work skills (unicef, 2014). limitation the process of collecting data on child development must be done several times because there are some children who refuse to be assessed development. conclusion the study showed the level of mother's education and nutritional status of children one of the factors associated with inuenced the development in toddler, which needs particular attention by the health stakeholders. acknowledgements the author would like to deeply thank jenderal achmad yani university yogyakarta, indonesia and principants. conflict of interest the authors declare no conict of interest with respect to the research, authorship, and/or publication of this article. references 1. aiello, m. a., and leuzzi, f. (2010), “waste tyrerubberized concrete: properties at fresh and hardened state.” journal of waste management, elsevier, 30,1696-1704. 2. the indonesian ministry of health (2016). guidelines for implementing early childhood growth, stimulation, detection and intervention. jakarta: indonesian ministry of health. 3. global research on developmental disabilities collaborators. (2018). developmental disabilities among children younger than 5 years in 195 countries and territories, 1990–2016:a systematic analysis for the global burden of disease study 2016. lancet glob health, 6. e110. http://dx.d oi.org/ 10.1016/s2214-109x(18)30309-7 4. the indonesian pediatrician association (idai). mengenal keterlambatan perkembangan umum pada anak. (2013). retrieved from http://www.id ai.or.id/artikel/seputar-kesehatan-anak/mengenal-keterlambatan-perkem banganumum-pada-anak 5. santri, a., idriansari, a., girsang, bm. (2014). factors affecting the growth and development of toddler age children (1-3 years) with a history of low birth weight babies. journal of public health sciences, 5 (1), 63. 6. kusumaningtyas, k., wayanti, s. (2016). income factors and family education on ne motor development in children aged 3-4 years. journal of forikes sound health research, vii (1), 52. 7. herlina. (2016). relationship between education level and mother's knowledge of the rough motor development of preschoolers (ages 4-6 years). journal of nursing and midwifery. 6 (1), 26-32. 8. harding, jf., morris, pa., hughes, d. (2015). the relationship between maternal education and children's academic outcomes: a theoretical framework. journal of marriage and family, 77(1). 9. jackson, m. kiernan, k., mclanahan, s. (2017). maternal education, changing family circumtances and children’s skill development in the united state and uk. the annals of the american academy of political and social science, 674(1), 59-84. 10. agarwal d, chaudhary ss, sachdeva s,misra sk, agarwal p. (2018). prevalence of developmental delay and factors affecting the development status among under 5 children in an urban slum of agra city . natl j community med. 9(7):474-479 11. suharyanti, e.r, hastuti, t.p, triredjeki, h. (2017). relationship of nutrition status and development of children ages 1 to 5 years in north tidar village, magelang city. journal of nursing sudirman (the soedirman journal of nursing).12(1). 12. jimoh, a., anyiam j., yakubu, am. (2018). relationship between child development and nutritional status of under-ve nigerian children. south african journal of clinical nutrition, 31(3), 50-54. 13. cusick, se., georgieff, mk. (2016). the role of nutrition in brain development: the golden opportunity of the “first 1000 days”. j. pediatri. 175, 16–21. doi:10.1016/j.jpeds.2016.05.013. 14. unicef. (2014). early childhood development : a statistical snapshot. building better brains and sustainable outcomes for children. retrieved from https://data.unicef.org/resources/early-childhood-developmentstatistical-snapshot/ 38 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra brief history: a 63 yrs old lady was brought in altered sensorium with complaints of diarrhea and vomiting of two days. associated with complaints of giddiness, headache, abdomen pain and myalgia. patient has no co morbid illness. her blood pressure was 90/60 mm of hg, pulse rate is 65 beats per min. her hematological, biochemical, microbiological investigations were normal and patient was treated with uids and antibiotics as an acute gastroenteritis case and resolved. on rd3 day of admission, patient complaints of sudden onset of blurring of vision. on examination, it was identied as weak adduction on one side and abduction nystagmus on the contralateral eye. mri brain was done and identied as lesion in the medial longitudinal fasciculus. discussion: the medial longitudinal fasciculus exists as a pair of tracts near the midline just under the fourth ventricle and cerebral aqueduct. it extends through the dorsomedial pontine and midbrain tegmentum. it is a heavily myelinated tract that allows conjugate eye movement by connecting the paramedian pontine reticular formation and abducens nucleus complex of the contralateral side to the oculomotor nucleus of the ipsilateral side. as it is proximal to the midline, more chances of bilateral injury. it primarily involves in coordinating synchronous horizontal moment and also regulates vertical pursuit, vertical vestibular signals and vertical alignment of two eyes. the major causes of internuclear ophthamoplegia are multiple sclerosis and cerebrovascular diseases. one third of the cases are caused by infection , trauma , tumour . associated syndromes: webino: wall-eyed bilateral internuclear ophthalmoplegia exists when there is bilateral damage to the mlf. this damage causes a primary position exotropia (eyes are looking at the opposite “wall.”, thus the possibly outdated term “wall eyed”). the most common etiology is infarction of the midbrain in older patients and demyelinating disease in young patients.[3] the exotropia is likely decompensation of fusional mechanisms and the xt is not present in every case of bilat eral ino. wemino: this is a less common variant of ino, similar to the webino above. as in webino, patients with a unilateral mlf lesion (monocular ino) have a primary position xt. one and one half syndrome: this syndrome occurs when there is a lesion to the mlf and the pprf or cn vi nucleus on the same side resulting in an ino in one eye and an ipsilateral horizontal gaze palsy eight and a half syndrome: this syndrome is characterized by having one-and-a-half syndrome and a facial fascicular nerve (cn vii) palsy. the fascicle of cn vii wraps around the nucleus of cn vi in the dorsal pons. there is conjugate horizontal gaze palsy on looking to one side followed by ino on looking to the opposite side, along with unilateral facial weakness. the close proximity of the pprf, facial nerve nucleus and mlf located in the dorsal pons makes this syndrome much more likely. the lesion is most often vascular or demyelinating in the dorsal tegmentum of the caudal pons half and half syndrome: a syndrome that consists of an ino case reporta case of internuclear ophthalmoplegia after bacterial diarrhea original research paper dr. kavuru naga siri junior resident department of general medicine , sree balaji medical college and hospital general medicine internuclear ophthalmoplegia is a manifestation of intrinsic brain stem disease which produces ischemia of demyelination of nerve. the most common cause is multiple sclerosis and cerebrovascular diseases. rare causes account for about 11%. incidences are equal in males and females. it is extremely rare in pediatric population. we report a case of internuclear ophthalmoplegia following acute diarrheal episode. abstract keywords : dr. suresh kanna* assistant professor department of general medicine , sree balaji medical college and hospital *corresponding author volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 18 x gjra global journal for research analysis in one eye combined with an ipsilateral cn vi fascicular involvement with sparing of the sixth nerve nucleus. thus, there is “half” of a horizontal gaze palsy (ino) plus an additional “half” (abduction decit from cn vi fascicular palsy). posterior ino: this syndrome is a rare ophthalmoplegia, either bilateral or unilateral that exhibits contralateral adducting eye (rather than abducting eye) nystagmus with abduction restriction on physical exam. it is the reverse of the typical ino, and although the lesion localization is not consistent, it likely is due to cn vi pre-nuclear input asymmetry partial third nerve palsy, other supranuclear gaze disturb ances, peripheral neuromusclular involvement are the differential diagnosis for this which can be elicited by a thorough clinical examination. the physical examination helps to arrive to the diagnosis an mri brain is the key diagnostic factor for evaluation. most patient will recover in days or months but in some , it still persists. conclusion : internuclear ophthalmoplegia is a disease with most common cause as multiple sclerosis but the frequency of other causes has also being increasing with similar prognosis. references: 1. cogan dg, kubik cs, smith wl. unilateral internuclear ophthalmoplegia; report of 8 clinical cases with one postmortem study. ama arch ophthalmol 1950;44:783-96. 2. thömke f, hopf hc, krämer g. internuclear ophthalmoplegia of abduction: clinical and electrophysiological data on the existence of an abduction paresis of prenuclear origin. j neurol neurosurg psychiatry 1992;55:105-11. 3. ushio m, iwasaki s, chihara y, murofushi t. wall-eyed bilateral internuclear ophthalmoplegia in a patient with progressive supranuclear palsy. j neuroophthalmol 2008;28:93-6. 4. fisher cm. some neuro-ophthalmological observations. j neurol neurosurg psychiatry 1967;30:383-92. 5. eggenberger e. eight-and-a-half syndrome: one-and-a-half syndrome plus cranial nerve vii palsy. j neuroophthalmol 1998;18:114-6. 6. xue f, zhang l, zhang l, ying z, sha o, ding y, et al. one-and-a-half syndrome with its spectrum disorders. quant imaging med surg 2017;7:6917. 7. rosini f, pretegiani e, guideri f, cerase a, rufa a. eight and a half syndrome with hemiparesis and hemihypesthesia: the nine syndrome? j stroke cerebrovasc dis 2013;22:e637 8. mahale rr, mehta a, john aa, javali m, abbas mm, rangasetty s, et al. “nine” syndrome: a new neuro-ophthalmologic syndrome: report of two cases. ann indian acad neurol 2015;18:335-7 volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 19gjra global journal for research analysis 83.karina sugih arto online.cdr introduction hemoglobin a1c (hba1c) is one of the measurement methods that helps to achieve the expected glycemic control, besides measuring blood sugar (self monitoring blood glucose / smbg), reporting of hypoglycemia events, type of treatment, 1patient age and quality of life. from a study conducted by diabetes control and complications trial (2008) reported that poor glycemic control for 5 to 7 years as a teenager could lead to an increased risk of microvascular and macrovascular 2complications 6 to 10 years later. at present the evidence shows that achieving good glycemic control can reduce complications from diabetes mellitus (dm). however, even with intensive diabetes management, less than one fth of dm 3patients achieve the recommended hba1c level target. a south east asian nutrition surveys (seanut) study in indonesia, malaysia, thailand and vietnam in 2016 showed that in indonesia only 5% of children with adequate 25 (oh) d 4levels (serum levels> 30ng / ml). vitamin d deciency affects 5almost 50% of the population worldwide. besides functioning to regulate calcium metabolism, vitamin d also functions in immunomodulating t helper cells, and inhibits the production of inammatory cytokines that can damage pancreatic � cells 6,7,8and helps insulin secretion. one study conducted by wulandari reported that there was a strong negative correlation between low vitamin d levels and 9high hba1c in dm patients. then, one study conducted by dehkordi (2018) reported that vitamin d supplementation for 12 weeks can reduce patients' hba1c levels and it is hoped that the results of these studies can be recommendations for 10additional therapy in dm patients. the results of studies increasingly support that vitamin d deciency is often related to autoimmune disease and poor 11,12glycemic control in dm patients. this statement is in line with studies conducted by wulandari (2014) type 1 dm patients who had vitamin d levels that were much lower than 9the comparison group. although vitamin d supplementation as insulin adjunctive therapy in type 1 dm patients can help with residual β cell function, however, studies by sharma (2017), and madar 13,14(2013) did not get a signicant decrease in hba1c levels. therefore, more studies are needed to support the provision of vitamin d supplementation for dm patients. the purpose of this study was to determine the efcacy of vitamin d supplementation in reducing hba1c level. methods this study was a cohort prospective study was conducted on diabetic children who were recruited from the pediatric endocrinology unit in h. adam malik general hospital medan, periods from may to october 2019. all patients were diagnosed with either dm type 1 or 2 are recruited consecutively. informed consent was obtained from all participants. patients with chronic kidney disease, chronic liver diseases, malnutrition, malabsorption disorders such as short bowel syndrome, previously receiving vitamin d supplementation or any drugs affecting vitamin d level, such as steroids, antiepileptics, methotrexate, inh (isoniazid), thiazides, antacids, calcium channel blockers, and anticonvulsants, were excluded. the health research ethical committee number 395/tgl/kepk fk usu-rsup ham/2019 was obtained from medical faculty of universitas sumatera utara and number lb.02.03/ii.4/154/2019 was obtained from the clinical research unit of h. adam malik hospital. the sample size in this study was calculated based on the sample size formula for testing hypotheses in a population of mean differences before and after treatment. the calculation was done using a 95% condence level with minimal sample size was 13 patients. history taking, physical examination, and anthropometry data were carried out and informed consent was obtained from the parents. blood drawn (t0) for laboratory tests was carried out when patients came for treatment or were hospitalized. blood tests included complete blood, blood sugar levels, hba1c, 25 (oh) vitd levels, urea, creatinine, urinalysis, and c-peptide. 25(oh)d level was examined by clia (chemiluminescent immunoassay) method. patients were given vitamin d3 2000iu per day for 3 months. second blood tests (t1) were done after the administration of vitamin d3 supplementation in the third month by re-examining the hba1c level and 25 (oh) vitd levels. all data obtained will be recorded and tabulated. the efficacy of vitamin d3 supplementation in diabetic children: a cohort prospective study original research paper s a karina department of child health, medical school, universitas sumatera utara, medan, indonesia paediatrics diabetes mellitus (dm) is a complex metabolic disorder characterized by chronic hyperglycemia due to defect from insulin secretion, insulin action, or both. despite intensive diabetes management, less than a fth of diabetic patients achieve the recommended hba1c target. this cohort prospective design study was conducted in the pediatric endocrinology division of haji adam malik hospital medan from marchoctober 2019. a total of 14 children were enrolled in this study. this study result showed increase of 25(oh)d level from 18.6±5.6ng/ml to 27.3±5.9ng/ml (p=0.00) and decrease of hba1c level from 9.8%±1.9 to 7,0%±1.1 (p=0.00). this study found a negative correlation between the hba1c value and 25(oh)d level (r-0.83;p=0.00). the management of dm with standard medication plus vitamin d supplementation showed a satisfactory result and is expected to become a routine recommendation in the management of children with dm. abstract keywords : diabetes mellitus, children, hba1c, vitamin d p winra* department of child health, medical school, universitas sumatera utara, medan, indonesia *corresponding author s a nindia department of child health, medical school, universitas sumatera utara, medan, indonesia 32 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra saphiro-wilk test was used for assessment of normality of data distribution. because the data were normally distributed, t-paired test was used to compare differences before and after receiving vitamin d3. pearson's correlation test was used to examined correlation between the independent and dependent variables (p <0.05). mann-whitney test was used to value the relationship between vitamin d levels with either type 1 dm or type 2 dm w the (p <0.05). data processing was performed using statistical package for social sciences for windows (spss) version 24.0, 2016 with p <0.05 was signicance, and 95% condence interval. result from may to october 2019, 14 subjects met the study's inclusion and exclusion criteria were collected. data is presented in tabular form. 14 subjects included male 35,7% and female 64,3% with type 1 dm 85,7% and type 2 dm 14,3%. all characteristic data from the research sample was listed in table 1. in this study, we found that all diabetic patients both type 1 and type 2 diabetes with vitamin d deciency or insufciency (listed in table 2). the levels of hba1c, c-peptide and vitamind in the rst month (t0) before receiving vitamin d supplementation and hba1c levels with vitamin d in the third month (t1) after the administration of vi tamin d supplementation were then analysed. the result of the tdependent test found that 25(oh)d level increased signicantly after supplementation of vitamin d (p <0.05) accompanied by signicant decrease in hba1c (p <0.05) (listed in table 3). from the pearson correlation test, we found that there was a strong negative correlation between 25 (oh) d and hba1c levels both before the intervention (t0) was given with r = -0.93 (p = 0.00) and after vitamin d supplementation (t1) with r = 0.64 (p = 0.01) (listed in table 4). we found that either type 1 or type 2 dm was in vitamin d deciency or insufcient status. therefore, the mann-whitney test obtained results that stated that the actual levels of vitamin d had no relationship with which type of dm (listed in table 5). discussion the incidence of dm varies greatly. the highest incidence of type 1 dm is found in finland which is 43/100,000 and the lowest incidence is found in japan 2.4 / 100,000 and china 0.1/100,000 for children aged 15 years. indonesia does not yet have the right dm incidence rate so that by referring to neighbour countries such as singapore and malaysia who have similar ethnic and cultural backgrounds, the estimated incidence of dm in children in indonesia is 0.3 / 100,000. the peak age of incidence of type -1 dm in children is at the age of 15 5-6 years and 11 years. although type 1 diabetes is the most common case in children and adolescents, the number of children and adolescents with type 2 diabetes has also 16increased in recent years. on study in sweden reported the use of c-peptide to classied types of diabetes. mostly children in c-peptide level between 0.2 -0.99 nmol/l were type 1 dm and c-peptide   1.0 nmol/l had predictive value for type 2 dm as 170.46 (95%ci 0.37 – 0.58). the proportion of diabetic patient in this study was found most in type 1 dm was 85.7% with the age ranged between 4-17 years old and c-peptide range between 0,1-7,9 with all type 1 dm were below 1 ng/dl. hba1c is formed as a result of glucose binding to hemoglobin permanently with an estimated erythrocyte life span of 120 days. therefore, hba1c describes the state of glycemia for 4 12 weeks. hba1c is believed to be the most useful parameter in evaluating metabolic control and has a close relationship with 17microvascular and macrovascular complications. the 18recommended hba1c target is ≤7%. in addition, one of the criteria for diagnosis of diabetes mellitus is the hba1c value ≥ 19 6.5%. the mean hba1c level while diagnosed with diabetes in this study was 9.8% ± 1.9. this level indicated poor glyce mic control. according to the endocrine society, the term vitamin d deciency when level of 25(oh)d are below 20 ng/ml (50 nmol/l) and vitamin d insufciency when level of 25(oh)d are 2021-29 ng / ml (52.5 72 , 5 nmol / liter). researchs in the united states, canada and europe explained that 20-100% of elderly people suffer from vitamin d deciency and around one billion people worldwide experience vitamin d deciency or insufciency (deluca hf, 2018). a south east asian nutrition surveys (seanut) study in indonesia, malaysia, thailand and vietnam in 2016 showed that in indonesia only 5% of children had adequate 25(oh)d levels (serum levels> 30ng / 4ml). effects of vitamin d on immune responses can be through various complex mechanisms. interaction of vitamin d with antigen presenting cell (apc) and t cells produced suppressive responses and down regulator immune responses. the effect of vitamin d began noticed since the discovery of vitamin d receptors on lymphocytes, which acted as anti-proliferation through the production of cytokines by t cells, had been found. vitamin d binds to the dna chain. vitamin d inhibits the production of th1, il2 and inf  media tors in cell transcription processes thereby inhibiting damage 21from pancreatic β-cells. a study conducted by savastio et al for 6 years on type 1 dm patients reported that the average of pediatric and adolescent patients with type 1 dm had vitamin 22d deciency. in this study, vitamin d deciency or insufciency was found in all diabetic patients therefore we stated that levels of 25(oh)d had nothing to do with the type of diabetes. the presence of vitamin d receptors (vdr) in pancreatic β cells is the origin of the working knowledge of vitamin d in glycemic control. its mechanism of action is through the vd3vdr complex which binds to the rxr and then forms the vd3vdr-rxr-dna polymerase complex which then binds to the insulin promoter gene and modulates the expression of the gene. in addition, the action of vitamin d also helps the inux 6of calcium thereby increasing insulin exocytosis. several studies had shown that there is a strong relationship between low vitamin d levels and high hba1c in both type 1 23-28and type 2 dm patients. then, several intervention studies conducted by dehkordi (2018) reported that vitamin d supplementation could reduce patients' hba1c levels and it is expected that the results of these studies can be the 10,29,30recommendation for additional therapy in dm patients. although many studies had revealed signicant effects and relationships, studies by sharma (2017) and madar (2013) did not get a signicant decrease in hba1c levels after vitamin d 13,14supplementation. research conducted by savastio reported that vitamin d supplementation had improved the body's metabolic status and glycemic control signicantly so it needs to be considered in additional therapy in diabetic 22 patients. in this study, supplementation of vitamin d 2000 iu for 3 months had signicantly increased 25(oh)d levels and an increase in 25(oh)d level was negatively correlated with the decrease of hba1c values. conclusion all children with type 1 and type 2 diabetes are accompanied by vitamin d deciency. there is a strong negative correlation between 25(oh)d and hba1c levels. giving vitamin d3 supplementation at a dose of 2000 iu per day for 3 months can signicantly increase levels of 25(oh)d diabetic children. in this study, supplementation of vitamin d3 combination with standard therapy will help reduce hba1c in diabetic children. x 33gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 5.3. hba1c and 25(oh)d levels before and after vitamin d supplementation (t-paired test) table 5.4. correlation between hba1c and 25(oh)d before (t0) and after supplementation (t1) tabel 5.5. relationship between 25(oh)d level and type 1 or type 2 dm references 1. rewers, m., pillay, k., beafort, c., craig, m.e., hanas, r., acerini, c.l., maahs, d.m. (2014), “assessment and monitoring of glycemic control in children and adolescents with diabetes. ispad clinical practice consensus guidelines 2014 compendium.” pediatr diabetes,15,102-4. 2. lachin, j.m., genuth, s., nathan, d.m., zinman, b., rutledge, b.n. (2008), “effect of glycemic exposure on the risk of microvascular complications in the diabetes control and complications trial--revisited.” diabetes,57, 995–1001. 3. watts, w., lamabadusuriya, h., edge, j. (2014), “targeting glycaemic control in children and young people with type 1 diabetes: getting it right from day one.” diabetes care for children and young people,3;1-7. 4. poh, b.k., rojroongwasinkul, n., nguyen, b.k., sandjaja, ruzita, a.t., yamborisut u, et al. (2016), “25-hydroxy-vitamin d demography and the risk of vitamin d insufency in the south east asian nutrition surveys (seanuts).” asia pac clin nutr,25,538-48. 5. nair, r., maseeh, a. (2012), “vitamin d: the “sunshine” vitamin.” j pharmacol pharmacother,3,118-26. 6. john, a.n., jiang, f.x. (2017), “an overview of type 2 diabetes and importance of vitamin d3-vitamin d receptor interaction in pancreatic �-cells.” j diabetes its complication,1-53. 7. wang, y., he, d., ni, c., zhou, h., wu, s., xue, z., et al. (2016), “vitamin d inuced autophagy of pancreatic �-cells and enhances insulin secretion.” mol med reports,14,2644-50. 8. gao, j., xiao, z., xue, x., liu, x., lu, y., yin, x., et al. (2003), “25-hydroxyvitamin d is closely related with the function of the pancretic islet � cells.” j med sci,29,809-13. 9. wulandari, d., cahyono, h.a., widjajanto, e., puryatni, a. (2014), “low levels of vitamin d correlate with hemoglobin a1c and interleukin-10 levels in pediatric type 1 diabetes mellitus patients.” j tropical life sci,4,182-6. 10. dehkordi, e.h., dehkordi, v.h., fatemi, s.m., zolfaghari, m. (2018), “effect of vitamin d supplement therapy on hba1c and igf-1 levels in children with type 1 diabetes mellitus and vitamin d deciency.” electron j gen med,15;69-75. 11. george, p.s., pearson, e.r., witham, m.d. (2012), “effect of vitamin d supplementation on glycaemic control and insulin resistance: a systematic review and meta-analysis.” diabetes med,29:e142-50. 12. hutchinson, m.s., figenschau, y., njølstad, i., schirmer, h., jorde, r. (2011), “serum 25-hydroxyvitamin d levels are inversely associated with glycated haemoglobin (hba1c). the tromsø study.” scand j clin lab invest,71(5),399406. 13. sharma, s., biswal, n., bethou, a., rajappa, m., kumar, s., vinayagam, v. (2017), “does vitamin d supplementatin improve glycemic control in children with type 1 diabetes mellitus? a randomized controlled trial.” j clin diagnostic res,11;15-8. 14. madar, a.a., kirsten, v.k., stene, l.c., brekke, m., meyer, h.m., lagerlev, p. (2014) “effect of vitamin d3 supplementation on glycated hemoglobin (hba1), fructosamine, serum lipids, and body mass index: a randomized, doubleblinded, placebo-controlled trial among health immigrants living in norway.” bmj open diabetes res care, l2,1-9. 15. rustama, d.s., yati, n.p., andriana, n., pulungan, a.b. (2018), “diabetes melitus. in: buku ajar endokrinologi anak. editor batubara jr, tridjaja b, pulungan ab. edisi ke-2.” idai:jakarta. pp.146-7. 16. lubis, s.m., julia, m., soesanti, f. (2018), “diabetes melitus tipe 2. dalam buku ajar endokrinologi anak. editor batubara jr, tridjaja b, pulungan ab. edisi ke-2.” idai: jakarta, pp. 156 17. ludvigsson, j., carlsson, a., forsander, g., ivarsson, s., kockum, i., lernmark, a., et al. (2012), “c-peptide in the classication of diabetes in children and adolescents.” pediatr diabetes,13, 45–50. 18. nice. 2019. blood glucose control in children and young people with type 1 diabetes. diabetes care for children and young people, pp1-11. 19. mayer-davis, e.j., kahkoska, a.r., jefferies, c., dabelea, d., balde, n., gong, c.x., et al. (2018), “ispad clinical practice consensus guidelines 2018: denition, epidemiology, and classication of diabetes in children and adolescents.” pediatr diabetes,19; pp7-19 20. holick, m.f., binklet, n.c., bischoff-ferrari, h.a., gordon, c.m., hanley, d.a., heany, r.p., et al. (2011), “evaluation, treatment, and prevention of vitamin d deciency: an endocrine society clinical practice guideline.” j clin endocrinol metab, 96;1911-30. 21. busta, a., alfonso, b., poretsky, l. (2011), “role of vitamin d in the pathogenesis and therapy of type 1 diabetes mellitus. in: liu cp. type 1 diabetes complications, pathogenesis, and alternative treatments.” intech, pp403-426. 22. savastio, s., cadario, f., genoni, g., bellomo, g., bagnati, m., secco, g., et al. (2016), “vitamin d deciency and glycemic status in children and adolescents with type 1 diabetes mellitus. plos,1,1-13. 23. elsayed, a.m., mohamed, g.a. (2016), “vitamin d deciency and its correlation to hemoglobin a1c in adolescent and young adult type 1 diabetes mellitus patients.” al azhar med j,14,pp.76-9. 24. al-sawah, s.a., compher, c.w., hanlon, a.l., lipman, t.h. (2016), “25hydroxyvitamin d and glycemic control: a cross-sectional study of children and adolescents with type 1 diabetes.” diabetes res clin practice, pp1-23. 25. alkhatatbeh, m.j., abdul-razak, k.k. (2018), “association between serum 25hydroxyvitamin d, hemoglobin a1c and fasting blood glucose levels in adults parameters n = 14 age (years),median(min-max) gender (n, %) ÿ boy ÿ girl nutritional status (n, %) ÿ severe wasting ÿ wasting ÿ normal ÿ overweight ÿ obesity 9 (4 – 17) 5 (35,7) 9 (64,3) 1 (7,1) 4 (28,6) 7 (50) 1 (7,1) 1 (7,1) types of dm type 1 dm(n,%) type 2 dm(n,%) 12 (85,7) 2 (14,3) parameters n = 14 (t0) n = 14 (t1) referal normal range 25(oh)d(ng/ml),mean(sd) normal (n.%) insusiensy (n,%) deciency (n,%) types of dm type 1 dm(n,%) type 2 dm(n,%) hba1c (%), mean (sd) c-peptide (ng/ml), median (min-max) 18,6 (5,65) 6 (42,9) 8 (57,1) 12 (85,7) 2 (14,3) 9,8 (1,9) 0,35 (0,1-7,9) 27,3 (5,9) 6 (42,9) 7 (50) 1 (7,1) 7,0 (1,1) 30-40 4 – 5,6 0,9 – 7,1 table 2. hba1c, c-peptide, and 25(oh)d levels in the rst month (t0) and third months after recieving vitamin d supplemention table 1. subject characteristics parameters suplementasi vit-d p before after 25(oh)d, mean(sd) 18,6 (5,65) 27,3 (5,9) 0.000 hba1c, mean(sd) 9,8 (1,9) 7,0(1,1) 0.000 parameters 25(oh)d r p hba1c (t0) -0.83 0.00 hba1c (t1) -0.64 0.01 parameters 25(oh)d n p type 1 dm 12 0,201 type 2 dm 2 34 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra with diabetes mellitus.” biomedical reports,9;pp523-30. 26. buhary, b.m., almohareb, o., aljohani, n., alrajhi, s., elkassi, s., sherbeeni, s., et al. (2017), “association of glycosylated hemoglobin levels with vitamin d status.” j clin med res,9;pp1013-8. 27. mehta, n., shah, s., shah, p.p., prjapati, v. (2016), “correlation between vitamin d and hba1c in type 2 diabetic patients.” gcsmc j med sci,5;pp1-5. 28. kanakaraju, k., ranganathan, r.s., shankar, r. (2017), “correlation of vitamin d3 levels and the blood sugar parameters among the patients with type 2 diabetes mellitus.” int j contemporary med res,4;pp.844-8. 29. giri, d., pintus, d., burnside, g., ghatak, a., mehta, f., paul, p., et al. (2017), “treating vitamin d deciency in children with type 1 diabetes could improve their glycaemic control.” bmc res notes,10;465-70. 30. randhawa, f.a., msutafa, s., khan, d.m., hamid, s. (2017), “effect of vitamin d supplementation on reduction in levels of hba1c in patients recently diagnosed with type 2 diabetes mellitus having asymptomatic vitamin d deciency.” pakistan j med sci, 33;pp.881-6. x 35gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra caesarean section is one of the commonly performed surgical procedures in obstetrics and is certainly one of the oldest techniques in surgery. its incidence continues to rise internationally. the rising rates of cs internationally have prompted the world health organization to make a proposal in 1985 that a cs rate of more than 10–15% is not justiable for 1any region in the world. caesarean section (cs) is an operation mainly evolved to save a maternal life during difcult child birth. the decision to perform a primary cs has important implications for maternal morbidity in the current pregnancy and mode of delivery and maternal morbidity in 2,3,4subsequent pregnancies increases in the caesarean rate for women of all ages, races, geographic areas, and gestational ages. the reasons mostly related to foetal distress especially in detection by continuous electronic foetal monitoring, advanced age, more liberal use of caesarean section for breech, intrauterine growth retardation (iugr), preterm labour, multiple gestation, medical complicating pregnancy like gestational hypertension, gestational diabetes mellitus and hypothyroidism and improved safety of caesarean section. aims and objectives to compare changing trends in caesarean section over one decade -increase caesarean section rate done to increase in antenatal surveillance and medically complicated pregnancies. materials and methods the study conducted in prospective and retrospective manner in 600 bedded government hospital; govenrment medical college, srikakulam, andhra pradesh. the caesarean rate was calculated as the number of caesarean births divided by total live births. to compare the caesarean delivery rates over the last decade, the data was collected for the year 2009 and 2018. the rates and indications of primary and repeat caesarean sections (cs) were analysed among 3476 live births during 2018 and present caesarean section rate was compared with that of 2009 and 2013 caesarean rates. the following variables of interest were retrieved from the database: maternal age; year of delivery; parity; total number of previous caesarean sections; mode of delivery; onset of labour; gestational age; birth presentation; birth weight. the categories of indications for caesarean section like foetal distress, multiple gestation, mal presentation, arrest of labour or vacuum extraction, cephalopelvic disproportion(cpd), maternal indications, and foetal indications were studied. cases with missing information after review were excluded. results a total of 1410 caesarean sections performed during the year 2018 at government general hospital (rims), srikakulam, andhra pradesh were analysed. the total number of deliveries during our study period was 3476. out of these 3476 patients 2066 had normal vaginal delivery and 1410 had caesarean delivery. the incidence of caesarean section at our institution was 40.56% as per table 1. there was increase in the rate of caesarean section over decade from 2009 to 2018 as per table – 2. in 2009 cs rate was 23.23% in 2018 40.56%. as per table – 3. incidence of primary section 54.32% and repeat section 45.67%. as per table -4 the incidence of primary emergency 39.07%, changing trends in the indications of caesarean over a decade at rims general hospital, srikakulam. original research paper dr. tulugu sasikala associate professor, department of obstetrics and gynaecology, acsr medical college, nellore, andhra pradesh. x 23gjra global journal for research analysis obstetrics and gynaecology background: this study was done to evaluate the changing trends in caesarean section over onedecade period and to determine as to whether increase in caesarean section rate is due to increase in antenatal surveillance or due to medically complicated pregnancies or conceived with infertility treatment. materials and methods: the study was conducted in a 600 bedded government general hospital, government medical collage (rims), srikakulam, andhra pradesh. data was collected retrospectively from database from 2009 to 2018. the rates and indications of primary and repeat caesarean sections (cs) were analysed among 3476 live births during 2018. caesarean section rates have increased as it has become the procedure of choice in high risk pregnancies to prevent prenatal morbidity and mortality; this has become possible due to improved patient care, availability of effective antibiotics, blood transfusion services, safer anaesthesia, improved surgical technique and sophisticated neonatal care services. results: as medically complicated pregnancies and antenatal surveillance have increased, there was an increase in caesarean section rate. caesarean section rate increased from 22.23% in 2009 to 40.56% in 2018. there was an increase in primary section and repeat sections. primary caesarean section rate is 54.32% compared to repeat caesarean section rate which was 45.67%. this increase in caesarean section rate is due to increase in indications like cephalo pelvic disproportion, pregnancy being associated with medical disorders (pih, gdm, hypothyroidism) and malpresentations. conclusion: rising rate of caesarean section over one decade is attributed to frequent diagnosis of foetal distress on electronic foetal heart monitoring, identication of high-risk mother and frequent resort to elective sections in high risk situations and precious pregnancies and institutional vaginal deliveries. abstract keywords : primary caesarean section, repeat caesarean section, caesarean rate, gestational hypertension, dr. jyothirmayi ponnada* assistant professor, department of obstetrics and gynaecology, rims medical college, srikakulam, andhra pradesh. *corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra mode of delivery no. of cases % vaginal delivery 2066 59.44 abdominal delivery(lscs) 1410 40.56 total no. of deliveries 3476 100 table 1. incidence of caesarean section 24 x gjra global journal for research analysis primary elective caesarean section 15.24%, repeat emergency 17.58% and repeat elective 28.08%. as per table 5. emergency cs contributed to 56.66%, elective cs 45.33%. this seems to be main reason for the rise of caesarean section rate. there is a need to encourage trial of labour following a caesarean done for non – recurrent indication. important indications for repeat elective caesarean sections performed in the year 2018 were as per table-9. cephalo –pelvic disproportion associated with medical disorders like gdm, pih, rh negative pregnancy, hypothyroidism epilepsy, bronchial asthma were the commonest indication for primary emergency lscs followed by foetal distress and malpresentations. cephalo-pelvic disproportion associated with medical disorders complicating pregnancy like pih, gdm, rh negative pregnancy, hypothyroidism, epilepsy, bronchial asthma, cephalo pelvic disproportion, pelvic abnormalities were the commonest indications for primary elective lscs and also for repeat caesarean section. apart from above. foetal distress amounted to more than one third of repeat emergency lscs followed by scar tenderness. the majority of cases were in the age group of 21-25 years (59%) as per table -11. this reects the early marriage and early age of child bearing among indian women. total 90.92% of women belonged to low socio-economic status as per table-12. total 78.15% patients belonged to rural area as per table -13. this indicates the awareness among rural women comparatively with urban women and shows the improved transport facilities are available through 108 services to our hospital. total 77.02% of patients had regular antenatal checkups but 22.97% were admitted as emergencies as per table -14. most of these cases were post caesarean pregnancies and referred from surrounding villages as our hospital is a referral hospital. majority of lscs were in primi gravid(41.41%) and second gravid(45.60%) as per table-15. total 68.93% cases were performed at term with good foetal survival chances as per table 16. discussion there is concern over the rising caesarean delivery rates, in 5,6both developed and developing countries across the world. the rates of both primary and repeat caesarean delivery have 7been on the rise. 8a study conducted by stavrou et al. in new south wales, australia, showed an overall increase in caesarean rate from 19.1 to 29.5 per 100 births from 1998 to 2008. in a study 9conducted in singapore by chong et al. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra year total no. of deliveries no. of caesarean sections % 2009 2051 456 22.23 2013 1816 449 24.72 2018 3476 1410 40.56 table 2. rate of caesarean section over a decade from 2009 to 2018 primary/ repeat no. of cases % primary section 766 54.32 repeat section 644 45.67 total no. of cd 1410 100 table 3. incidence of primary / repeat caesarean sections type of cs no. of cases % primary emergency 551 39.07 primary elective 215 15.24 repeat emergency 248 17.58 repeat elective 396 28.08 table 4. incidence of primary and repeat emergency/elective caesarean section type of cs no. of cases % emergency cs 799 56.66 elective cs 611 43.23 total no. of cd 1410 100 table 5. incidence of emergency/elective cs indications no. of cases % foetal distress 203 36.84 cephalo-pelvic disproportion associated with medical disorders complicating pregnancy like pih, gdm, rh negative pregnancy, hypothyroidism, epilepsy, bronchial asthma, including failed induction. 201 36.47 big baby (birth weight 3.5 kg and more) 24 4.35 malpresentations 28 5.08 oligohydramnios 42 7.62 preterm 18 3.26 pelvic abnormalities 21 3.81 precious pregnancy 14 2.54 table 6. important indications for primary emergency caesarean sections performed in the year 2018 indications no. of cases % cephalo-pelvic disproportion associated with medical disorders complicating pregnancy like pih, gdm, rh negative pregnancy, hypothyroidism, epilepsy, bronchial asthma. 79 36.74 cephalo-pelvic disproportion 42 19.53 malpresentations 18 8.37 pelvic abnormalities 26 12.09 precious pregnancy 12 5.58 table 7. important indications for primary elective caesarean sections performed in the year 2018 indications no. of cases % scar tenderness 52 20.96 cephalo-pelvic disproportion associated with medical disorders like pih, gdm, hypothyroidism, rh negative pregnancy, epilepsy. 86 34.67 malpresentations 18 7.25 pelvic abnormalities 14 5.64 foetal distress 78 31.45 table 8. important indications for repeat emergency caesarean sections performed in the year 2018 indications no. of cases % cephalo-pelvic disproportion associated with medical disorders like pih, gdm, hypothyroidism, rh negative pregnancy, epilepsy, bronchial asthma 196 49.49 big baby (birth weight 3.5 kg and more) 46 11.61 malpresentations 20 5.05 past-dates 48 12.12 oligoamnios 46 11.61 iugr with oligoamnios 11 2.77 intrauterine growth retardation (iugr) 9 2.27 pelvic abnormalities 13 3.28 precious pregnancy 7 1.76 table 9. important indications for repeat elective caesarean sections performed in the year 2018 in our study the rates and indications of primary and repeat caesarean sections (cs) were analysed among 3476 live births during 2018 and present caesarean section rate was compared with 2009 and 2018 caesarean rates. in our study, the caesarean rate was 40.56%. there is an increase in the lscs rate over last decade from 22.23% in 2009, 24.72% in 2013, and 40.56% in 2018. an increase in primary and repeat caesarean rates has been 8reported by stavrou et al. in our study primary emergency rate is higher than repeat emergency. both multiple gestation and pre-eclampsia increased as indications for caesarean delivery at a much faster rate than the incidences of multiple 10 11,12 gestation and pre-eclampsia in the population are increasing. as in our study, the largest contributor to the primary caesarean rate was cephalopelvic disproportion associated with medical disorder complicating pregnancy like hypertension, gdm, hypothyroidism. indian national survey report also showed cephalo pelvic disproportion associated with medical disorders like pih, gdm, rh negative, bronchial asthma, hypothyroidism as the largest contribution in our study both big baby and iugr was also similar to the study by barber et al,.7 the higher contribution by foetal indications reects better neonatal care with improved survival of iugr babies. for the repeat caesarean, there is an increase in the 9number of cases with cpd and scar tenderness. foetal distress, especially its detection by continuous electronic foetal monitoring, more liberal use of caesarean section for breech presentation, abdominal delivery for growth-retarded fetus, delayed childbearing, increasing maternal body mass, multiple gestation, prematurity, and improved safety of caesarean section are commonly cited causes for caesarean section in our as well as many other studies. the limitation of this study is that this data represents one institution. conclusion the rate of caesarean section has increased from 2009 to 2018 with primary and repeat caesareans both showing an increase. in the primary caesarean section rate, indications like labour arrest disorders, cephalo pelvic disproportion, show an increase. in repeat caesarean sections, history of foetal distress and two or more previous sections contributed more than the scar tenderness. rising rate of caesarean section over one decade are justied and mainly attributed to frequent diagnosis of foetal distress on electronic foetal heart monitoring, identication of highrisk mother and frequently resorting to elective sections in high risk situations and precious pregnancies and institutional vaginal deliveries. references: [1] appropriate technology for birth. lancet 1985;2(8452):436-437. [2] lydon-rochelle m, holt vl, easterling tr, et al. risk of uterine rupture during labour among women with a prior caesarean delivery. n engl j med 2001;345:3-8. [3] taylor lk, simpson jm, roberts cl, et al. risk of complications in a second pregnancy following caesarean section in the rst pregnancy: a populationbased study. med j aust 2005;183(10):515-519. [4] smith gc, pell jp, cameron ad. risk of perinatal death associated with labour after previous caesarean delivery in uncomplicated term pregnancies. jama 2002;287(20):2684-2690. [5] tollånes mc. increased rate of caesarean sections--causes and consequences. tidsskr nor laegeforen 2009;129(13):1329-1331. [6] oladapo ot, sotunsa jo, sule-odu ao. the rise in caesarean birth rate in sagamu, nigeria: reection of changes in obstetrics practice. j obstet gynaecol 2004;24(4):377-381. [7] barber el, lundsberg ls, belanger k, et al. indications contributing to the increasing caesarean delivery rate. obstet gynecol 2011;118(1):29-38. [8] stavrou ep, ford jb, shand aw, et al. epidemiology and trends for caesarean section births in new south wales, australia: a population based study. bmc pregnancy childbirth 2011;11:8. [9] chong c, su ll, biswas a. changing trends of caesarean section births by the robson ten group classication in a tertiary teaching hospital. acta obstetrics gynecol scand 2012;91(12):1422-1427. [10] martin ja, sutton pd, ventura sj, et al. births: final data for 2008. natl vital stat rep 2010;59(1):1,3-71. [11] kuklina ev, ayala c, callaghan wm. hypertensive disorders and severe obstetric morbidity in the united states. obstet gynecol 2009;113(6):12991306. [12] kuklina ev, meikle sf, jamieson dj, et al. severe obstetric morbidity in the united states: 1998-2005. obstet gynecol 2009;113(2 pt 1):293-299. x 25gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra indications emergency elective emergency elective cephalo-pelvic disproportion associated with medical disorders like pih, gdm, hypothyroidism, rh negative pregnancy, epilepsy, bronchial asthma 36.47 36.47 34.67 49.49 pelvic abnormalities 3.891 12.09 5.64 3.28 foetal distress 36.84 31.45 precious pregnancy 2.54 5.58 1.76 big baby 4.35 11.61 malpresentations 5.08 8.37 7.25 5.05 scar tenderness 20.96 iugr 2.27 table 10. comparison of various indications for all types of cs age group no. of cases % 19 years and below 262 18.58 21-25 years 832 59 26-30 years 294 20.85 31-35 years 22 1.56 table 11. pattern of age distribution gestational age (weeks) no. of cases % 32-34 22 1.56 35-36 74 5.24 >37 972 68.93 >40 342 24.25 table 16. status of gestational age gravida no. of cases % primi gravida 584 41.41 ii gravida 643 45.60 iii gravida 146 10.35 iv gravida 30 2.12 v gravida and above 7 0.49 table 15. status of gravida registration status no. of cases % booked 1086 77.02 residential status no. of cases % urban 308 21.84 rural 1102 78.15 table 13. pattern of residential status economic status no. of cases % low income group 1282 90.92 middle income group 126 8.93 high income group 2 0.14 table 12. pattern of economics status unbooked 324 22.97 table 14. pattern of registration status 27.kiran l hunashikatti.cdr introduction hypertension is one of the leading causes of the global burden of disease. approximately 7.6 million deaths and 92 million disability adjusted life years worldwide were attributable to high blood pressure in 2001.(1)(2)the who rates hyperte nsion as one of the most important causes of premature death worldwide.(3)(2) there is strong positive and continuous correlation between bp and the risk of cardiovascular disease (myocardial infarction, heart failure), renal disease, stroke and mortality. this correlation is more related with systolic than diastolic blood pressure. hypertension is due to specic (4) causes in a small fraction of cases, but in the vast majority of individuals (≈90-95%), its etiology cannot be determined; therefore, the essential hypertension term is employed.(5–7) essential hypertension is currently understood as a multifactorial disease arising from the combined action of many genetic, environmental, and behavioral factors.(8–10). alterations in the intracellular free calcium regulation as well as disturbances of extracellular calcium homeostasis have been observed in patients with essential hypertension. (11) many researchers even recommend a regular consumption of the recommended daily levels of dietary calcium to combat with hypertensive disorders.(12)(13) in a country like india, people tend to have a diet rich in sodium and poor in potassium and calcium, this change in diet can change hypertension course and progress.(11) objectives 1. to study the levels of serum calcium in patients with essential hypertension. 2. to correlate the serum calcium levels with severity of disease. 3. to correlate the serum calcium levels in the patients with essential hypertension and in comparison with normo ten sive subjects. methodology the information for the study will be collected from patients admitted to s.nijalingappa medical college and hangal shri kumareshwar hospital and research center, bagalkot from april 2018 to august 2019. information will be collected through prepared proforma from each patient. qualifying patients will be undergoing detailed history, clinical examination and laboratory investigations and will be matched for sex and age.(11) included the patients who are diagnosed as essential hypertension and who are not on any medication ,age above 18 years, both the sexes. exclu ded patients with renal disease or on drugs that alter the calcium levels, already on anti hypertension drugs sample size this was calculated by using openepi, version 2, open source calculator ssmean software. sampling: it will be done by simple sd mean table.with condence levels of 95% and power of 80%.hence 41 cases will be included in group (stage i, stage ii ) and 82 will be included in controls.total sample size = 164.statistical analysis-mean +/sd²,statistical tests like students t test / comparative test.it was done using software spss version 17 . the patients who have been diagnosed as essential hypertension after excluding the secondary cause of hypertension will be taken the 5ml blood sample for the estimation of the serum calcium levels and correlating the severity of the levels with the disease results a study of s.total calcium was done in total 164 patient were, 82 cases are divided equally in 2 groups named stage 1 hypertensives and stage 2 hypertensives and 82 as controls or normotensive subjects. age distribution: * chi square test p<0.000, highly signicant the study of serum calcium level in essential hypertension in comparision with normotensive subjects original research paper dr samarat assistant professor,department of medicine,hsk,bagalkot x 17gjra global journal for research analysis general medicine hypertension is one of the leading causes of death and disability among adults all over the world and emerging health problem in india. alterations in the intracellular free calcium regulation as well as disturbances of extracellular calcium homeostasis have been observed in patients with essential hypertension. to study the levels of serum calcium in patients with primary hypertension and correlate the serum calcium levels with severity of disease. information for the study was collected from patients admitted to s.nijalingappa medical college and hangal shri kumareshwar hospital and research center, bagalkot from april 2018 to august 2019. patients met inclusion criteria were studied. a comparative study was done. serum calcium was done in total 164 patient which were divided equally in 3 groups stage i hypertensives, stage ii hypertensives, and controls, 41 patients in each groups of hypertension and 82 patients in control group, results were obtained compared. in patients of essential hypertension mean serum calcium levels were found to be low in comparison to normotensives. further, stage ii hypertensive patient has more reduced levels of serum calcium than stage i hence low serum calcium levels were associated as the severity of the disease increases. abstract keywords : hypertension, calcium, stage volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra stage total control stage i stage 2 <30 17 0 5 22 31-40 25 1 5 31 41-50 10 4 10 24 51-60 12 6 14 32 >60 18 12 25 55 total 82 23 59 164 dr kiran l hunashikatti* junior resident,department of medicine,hsk,bagalkot *corresponding author 18 x gjra global journal for research analysis table 2: distribution of cases by normal and low serum calcium in total cases of hypertension figure 2: graphical distribution of cases by normal and low serum calcium in total cases of hypertension table 3: distribution of cases by normal and low serum calcium in different stages of hyper tension figure 3: graphical distribution of cases by normal and low serum calcium in different stages of hypertension table 4: comparision of serum calcium levels between all hypertensive cases and controls table 5 : comparision of serum calcium between hypertension stage i, stage ii and control groups discussion considering the above study was conducted s.nijalinc ga ppa medical college and hangal shri kumare shwar hospital and research center, bagalkot over a period of 2 year in which a study of serum calcium was done in total 164 patients which were divided as 42 in each groups named stage i hypertensives, stage ii hypertensives, and controls or normotensives, 82 patients in one group and the results were obtained and compared. lian ia and asberg a(51), did a study which has concluded that unadjusted total cacium has better diagnostic accuracy than commonly used adjustment formulas, so clinician should stop use of this formulas. in our study corrected s.calcium levels were not obtained and compared. in our study mean age in hypertensive patients was 58.10 ± 14.34 and in controls it was 45.28 ± 16.81. there was signicant difference was obtained in relation to age in both the stage of hypertension but jorde.,et al.(52), has noticed that there was a signicant decrease in serum calcium with increasing age in men as age increases there is signicant decrease in s. calcium levels while in women it increases with age our study showed there was signicant difference in relation to gender (p value <0.02) in both stages.in our study while comparing s. caclium values in different groups with each other, the observation was that overall > 50 % of hypertensive cases has low s.calcium level. and number of cases with low s. calcium were more in stage ii than in stage i group. out of 82 controls only 3 has low s. calcium level. in total hypertensives cases mean ± sd of s. calcium was 8.23 ± 0.97 mg/dl while in normotensives cases it was 9.57 ± 0.64 mg/dl hence difference of 1.34 ± 0.33. g. ranjani(43) showed similar difference of s.calcium levels in which hypertensive patient has mean serum calcium of 8.9160 ± 0.62529 mg/dl and 9.7042 ± 0.79350 mg/dl in normotensives and difference was 0.7882 0.16821 mg/dl which were statistically signicant as in our study. k. sudhakar et al(47),in indian population, serum calcium levels were measured in 117 subjects and 77 rst degree relatives. serum calcium levels were decreased in hypertensive which were statistically signicant. strazzullo p et al.(53), showed there is elevated fractional urinary calcium excretion in cases of prinary hypertension and had obtained signicant reduction in total s. calcium levels, but no signicant reduction in ionized calcium levels. tillman dm and semple pf(45), showed that there is disturbance of calcium metabolism in hypertension, and although result of ionized calcium, total serum calcium concentration in the hypertensive was not signicant, there was signicant correlation between total calcium and systolic pressure wright gl, rankin was a study in rats showed a lower serum ionized and total serum calcium concentrations in spontaneously hypertensive rates. in all stage i hypertensive case mean ± sd of s. calcium was 8.29 ± 0.78 mg/dl while in stage ii hypertensive it was 8.21 ± 1.04 mg/dl ( p = 0.0001). this results were signicantly low than normotensives. but comparing both stage of hypertension mean was lower in stage ii but it is not signicantly low. so level of s.calcium has inverse relation with hypertension severity. kamlesh jha m(11) support this observation of inverse relation between calcium levels and severity of disease. in stage i hypertensives mean was 2.30 ± 0.072 mmol/l which was signicantly lower (p<.0001) than that of normotensives, but in comparison to stage ii hypertensives it was signicantly higher (p=.009) where mean serum calcium level was 2.25 ± 0.09 mmol/l there are difference studies which showed that calcium supplementation can alter outcome of disease or not. jolma at al, a study in rats showed increased dietary calcium reduce the development of hypertension there will be the improved vasorelaxation after calcium supplementation in no de cient hypertension. on human populations also several similar studies are done for dietry supplementation in volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra s. calcium groups total htn control < 8.5 61 3 64 ≥8.5 21 79 100 total 82 82 164 chi square test p<0.000, highly sig s.calcium (mg/dl) htn stage total stage-1 stage-2 < 8.5 15 46 61 ≥8.5 8 13 21 total 23 59 82 chi square test p<0.08, not signicant groups serum calcium (mg/dl) unpaired t testmean std. deviation hypertensive 8.23 0.97 p = 0.001* control 9.57 0.64 total 8.90 1.06 hypertension serum calcium kriskal wallis test mean std. deviation stage i 8.29 0.78 p = 0.001* stage ii 8.21 1.04 control 9.57 0.64 total 8.90 1.06 england(54), oregon(55), indiana(56) showed reduction in blood pressure. the ndings have been highly variable across various studies but the largest study (tohp) trials and hypertension prevention study found no signicant blood pressure lowering at 600mg per day. based on the data and experience available, calcium supplementation on increased dietary intake of calcium rich foods can be recommended nonspecically for prevention of hypertension, and in osteoporosis it will have. therefore, intake be maintained at 1.0 to 1.5gm per day is recommended through dietary intake on supplements for both adolescent and adults conclusion hypertensive cases are found to have low s. calcium level. cases with low s. calcium were more in stage ii than in stage i group. average serum calcium is low in hypertensive patients. and when comparing all cases of stage i and stage ii groups, average s. calcium is normal in stage i and low in stage ii. but in comparison to control group both stages has statistically signicant low s. calcium level. low serum calcium level in stage i hypertension and stage ii hypertension is statistically signicant in comparison to controls. when the cases with low s.calcium is compared in both stages, stage ii hypertensives patients has more reduction in s. calcium level than reduction in s. calcium in stage i hence there is inverse relation between blood pressure and serum calcium our study shows there is correlation between serum calcium levels and essential hypertension and also shows severity of disease and serum calcium has inverse relationship. references 1. anchala r, kannuri nk, pant h, khan h, franco oh, di angelantonio e, et al. hypertension in india. j hypertens [internet]. 2014;32(6):1170–7. available from:http://content.wkhealth.com/linkback/openurl?sid=wkptlp :landingp age &an=00004872-201406000-00003 2. kearney pm, whelton m, reynolds k, muntner p, whelton pk, he j. global burden of hypertension: analysis of worldwide data. lancet (london, england) [internet]. 2005 jan 15 [cited 2016 aug 30];365(9455):217–23. available from: http://www.thelancet.com/article/s0140673605177411/fulltext 3. bell k, twiggs j, olin br. hypertension� : the silent killer� : updated jnc-8 guideline recommendations. alabama pharm assoc. 2015;1–8. 4. carretero oa, oparil s. clinical cardiology�: new frontiers. am hear assoc. 2000;101(february):329–35. 5. messerli fh, williams b, ritz e. essential hypertension. 2007;370. 6. staessen ja, wang j , bianchi g, birkenhäger wh. essent ial hypertension.2003;361:1629–41. 7. hypertension e. clinical cardiology�: new frontiers. 2000;329–35. 8. meneton p, jeunemaitre x, wardener hede, macgregor ga. links between dietary salt intake , renal salt handling , blood pressure , and cardiovascular diseases. 2018;679–715. 9. takahashi h, yoshika m, komiyama y, nishimura m. the central mechanism underlying hypertension� : a review of the roles of sodium ions , epithelial sodium channels , the renin – angiotensin – aldosterone system , oxidative stress and endogenous digitalis in the brain. 2011;34(11):1147–60. available from: http://dx.doi.org/10.1038/hr.2011.105 10. blood r, to f. genetic and non-genetic basis of essential hypertension� :m maladaptation of human civilization to high salt intake. 1998; 11. jha k. serum calcium in essential hypertension and its co-relation with severity of the disease. adv stud biol. 2011;3(7):319–25. 12. peer reviewed title� : calcium and hypertension journal issue� : author� : martinez , christina , university of california , los angeles publication date� :permalink� : keywords� : calcium , hypertension abstract� : hypertension affects millions of americans . . 1998;4(2):2–6. 13. karen l. margolis, roberta m. ray, linda van horn et al. pressure� : the women ‘ s health initiative randomized trial. nih public access. 2009;52(5):847–55. 14. ranjani g. estimation of serum calcium and serum phosphorus levels in newly detected essential hypertensive patients. 2017;4(9):47–53. 15. article o, pawade yr, ghangale ss, apte ic, nagdeote an, warade jp. serum calcium�: can it be a diagnostic and prognostic marker in essential hypertension�? 2011;5(1):58–62. 16. sharma b, sarmah d. serum calcium and magnesium in patients with essential hypertension and their rst degree relatives. int j basic med sci pharm[internet]. 2012;2(2):66–9. available from: http://ijbmsp. org/index.p hp/ijbmsp/article/view/13 17. lian ia, åsberg a. should total calcium be adjusted for albumin� ? a retrospective observational study of laboratory data from central norway. 2018;1–7. 18. jorde r, sundsfjord j, fitzgerald p, bønaa kh, jorde r, sundsfjord j, et al. serum calcium and cardiovascular risk. 1999;484–90. 19. halhali a, diaz l, avila e, ariza ac, garabedian m, larrea f. decreased fractional urinary calcium excretion and serum 1,25-dihydroxyvitamin d and igf-i levels in preeclampsia. j steroid biochem mol biol. 2007 mar;103(3–5):803–6. 20. ferrier ke, muhlmann mh, baguet jp, cameron jd, jennings gl, dart am, et al. intensive cholesterol reduction lowers blood pressure and large artery stiffness in isolated systolic hypertension. j am coll cardiol. 2002 mar;39(6):1020–5. 21. stamler r, stamler j, riedlinger wf, algera g, roberts rh. weight and blood pressure. findings in hypertension screening of 1 million americans. jama.1978 oct;240(15):1607–10. 22. hill c, carolina n, hill c, carolina n. nih public access. 2010;124(5) x 19gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction ebstein's anomaly is rare congenital heart disease ,in which there is downward displacement and elongation of tricuspid valve with poor contractile right ventricle ,characterized by dysplastic abnormalities of both basal and free attachments of tricuspid valve leaets resulting in tricuspid regurgitation. it is frequently associated with intracardiac shunting , pulmonary hypertension,cardiac dysrhythmias, cyanosis, congestive heart failure and sudden collapse are the most common causes of death . the incidence in general population is 1:10,000 and no sex difference. case report: a 50 years old male patient moderately built presented with varicose veins of left leg. he had chest pain ,easy fatigability,exertional dyspnoea since 25years.he is the known case of ebstein's anomaly, which was diagnosed in jayadeva hospital 10 years back. on examination he had regular pulse rate of 92bpm and blood pressure of 100/60mm of hg with grade 2 clubbing. there was no signs of cardiac failure.on auscultation of heart sounds ,a pansystolic murmur was audible in mitral and tricuspid areas.2d echo shows ebsteins anomaly, severe tricuspid regurgitation, patent foramen ovale r>l shunt with ejection fraction 60% .ecg shows low voltage complexes and tall p waves in lead 2,avr,avf with rbbb . chest x ray shows cardiomegaly with ct ratio of 11:17, hes on tablet frusilac (frusemide 20mgand spirinoactone50mg) and tablet daion 500mg,routine bloodinvestigations were within normal limits , epidural anaesthesia was planned for trendelenberg surgery. tablet pantoprazole 40mg and tablet anxit 0.5mg was given the previous day and ranitidine 150mg,ttablet frusilac was continued on the day of surgery. iv line was secured with 18g canula ,antibiotic prophylaxis for infective endocarditis was given ( inj ampicilin 2gm and gentamycin 80mg),routine monitoring was done .in the sitting posture under aseptic precautions epidural anaesthesia achieved by injecting 10m lof 0.25% of bupivacaine with 75mcg fentanyl at l3-l4 epidural space with loss of resistance technique and hanging drop test, epidural catheter passed and drug is given. no intaoperatve fall in blood pressure . bp was maintained 100/60 mmof hg which was maintained with ephedrine infusion, haemodynamics were maintained, surgery was lasted for 44 minutes. post op analgesia given with 0.0625% of 8cc bupivacaine and advised for low molecular weight heparin and early ambulation was advised to prevent thromboembolic episodes. figure 1: clubbing is present grade 2. figure 2:ecg showing tall himalayan p wavesin lead ii,iii,avf with left axis deviation. figure 3:ecg showing rbbb with tall p waves. table 1: these are echo reports of the patient. figure 4:chest x ray pa view showing cardiomegaly, box shaped heart. discussion the prime consideration in managing our case was to maintain haemodynamic stability ,maintaining preload and afterload and prevention of supraventricular and ventricular arrhythmias during and in the post operative period .the case study shows the safety of low dose epidural with ebsteins anamoly with severe tricuspid regurgitation.the advantages of epidural anaesthesia are minimal intravascular volume anaesthetic management of a case of varicose veins surgery,in a patient with ebstein's anomaly. original research paper dr mahalakshmi m baddi anaesthesiology keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr nirmala b c* *corresponding author 2009 2014 2019 congenital heart disease congenital heart disease congenital heart disease situs solitus . situs solitus. situs solitus. ebstein's anamoly. ebsteins anamoly. ebsteins anamoly mild tricuspid regurgitation. ostium secundum asd r>l shunt severe tricuspid regurgitation ( grade 3). asd r>l shunt severe tricuspid regurgitation . pfo r>l shunt normal lv function(60%) normal lv function(65%) normal lv function(60%) 14 x gjra global journal for research analysis shi f t , decreased cathecolamine levels and good postoperative analgesia.low concentrationof 0.25% of bupivacaine has low cardiac and systemic toxicity. fentanyl 75mcg helps in attenuating the hormonal responses to stresses associated with surgery conclusion a thorough understanding of the pathophysiology of this condition is essential for the successful anaesthetic management in ebsteins anamoly and anaesthetic techniquechoosen should be individualized based on cardiac status , type of surgery, site of surgery and also the duration of surgery, our experience shows that , a low dose epidural should be considered as one of option available in ebsteins anomaly for lower limb surgeries. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 15gjra global journal for research analysis introduction: distal end of radius fractures are more common due to high energy trauma in young individuals and because of 1osteoporosis in older population . there are several treatment modalities for this fractures like cast immobilization, percutaneous k wires and external xation or volar locking plating. surgical xation enables patients to resume daily activity earlier and more independently. thus, there has been a trend toward more aggressive fracture xation in patients. closed or limited open reduction with percutaneous pinning and external xation, which has traditionally been used in unstable intra-articular fractures, does not always lead to anatomic reductions and can result in residual instability with secondary displacement. volar plates have gained popularity because of their low complication rates and high stability in (2,3,4)osteoporotic bone without joint distraction . in this study we try to compare overall outcome in patients treated with external xator and volar locking plate. material methods: we included 51 patients of having distal end of radius fracture those came to our institute between year 2015 to 2018. among them 26 were treated with percutaneous k wire xation and external xator, rest 25 were treated with open reduction and internal xation with volar locking plate. inclusion criteria for study is more than 18 years of age without any other skeletal injury. bilateral fracture and open fractures were excluded from the study. all the procedures done under regional or general anaesthesia at the same institute. external xator group: 2.5 mm of two shanz screws were inserted in second metacarpal and 3.5 mm of two shanz screws were inserted into radial shaft proximal to fracture. frame was constructed using connecting bars and clamps. reduction was checked under c arm. one k wire from radial styloid and other k wire from lunate fossa of radius inserted in a cross fashion. pin tract dressing and below elbow slab applied. volar plating group: skin incision longitudinally over exor carpi radialis. tendon sheath opened and tendon retracted radially. beneath if lies exor pollisis longus which is retracted ulnarlly to expose pronator quadratus and elevated from radial border to expose distal end of radius. fracture reduction done under image intensier and internal xation done using volar locking plate. plaster slab was applied till suture removal. follow up: thboth group discharged on 4 day and active nger moments are allowed. suture removal done after two weeks. active assisted wrist mobilization started in palting group. external xator was removed after 6 weeks followed by wrist mobilization exercise. further they were followed 1 month, 3 month, 6 month and 1 year clinically as well as radiologically. (1)radiological criteria for acceptable reduction is 1. radial inclination of >15degree. 2. radial shortening of <5 mm compared to the contralateral side. 3. sagittal tilt between 15 degree dorsal and 20 degree volar tilt. 4. intra-articular step-off of <2 mm. evaluation of outcome: radiologically we use sarmiento modication of lindstrom (5)criteria . comperative study between volar locking plate and external fixator in distal end of radius fracture original research paper ejajahmed ansari* senior resident, department of orthopedics, s c l general hospital, ahmedabad *corresponding author orthopedics objective: to compare the function out come of distal radius fracture in external xator and voalr locking plate. material and method: 25 pateint treated with volar locking plate and 26 were treated with external xator.both the group were followed up for a period of 1 year. radiologically evaluation done using sarmiento modication of lindstrom criteria and functional out come as prwe score. results: early mobilization and return to activity is an advantage in plating group but in long term almost equal function results external xator group (84%) and plating group (92%) are seen. abstract keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra bhargav parmar resident, department of orthopedics, s c l general hospital, ahmedabad harshal damor assistant professor, department of orthopedics, s c l general hospital, ahmedabad residual deformity loss of palmer tilt {degrees} residual shortening {mm} loss of radial deviation {degrees} excellent no or signicant 00 <3mm <50 good slight 1o to 10o 3 to 6 mm 50 to 90 fair moderate 110 to 140 7 to 11mm 100 to 140 poor severe at least 150 at least 12mm >140 2 x gjra global journal for research analysis wrist range of motion was measured in exion, extension, pronation, supination, ulnar deviation & radial deviation and was compared with uninjured limb. the overall function of the upper limb was assesses using the gartland & werley score, & patient rated wrist evaluation score (prwe). external xator group: plating group : results: the result of volar locking plate is summarized below. functional range of motion of injured wrist after nal follow up is as below: radiological outcome: over all functional outcome according to garland and werney scoring system was: discussion: we use a o classication for our study. among the external xator group 20 patients of type a and 6 patients were type c. in volar plating group 6 were type a , 11 were type b and 8 were type c. no infection was found in any of our patients. among external xator group, 3 patients had residual dorsal tilt and 3 had grip weakness. among plating group 2 patients had residual dorsal tilt and one patient had prominent ulnar styloid process. after one year of followup, we found almost equal wrist range of motion in both groups. radiologically we found almost equal results except for loss of palmer tilt in external xator group. 3 patients had residual dorsal tilt because of comminution and collapse. the advantages of open reduction and internal xation include direct visualization and manipulation of the fracture fragments, stable rigid xation, and the possibility of immediate postoperative motion. the subchondral placement of smooth pegs is useful to buttress small articular fragments and successful ly control shortening and angular displacement, especially in osteoporotic bone. some studies suggested that crps i is more likely to occur after ef than after other surgical procedures. in the current study, there was no signicant difference in the occurrence of crps i between the vp and ef groups, which is consistent with other studies.27 this suggests that the high incidence of crps i after ef in the literature may be related to the recruitment of subjects with more severe drfs or excessive (6,7,8)distraction during ef . in the present study, 92 % of volar plating patients and 84% of external xator group patient had an excellent to good result. (10)gradl et al reported 100 and 97.5 % with good or excellent (9)results in these two groups, respectively. rozental et al reported similar ndings on exeternal xator and plating group, that both groups doing equally well by 6 months. recently randomized trials have reported rapid functional recovery after volar plating in the early period after surgery. however, at 1 year, there were no signicant differences between the volar locking plate and external xator groups (13-17)based on objective and subjective functional assessments . in our study we found plating group having slightly superiority in terms of early mobilization and return to activity, however after 1 year there is no signicant difference between these two groups. references 1. rajeev shukla,ravi kant jain,neeraj k. sharma, ravindra kumar,external xation versus volar locking plate for displaced intraarticular distal radius fractures: a prospective randomized comparative study of the functional outcomes, j orthopaed traumatol (2014) 15:265–270. 2. orbay jl, touhami a. current concepts in volar xed-angle xation of unstable distal radius fractures. clin orthop relat res. 2006;(445):58e67. 3. fernandez dl. should anatomic reduction be pursued in distal radial fractures? j hand surg br. 2000;25(6):523e527. 4. kawaguchi s, sawada k, nabeta y, et al. recurrent dorsal angulation of the distal radius fracture during dynamic external xation. j hand surg am. 1998;23(5):920e925. 5. sarmiento a, pratt gw, berry nc, sinclair wf .colle's fractures, functional bracing in supination. j bone joint surgery am 1975;57:311-7 6. suso s, combalia a, segur jm, et al. comminuted intra-articular fractures of the distal end of the radius treated with the hoffmann external xator. j trauma. 1993;35(1):61e66. 7. hegeman jh, oskam j, vierhout pa, et al. external xation for unstable intraarticular distal radial fractures in women older than 55 years: acceptable functional end results in the majority of the patients despite signicant secondary displacement. injury. 2005;36(2):339e344. 8. zollinger pe, kreis rw, van der meulen hg, et al. no higher risk of crps after external xation of distal radial fractures: subgroup analysis under volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra palmer exion dorsi exion prona tion supin ation radial deviation ulnar deviation plating group average (degrees) 75 80 87 81 11 25 external xator group average (degrees) 74 78 75 80 14 30 loss of radial inclination (degrees) no. of patients[%] volar plating no of patients [%] external xator <5 56% 56 % 5-9 32% 40% 10-14 12% 4% >14 0 0 radial shortening in mm no of patients volar plating no of patients external xator <03 72% 81% 03-06 28% 15% 07-11 0 4% >11 0 0 loss of palmer tilt [degrees] no. of patients volar plating no of patients external xator 0 24% 28% 1-10 40% 40% 11-14 36% 20% at least 15 0 12% g&w score number of patients volar plating group number of patients external xator group excellent 0-2 21( 84%) 20(77%) good 3-8 2(8%) 2(7%) fair 9-20 2(8%) 3(12%) poor >20 0 1(4%) x 3gjra global journal for research analysis randomised vitamin c prophylaxis. open orthop j.2010;(4):71e75. 9. rozental td, blazar pe, franko oi, et al. functional outcomes for unstable distal radial fractures treated with open reduction and internal xation or closed reduction and percutaneous xation: a prospective randomized trial. j bone joint surg am. 2009;91(8):1837e1846. 10. gradl g, gradl g, wendt m, mittlmeier t, kundt g, jupiter jb (2013) nonbridging external xation employing multiplanar k-wires versus volar locked plating for dorsally displaced fractures of the distal radius. arch orthop trauma surg 133(5):595–602 11. margaliot z, haase sc, kotsis sv, kim hm, chung kc (2005) a meta-analysis of outcomes of external xation versus plate osteosynthesis for unstable distal radius fractures. j hand surg am 30:1185–1199 12. westphal t, piatek s, schubert s, winckler s (2005) outcome after surgery of distal radius fractures: no differences between external xation and orif. arch orthop trauma surg 125: 507–514 13. wolfe sw (2009) patterns and treatment of distal radius fractures.in: proceedings of the aaos/assh update on the painful and injured wrist. may 29–30, rosemont, il, p 66 14. grewal r, macdermid jc, king jc, faber kj (2011) open reduction internal xation versus percutaneous pinning with external xation of distal radius fractures: a prospective, randomized clinical trial. j hand surg 36:1899–1906 15. kamano m, honda y, kazuki k, yasuda m (2002) palmar plating for dorsally displaced fractures of the distal radius. clin orthop relat res 397:403–408 16. landgren m, jerrhag d, ta¨gil m, kopylov p, geijer m, abramo a (2011) external or internal xation in the treatment of nonreducible distal radial fractures? a 5-year follow-up of a randomized study involving 50 patients. acta orthop 82:610–613 17. wilcke mk, abbaszadegan h, adolphson py (2011) wrist function recovers more rapidly after volar locked plating than after external xation but the outcomes are similar after 1 year.acta orthop 82:76–81 volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 4 x gjra global journal for research analysis introduction: ahara plays an important role in maintaining health .the food taken in appropriate quantity, helps individual in bringing out strength, complexion, happiness and longevity without 1disturbing the equilibrium of dhatus and dosas of the body. the 12 aahar varga described in charak namely shook, sahmi, mamsa, shak, phala, harita, madya, jala, gorasa, ikshu, krutanna, aaharupyogi, varga. as per modern classicationenergy rich foods, body building foods, productive foods etc. the classication of ahara varga in charak samhita is near to balanced diet. shak varga: śākavarga is the sanskrit name for a group of medicinal plants, classied as “potherbs/vegetables”, of which the leaves, stems and fruits are used. it was and originally composed by caraka in his carakasaṃhitā sūtrasthāna xxvii. the collection of herbs named śākavarga is one of the seven groups that were classied based on its dietic value. in ayurveda the aahar is also classied as satvik, rajsik, tamsik. the different groups of foods listed below may be broadly classied under three heads from the nutritional point of view. 1. energy yielding foods; 2. body building foods and 3. protective foods. aim and objectives: to study classication of aahar (diet) according to ayurveda and modern science. material & methods: charak has classied anna (food) into 12 groups. 1. shuka dhanya: corns with bristles 2. shami shanya: pulses 3. mamsa: meat 4. shaak: vegetables 5. phala: fruits 6. harit: green and salads 7. madya: wines 8. ambu: water 9. gorasa: milk & milk products 10. ikshu vikar: sugar cane products 11. krutanna: food preparation, recipes 12. ahar upyogi: aaccessory food articles shook dhanya and shimbi dhanya comes under category of dhanya varga. 1) shukashali, shastik, vreehi, shyamak, yava, godhuma 2) sahmi green gram –mudga masha, raja masha, kulatha, makuska, chanaka sesame seed (tila), shimbi adhaki 3) mamsa varga the group of animal whose meat is commonly used in food. prasaha, bhumishaya, anupa, vaarishaya, varichara. jangal, viskira, pratuda 4) shaaka varga vegetable group patha, shusha, shati, vastuka, sunishannaka, kakmacli, rajshavak 5) phala varga raisin, khajura (dates), phalgu, ripe aruka, kapitta, amra (mango) jambu, amla, bhibitaka, dadim etc. 6) harita varga adrak (ginger), jambira, mula, tulasi, yavani, gandir, dhanaya, palandu. 7) madya varga jagala, sharakara, pakwa rasa, gaud, madavasav, 8) jala varga (water)9) gorasa varga milk, and milk products dadhi, takra, gogruta, godugdha, buffalo milk , camel milk, ekshapha, goat, human milk etc. 10) ikshu varga sngar cane , madhu (guda) 11) krutanna varga cooked food preparations. peya, manda, vilepi etc. juices and soups. 12) aahar upyogi varga: it contains different types of oils, condiments, spices and different types of salts. classication :energy rich foods: major nutrients carbohydrates and fats. food sources are cereals, oil, nuts, sugar and sugar products. body building foods: major nutrient protein food sources are meat, sh, poultry, legumes and pulses, milk and milk products, nuts and oil seeds. productive foods: major nutrients vitamins and minerals food sources are green leafy vegetables, other vegetables and fruits, milk, eggs, am food for planning of adequate diet, food have been conventionally grouped as cereals, millets, pulses, vegetables and fruits, milk and milk products, eggs, meat, sh, oil and fats and nuts, oil seeds and sugars. classification of aahar (diet) according to ayurveda and modern science original research paper dr. arbune anadrao b. principal, hod & prof. sharer kriya dept, riarch, mayani. ayurveda ahara kalpana is an important factor in the eld of prevention of health; where different dravyas are used for maintaining and sustain the living body. concept of ahara kalpana is more important to achieve the status of complete health which is said as prakritisthapana (establishment of original health status) by acharya charaka. acharya charaka has narrated many important principles related to the health. ahara is the one of the prime factors described in ayurveda for healthy living. the 12 aahar varga described in charak namely shook, sahmi, mamsa, shak, phala, harita, madya, jala, gorasa, ikshu, krutanna, aaharupyogi, varga. as per modern classicationenergy rich foods, body building foods, productive foods etc. abstract keywords : aahar, diet, classication volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 42 x gjra global journal for research analysis 1) cereals, grains and cereals products : this group includes cereals, such as whole wheat jowar, bajara, ragi, maize, rice, oats. the cervical products such as wheat our, rened wheat our, other cereals our etc. bread (white and red), rice akes, pastas, noodles are also included in this group. the major nutrients provided are energy, protein, invisible fats viamin b1, b2, folic acid, iron, calcium and ber. 2) pulses and legumes : this group includes all the whole pulses and dhals and other legumes. pulses and legumes included in this group are red gram, bengal gram, black gram, lentils, coupea peas, rajmah, soyabean etc. the major nutrients provided are protein energy, invisible fats vitamins, b1, b2, folic acid, iron, calcium ber. 3) milk and milk products : all type of milk and milk products such as cheese, yoghurt, cottage cheese (paneer) under this group. the major nutrients provided are calcium, protein, invisible fats, vitamin a, b2, b12. 4) meat, fish and poultry: all types of meat such as chicken, lamb, poultry, such as eggs, sh and sea foods are in this group. the major nutrients provided are protein, invisible fats, vitamin b2, and b12, vitamin a, and calcium. 5) fruits and vegetable: all fruits like apple, banana, apricots, dates, grapes, oranges, melons, peaches, pineapple, raisins and strawberries and vegetables are included in this group. the yellow orange fruits and vegetables like mango, carrot pumpkin, dark green leafy vegetables like amaranth, spinach, drumstick, leaves, mustard leaves, fenugreek leaves are included in this group. also other vegetables like brinjal, ladies nger, capsicum, beans, drumsticks, broccoli, potatoes, tomatoes etc are included in this group. the major nutrients present are carotenoids, vitamins, ber, invisible fats, iron, calcium, folic acid and carbohydrates. conclusion: 1. the classication of ahara varga in charak samhita is near to balanced diet. 2. these vargas are the rich source of carbohydrate, protein, fat, vitamins and minerals in body. 3. modern classication is according to energy rich, body building and productive foods. references: 1. le:///c:/documents%20and% 20settings/dr.% 20sanjay/my%20 docu ments/downloads/ayurpharm2102.pdf 2. charaka. charaka samhita (ayurveda dipika commentary of chakrapanidatta). jadavaji trikamji acharya, editor. 7th ed. varanasi: chaukhambha surbharati prakashan; 2008. cha su 26. 3. acharya vidyadhar shukla, prof. ravi dutt tripathi, “charak samhita”, vaidya manorama hindi commentary, sutra sthan 5/8. 4. http://ijaar.in/posts/images/ upload/ijaar_ volume_iii__ issue_v_ nov_ dec_2017_935_944.pdf 5. https://www.slideshare.net/drnikhila/nutri t ion-ayurveda-part-1classication-of-fooda 6. https://easyayurveda.com/2014/08/08/classication-of-foods-and-drinkscharaka-sahmita-sutrasthana-27/ volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 43gjra global journal for research analysis introduction breast diseases are increasing in incidence and prevalence due to the advances in diagnostic techniques and chronicity of the disease. breast lumps unless and other wise proved as benign are a nightmare for both the patients and the surgeons. therefore proper easy and early detection of malignancies of the breast is the need of the hour. since the incidence of carcinoma breast amongst younger women is in an increasing trend especially less than 40 ,child bearing productive age groups, the diagnosis of carcinoma breast plays a major role even with respect to social and national importance. a triple test of clinical examination, mammogram and ultrasound study of breast was being carried out with a fair amount of success rates. but there are not cases that have not been missed by this triple test. so in order to improve our diagnostic standards, from non invasive to invasive mode of investigation but yet a simple and outpatient basis procedure was incorporated in to this system of screening test . this is now to be called as modied triple test. aims and objectives earlier detection of malignancy in breasts with the aid of modied triple test which includes clinical examination, usg breast, fnac of breast lump. materials and methods a prospective study of 103 patients were included in the study. a proper ethical clearance and informed written consent was obtained from the individuals subjected to the study. inclusion criteria included female > 20yrs and willing for lump excision. exclusion criteria included females<20 yrs, males, advanced diseases of breast, patients not willing for lump excision results patients were clinically radiologically and by aspiration cytology from breast lump were evaluated. they were taken up for excision and biopsy surgery. postoperatively hpe report was compared with the preoperative diagnosis and the effectiveness of modied triple test was studied. fig 1 surgical method fig 2 hpe report table 1 hpe report table 2 axillary lymphnodes in relation with hpe report p value-0.001 table 3 fnac report in relation with hpe report a study on early detection of breast lumps malignancies by modified triple tests original research paper general surgery introduction: breast diseases are at a rising trend in recent years among young women. many cancers are diagnosed at advanced stages. carcinoma breast that too invasive ductal variety is the most commonest of all. aims and objectives: earlier detection of malignancy in breasts with the aid of modied triple test which includes clinical examination usg breast, fnac of breast lump. materials and methods: a prospective study of 103 patients were included in the study. inclusion criteriafemale > 20yrs and willing for lump excision. exclusion criteriafemales <20 yrs,males, advanced diseases of breast, patients not willing for lump excision. results: based on the studies 17 /20 of nipple discharge cases ,30/50 painless lumps,19/21 axillary lymphnode cases,33/39 hard lumps were malignant. sensitivity of usg ,clinical examination, fnac,mtt 86.8% ,86.34% 92% ,97.36% respectively. conclusion: modied triple test is far better in early detection of breast malignancies than individual tests abstract keywords : breast, clinical examination, fnac, malignancy, ultrasonography volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. upendra kumar rajendra institute of medical sciences ranchi, jharkhand -834009 dr. milandeep* guru gobind singh medical college, faridkot, punjab-151203 *corresponding author dr. gajendra pandit rajendra institute of medical sciences ranchi, jharkhand -834009 prof. dr. sudhir khichy guru gobind singh medical college, faridkot, punjab-151203 prof. dr. r. s. sharma rajendra institute of medical sciences ranchi, jharkhand -834009 hpe-benign hpe-malignant no.of patients 65 38 percentage 38 36.9% hpe-benign hpe-malignant axillary lymphnode + 2 19 axillary lymphnode 63 19 hpebenign hpemalignant fnac + for malignancy 0 33 52 x gjra global journal for research analysis p value -0.001 table 4 usg report in relation with hpe report p value -0.001 table 6 mtt results p value -0.001 table 7 mtt statistics table 5 comparison of sensitivity and specicity of each of the tests with all in combination discussion based on the above results it can be concluded that that a combination of different types of evaluating methods confers a greater advantage in terms of diagnostic accuracy and saves valuable time with respect ot commencement of treatment for malignant cases. clinical criteria suggestive of malignancy such as painless lump, hardness of lump, nipple retraction, xed axillary node involvement, peau-d-orange appearance of skin xity of the lump can not be taken up for conrmation of malignancy. similarly breast lumps assessed by usg in the grades of birads are also at risk of being missed for malignancy when done alone. more invasive procedure like fnac can be relied upon with comparative credibility but exceptions in that too are there at times. a combination of all factors in the diagnosis of a cancer breast is more reliable since the results are commanding its accuracy. the triple test was initially described in the mid-1970s, by johansen c. as the evaluation of palpable breast masses by physical examination, mammography, and fnac. the triple test has proved a reliable tool for the accurate diagnosis of palpable breast masses, due to its technical simplicity, and resulted in substantially reduced expense and morbidity compared with open surgical biopsy.[5] due to the reduced sensitivity and specicity of lesion detection by mammography in young women under 40 and the usefulness of sonography in this group of patients, researchers dealing with women under 40 combined sonography with mammography to the scoring system and the modied tts was introduced which is an integration of clinical breast examination, sonography and fna.[10] the tts reliably guides evaluation and treatment of breast lesions. lesions scoring 3 or 4 are always benign. lesions with scores ≥6 are malignant and should be treated accordingly. conrmatory biopsy is required only for the lesions that receive a tts of 5. conclusion at present the modied triple test is a well developed tool that can , with fair amount of success be used for early detection of carcinoma breast at younger age groups their by avoiding life long morbidity and mortality. this eld is evolving day by day and the means to detect wide spread metastasis cannot be picked up by this test. there are many hormonal and receptor assays that are creeping into practice to references [1]. chopra r. the indian scene. j clin oncol. 2001;19:106s–11. [pubmed] [2]. pant i, singh pk, singh sn, agarwal a, singh nb. cyto morphological study of palpable breast lesion and histopathologic correlation. j cytol. 2003;20:129–32. [3]. meena sp, hemrajani dk, joshi n. a comparative and evaluative study of cytological and histological grading system prole in malignant neoplasm of breast — an important prognostic factor. indian j pathol microbiol. 2006;49:199–202. [4]. lester sc. the breast. in: kumar v, abbas ak, aster jc, fausto n, editors. robins and cotran pathologic basis of disease. 8th ed. vol. 23. philadelphia: saunders an imprint of elsevier; 2010. pp. 1068–9. [5]. morris a, pommier rf, schmidt wa, shih rl, alexander pw, vetto jt. accurate evaluation of palpable breast masses by the triple test score. arch surg. 1998;133:930–4. [pubmed] [6]. rubin m, horiuchi k, joy n, haun w, read r, ratzer e, et al. use of ne needle aspiration for solid breast lesions is accurate and cost-effective. am j surg. 1997;174:694–6. [pubmed] [7]. somers rg, sandler gl, kaplan mj, najjar d, anderson av, cohen mh. palpable abnormalities of the breast not requiring excisional biopsy. surg gynecol obstet. 1992;175:325–8. [pubmed] [8]. morris kt, pommier rf, morris a, schmidt wa, beagle g, alexander pw, et al. usefulness of the triple test score for palpable breast masses. arch surg. 2001;136:1008–12. [pubmed] [9]. tabbara so, frost ar, stoler mh, sneige n, sidawy mk. changing trends in breast ne-needle aspiration: results of the papanicolaou society of cytopathology survey. diagn cytopathol. 2000;22:126–30. [pubmed] [10]. ghafouri a, attarian sh, tavangar m, sedighi n. modied triple test score (mtts) for evaluation of palpable breast masses in women under age 40. med j islam repub iran. 2006;20:115–8. [11]. vetto j, pommier r, schmidt w, wachtel m, dubois p, jones m, et al. use of the �triple test� for palpable breast lesions yields high diagnostic accuracy and cost savings. am j surg. 1995;169:519–22. [12]. hermansen c, skovgaard poulsen h, jensen j, langfeldt b, steenskov v, frederiksen p, et al. diagnostic reliability of combined physical examination, mammography, and ne-needle puncture (�tripletest�) in breast tumors. a prospective study. cancer. 1987;60:1866–71. [13]. choi yd, choi yh, lee jh, nam jh, juhng sw, choi c. analysis of ne needle aspiration cytology of the breast: a review of 1,297 cases and correlation with histologic diagnoses. acta cytol. 2004;48:801–6. [pubmed] [14]. park ia, ham ek. fine needle aspiration cytology of palpable breast lesions. histologic subtype in false negative cases. acta cytol. 1997;41:1131–8. [pubmed] [15]. mohammed az, edino st, ochicha o, alhassan su. value of ne needle aspiration biopsy in preoperative diagnosis of palpable breast lumps in resource-poor countries: a nigerian experience. ann afr med. 2005;4:19–22. [16]. kim a, lee j, choi js, won nh, koo bh. fine needle aspiration cytology of the breast. experience at an outpatient breast clinic. acta cytol. 2000;44:361–7. [pubmed] [17]. sankaye sb, dongre sd. cytological study of palpable breast lumps presenting in an indian rural setup. indian j med paediatr oncol. 2014;35:159–64. [pmc free article] volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra fnac – for malignancy 59 1 inconclusive 6 2 hpe-benign hpe-malignant usg + for malignancy 0 33 usg – for malignancy 60 0 inconclusive 5 5 mtt hpe malignant hpe benign malignant 37 0 benign 1 65 sensitivity 97.36% specificity 100% positive predictive value 100% negative predictive value 98.48% test sensit ivity specifi city +predicit ve value -prediciti ve value clinical examination 86.34% 91% 85% 84.42% usg breast 86.84% 100% 100% 92.86% fnac 92.10% 100% 100% 95.58% modified triple test 97.36% 100% 100% 98.48% x 53gjra global journal for research analysis introduction epilepsy has been dened as a brain disorder characterised by predisposition to generate recurrent seizures and it is associated with negative neurobiological, cognition, social and also psychological consequences. earlier studies on epileptic patients have addressed psychosis, cognitive decline, sexual dysfunction, dysthymia are common among them. studies done previously on epileptic patients have addressed that depression are much more common among people with complex partial seizures. the current study has been planned to focus on the generalized tonic clonic seizures-gtcs sub type which is much more common than other types of seizure. scope of this study: hence the study here is planned to assess depression in patients with gtcs and relating it with seizure related and socio demographic variables,and assessing the quality of life. definition of seizure: an abnormal paroxysmal electrical discharge which is due to the hyperactivity of the cerebral neurons and thereby causing sudden alteration in neurologic function. principles and mechanisms of seizures: the normal brain can develop seizures by electrical stimulation, excitatory drugs, metabolic alterations as well as changes in neurotransmitter substances. these changes are reected in nearby environment in brain which in turn causes an aggregate of neurons are hyperexcitable and as a result abnormal electrical discharges are formed. these abnormal electrical discharges are either within specic brain region which manifest as focal seizures or may be spreading to whole of the brain as in the case of generalized seizures. generalized seizures: 6 types of generalized seizures are present. definition of gtcs : it is generalized behaviourally and electrographically from the onset of seizures. the features include a sequential motor events that evolves progressively from tonic muscular contraction to clonic jerky movements, always associated with loss of consciousness from seizures onset. clinical manifestations of gtcs: 1. premonitory signs and symptoms. 2. immediate pretonic – clonic 3. tonic-clonic 4. immediate postictal 5. post ictal recovery psychiatric aspects of gtcs : psychiatric co-morbidity is frequently more common among people with epilepsy than the general population owing to three major factors, include the manifestations of the diseases and its implication in day to day life, abnormality in neuro transmitter function and the environment and the social stigma. classification of psychiatric disorders in relation to time of onset of seizures: preictalprodromal states characterised by irritability, mood changes, fatigue. ictal –aura, automatism, ictal depression, anxiety, panic attacks. postictalpsycosis , delirum and depression inter ictal manifestation of psychiatric disorder may include: 1. affective disorder 2. personality disorder 3. schizophrenia like psychosis 4. behavioural disorder 5. dementia 6. suicide &delibrateself harm 7. dissociative seizures. prognosis of gtcs : elwes et al reported that the remission rate in gtcs is greatest among epilepsy compare to other seizure subtypes when it is being diagnosed before the age 10years. epidemiology of depression in epilepsy: the prevalence of psychiatric co-morbidity among epileptic patients ranges from 29% to about 58%. in patients with good control of seizures with treatment the prevalence of depression ranges between 10-20%. the risk of depression increased to 60% prevalence in those with recurrent seizures. types of depression in epilepsy: 1. major depressive disorder 2. interictal dysphoric disorder 3. dysthymia effect of depression in epilepsy: 1. poor drug adherance to treatment. 2. lower productivity. 3. lower productivity tend to result in disability and hence lower employment rate. 4. social withdrawal. assessment of depression in patients with generalized tonicclonic seizures original research paper dr. a.geetha md.(psy). asst. prof. govt. kap viswanathan medical college. x 47gjra global journal for research analysis psychiatry depression is the most common psychiatric comorbidity in epilepsy, it may mimic primary depressive disorders, but in a signicant percentage of patients, depression presents with atypical pleomorphic characteristics. diagnosis cannot be established by the sole use of screening self-rating scales, but with additional, in-depth evaluation. timely recognition and treatment of depression is of the essence in epilepsy management. neurologist should be well trained to provide psychopharmacologic treatment for major depressive episodes, dysthymic disorders, and minor depression as they are the health care provider to initiate treatment. however, patients with suicidal ideation, psychotic symptoms, or bipolar disorders should be referred immediately to the care of a psychiatrist. abstract keywords : generalised tonic clonic seizures, depression, quality of life volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. m. rajasundari* md.(psy).dch. asst.prof. madurai medical college. *corresponding author 48 x gjra global journal for research analysis 5. co-morbid depression worsen memory, cognition. 6. depression perse worsen sleep architecture thereby further provocating seizures. 7. increased suicidality rate. 8. further worsening of seizure the risk being six fold. risk factors for depression in people with epilepsy 1. symptomatic focal epilepsy. 2. young age of onset of seizures. 3. poor social support 4. patients who are on poly drug therapy 5. mesial temporal structural abnormality 6. patients who had poor seizures control. (1 or more seizures in past 3-6 months) 7. psychosocial burden of epilepsy due to unemployment. 8. restrictions in employment and driving / sports. 9. unmarried / living alone 10. dependence on others due to injuries sustained previously and loss of job. aim: to assess depression in patients with gtcs and its relation with seizure disorder. assessment is to be done in patients who are attending epileptic clinic in the department of neurology in govt. rajaji hospital. objectives: 1. to assess depression in patients with gtcs and to study relationship with seizures. 2. to study the association between seizure frequency, duration of illness, age of onset of seizure and severity of depression. 3. to study the association of depression with socio demographic variables in patients with gtcs. 4. to assess the quality of life in epileptic patients suffering with depression. inclusion criteria: 1. male & female patients attending epileptic clinic with a denitive diagnosis of gtcs based on clinical ndings,eeg and neuroimaging. 2. participants between 20 and 45 years of age. 3. patients willing to provide informed consent for the interview and assessment. 4. patients whose last duration of seizure was more than 7 days. exclusion criteria: 1. patients not willing to provide informed consent for the interview and assessment. 2. patients already diagnosed to have psychiatric illness before the onset of seizures. 3. patients with other chronic physical illness substance abuse or dependence/other neurological disorders. duration of study: 6 months materials and methodology 1. patients who are on follow up in epilepsy clinic in department of neurology will be considered for study. 2. sample size consists of 120 gtcs patients. 3. selection will be done by random sampling method. 4. patients satisfying the inclusion and exclusion criteria will be chosen for undergoing study. 5. after getting informed consent, patients will be interviewed and details will be collected as per proforma. 6. thorough physical examination and clinical psychiatric evaluation done. 7. based on symptomatology and examination patients are administered the following scales; mini international neuropsychiatric interview. hospital anxiety and depression scale hamilton depression rating scale quality of life in epilepsy 31 (qolie31) kuppuswamy's scale for socio economic status 8. after which depression are correlated with seizure related and socio-demographic variables 't' test results based on sex it has been found that the mean age of onset of seizure in males is 26.03 and in female it is 21.00 p = 0.005. here the difference in statistically signicant. ‘t' test results based on positive family history in patients who had a positive family history of psychiatric illness scores high mean value on hads ,ham d,qol when compared to other who had a negative family history. p value is statistically signicant. hence patients with positive family history had a high hads score, more depression and poor quality of life. 't' test results based on drug therapy from the above table the people who were on poly drug therapy had higher mean scores on hads and ham-d and lower scores on qol. here p value is < 0.05 which is signicant. hence patients on poly drug therapy had more depression and poor qol. one way anova results based on seizure severity volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra s. no factors mean sd 't' value 'p' value 1 age of onset of seizure 1.male 64 26.03 9.749 2.855 .005 sig 2. female 56 21.00 9.525 total 120 23.68 9.930 s.no. factors mean sd t value p value 1 hads 1 present 41 12.56 4.691 2 absent 79 9.72 5.260 total 120 2.907 0.004 sig 2 ham d 1 present 41 12.78 6.609 2 absent 79 5.84 4.678 total 120 6.669 .000 sig. 3 qoli over all score 1 present 41 46.4035 17.21041 2 absent 79 62.5934 12.83315 total 120 -5.814 .000 sig. s.no. factors mean sd 't' value 'p' value 1 hads 1 mono 91 10.18 5.310 -1.936 .012 sig 2 poly 29 12.31 4.699 2 ham d 1 mono 91 6.81 5.627 -4.637 .000 sig 2 poly 29 12.59 6.473 3 qolie over all score 1 mono 91 60.5225 13.77578 4.418 .000 sig 2 poly 29 46.2027 19.06713 s. no. factors mean sd 't' value 'p' value 1 hads 6.239 .003 sig 1 mild 86 9.71 5.099 from the above table it was found that people who had frequent seizures scored signicantly on hads, hamd and qol. hence in patients who had frequent seizures the prevalence of depression is higher who also had a poor qol. one way anova results based on quality of life from the table it was found that people without illness had high scores on qol. people with mild, moderate and severe depression had poor qol. f ratio here is statistically signicant at 0.05 level. discussion out of the study group, majority of the participants (32.5%) were in the age group 26-30 years. 53.3% of the study group was male population and the remaining was females. patients adhered to regular treatments were classied as good and irregular treatment within past 1month were classied as poor compliance. in this study the prevalence of depression was 34.2%. according to literature evidences the prevalence of depression in epilepsy ranges between 10-55%. the previous studies supporting evidence for prevalence of depression within the range of our study are r. jones et all 2012 (24-75%), ekaterina v 2014 (40.63%) rajesh j et al 2002 (34%), adhikari a et all 2013(36.8%), ettinger et al 2004 (36.5%), koban et al 2006 (32.6%). in this study regarding nding was when the severity of seizures is more there is higher prevalence of depression. it correlates well with previous studies that seizures freedom in past 6 months is associated with less depression and better qol andreas m. kanner et al (2010), kanneret all (2009), vsiliosk et al (2007) kiki mohammed et al (2006). drug compliance has no effect on depression. another new nding in this study is that patients on polydrug therapy reported poor qol and the prevalence of depression is more in them. with regard to socio demographic details, ndings are males with higher literacy and higher socio economic status is associated with more depression and hence poor qol. it was found that unemployed people have higher prevalence of depression. it well correlates with previous studies that unemployment in past 6 months has a signicant association with depression supported by saygin gd et al (2014) williams j et al (2003), alanis gi et al (2005), hesdorffer d et al (2005),heaney dc et al (2012). qol is poor in patients with mild, moderate and severe depression. it correlates well with previous studies andres m et al 2010,perrine et al 1995, boylan et 2004, gilliam et al 2005. this study has found that when the seizure severity is more the qol is poor. it supports earlier studies dierdre et al 2010, eva tlusta et al 2009. in this study the prevalence of depression is more in patients with higher literacy and high socio economic status. new nding in this study is qol is poor in patients with longer duration of illness and with earlier age of onset of epilepsy. conclusion: from the study, it was found that the prevalence of depression in epileptic patients is high. seizure frequency and long duration of illness, early age of onset of epilepsy have a signicant positive correlation with depression. depression is more common in patients with high literacy prole. positive family history of psychiatric illness is associated with more prevalence of depression. unemployment and low socioeconomic status positively associated with more depression. depression beyond epilepsy by itself further worsens the qol in epileptic patients. over all qol is poor in patients with co-morbid depression and who are unemployed and in lower socio economic status. references: 1. jones je, herman bp, berry jj, gilliam f, kanner am, meador kj. clinical assessment of axis i psychiatric morbidity in chronic epilepsy: a multicenter investigation. j neuropsychiatry clin neurosci. 2005;17:172–179. 2. mendez mf, cummings jl, benson df. depression in epilepsy. signicance and phenomenology. arch neurol. 1986;43:766–770. 3. kraepelin e. psychiatrie. vol. 3. leipzig: johann ambrosius barth; 1923. 4. bleuler e. lehrbuch der psychiatrie. 8. berlin: springer; 1949. 5. blumer d, altshuler ll. affective disorders. in: engel j, pedley ta, editors. epilepsy: a comprehensive textbook. ii. philadelphia: lippincott-raven; 1998. pp. 2083–2099. 6. kanner am, wuu j, barry j, hermann b, meador kj, gilliam f. atypical depressive episodes in epilepsy: a study of their clinical characteristics and impact on quality of life. neurology. 2004;62(suppl 5):a249. x 49gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 2 moderate 27 12.78 4.209 3 severe 7 14.71 6.726 total 120 10.69 5.230 2 ham d 12.999 .000 sig 1 mild 86 6.55 5.555 2 moderate 27 11.96 5.874 3 severe 7 14.14 7.862 total 120 8.21 6.322 3 qolie over all score 18.962 .000 sig 1 mild 86 62.1162 12.58025 2 moderate 27 45.8632 21.14804 3 severe 7 43.8749 17.96327 total 120 57.0619 16.33900 s.no. factors mean sd 't' value 'p' value 1 qolie over all score 35.292 .000 sig 0 no disease 57 68.3039 4.58487 1 mild depression 14 20.5549 10.92651 2 moderate depression 20 22.1407 11.71298 3severe depression 7 18.7107 6.31228 total 120 57.0619 16.33900 introduction perforation peritonitis has been found to be a common surgical emergency in india. the causes of perforation in india have been found to be quite different from that in 1western countries dorairajan et al. but there is a lack of data about the etiology and the morbidity and mortality patters in 2cases of perforation peritonitis from india sharma et al. it has been found that the prognosis of patients with peritonitis and intra-abdominal infections is poor. this is especially so when multi organ failure sets in despite advancements in antimicrobials and supportive care, mortality associated with 3-5diffuse suppurative peritonitis is high. accurate diagnosis and management of suppurative peritonitis is a challenge. complex surgical interventions, multifaceted treatment aspects and difculties of icu support make evaluation of new therapeutic advances very difcult in this eld. in these situations scoring systems which provide accurate assessment of the patient's conditions at a specic point in the disease simplies the understanding of these problems. these scoring systems serve as a prognostic marker and help us evaluate our line of management. of the many scoring systems the mannheim peritonitis index which was developed by wacha et al was found to be one of the simplest scoring systems that easily allow the surgeon to 6predict the outcome in patients with peritonitis. the mpi score was based on the analysis of retrospective data from 1253 patients with peritonitis. a total of 20 possible risk factors were considered. of these only 8 proved to be of prognostic relevance and were entered into the mannheim peritonitis index. the mannheim peritonitis index is a specic score, which has a good accuracy and has ease of handling of clinical parameters. it allows for easy prediction of the prognosis in patients with peritonitis. understanding the pathophysiology of peritonitis, the concept of sepsis and multi organ failure has furthered the management of 7peritonitis. in patients who have progressed to multiorgan failure conservative treatment and newer modalities of treatment such as immune-modulation and programmed re8-10laparotomy are being tried. the objective of this study was to assess the effectiveness of the mannheim peritonitis index in predicting the outcome of patients with peritonitis, to assess the signicance of each risk factor of the mannheim index in predicting the prognosis. and to assess the morbidity and mortality rates in patients with peritonitis, evaluate various conditions leading on to peritonitis. ÿ mannheim peritonitis index (mpi) ÿ mpi was originally devised from a study conducted in 1253 patients with peritonitis by wacha et al. the study was conducted between 1963 and 1979. a total of 20 factors 6which affect the prognosis of the patients were considered ÿ 8 out of the 20 factors were found to be of signicance in determining the prognosis of patients with peritonitis ÿ the information is collected at the time of admission and rst laparotomy ÿ each risk factor is assigned a score based on its inuence in determining the outcome and a nal score is arrived at. the maximum possible score by applying mpi index is 47. those patients who had scored more than 29 were deemed to be at high risk for mortality ÿ detailed study of mpi was done by a. billing in 7 different centres and their data compared. they considered patients of perforated or post-operative peritonitis, peritonitis caused by pancreatitis, appendicitis and mesenteric ischemia for study ÿ fugger et al divided patients into three groups based on their mpi score. patients were classied as having scored less than 21, between 21 and 29 and those with score greater than 29. those with score of less than 21 had the least risk for developing morbidity and mortality, whereas those with score greater than 29 had a high mortality chance. patients with score between 21 and 29 were 11designated as having intermediate risk. a case study of mannheim peritonitis index role in predicting mortality in case of perforative peritonitis original research paper dr. upendra kumar rajendra institute of medical sciences ranchi, jharkhand -834009 general surgery background: a scoring system which can compare patient populations and severity of illness, objectively predict mortality, morbidity and can help to evaluate the treatment strategy is the dire need for evaluative research of intensive care. methods: the study is done after obtaining a detailed history, complete general physical examination and systemic examination. the patients are subjected to relevant investigations like x-ray erect abdomen, cxr, usg and routine investigations like hb, tc, urea, creatinine, serum electrolytes. results: the study was conducted in a population of 50 patients who had been diagnosed as having peritonitis secondary to hollow viscous perforation. it was observed that perforated appendix was most common cause of peritonitis in our study accounting for 26 percent of the cases. conclusions: despite advancements in the realm of medical science, the management of patients with peritonitis continues to be demanding. in our study it was found that appendicular perforation was the most common cause followed by gastro duodenal perforation. abstract keywords : multi organ failure, mpi scoring system, peritoneum, perforation peritonitis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. milandeep* guru gobind singh medical college, faridkot, punjab-151203 *corresponding author dr. gajendra pandit rajendra institute of medical sciences ranchi, jharkhand -834009 prof. dr. sudhir khichy guru gobind singh medical college, faridkot, punjab-151203 prof. dr. r. s. sharma rajendra institute of medical sciences ranchi, jharkhand -834009 48 x gjra global journal for research analysis methods the study was done in 50 patients with peritonitis due to hollow viscous perforation who presented to general surgery department emergency. the study is a clinical, prospective, observational and open study. method of collection of data the study is done after obtaining a detailed history, complete general physical examination and systemic examination. the patients are subjected to relevant investigations like x-ray erect abdomen, cxr, usg and routine investigations like hb, tc, urea, creatinine, serum electrolytes. all investigations and surgical procedures were carried out with proper informed written consent. the data regarding patient particulars, diagnosis, investigations, and surgical procedures is collected in a specially designed case recording form and transferred to a master chart. the data is subjected to statistical methods like mean, proportion, percentage calculation and wherever necessary chi square test for proportion are used. inclusion criteria ÿ age > 15 years ÿ diagnosed to have peritonitis and on whom surgical intervention is planned. exclusion criteria ÿ conservatively managed patients pancreatitis, spontaneous bacterial peritonitis, patients on peritoneal dialysis ÿ abdominal injuries with associated solid organ or vascular injuries ÿ poly-trauma patients ÿ peritonitis secondary to anastomotic leak. mode of study the detailed history and proper clinical ndings were entered in a case recording form. patients were subjected to methodical physical examination to assess their general condition. local examination of abdomen was done and relevant ndings were recorded. rectal examination was done in all cases; the required and routine investigations were done to establish the diagnosis. pre-operatively all patients received supportive treatment for correction of hypotension and electrolyte abnormalities. during laparotomy, intraabdominal examination of all organs was made in addition to the specic pathology. mpi scoring was done in all patients and patients were classied as those with score less than 21, between 21 to 29, and more than 29. the nature of surgical procedure was planned preoperatively based on the suspected pathology and the general condition of the patient. but the nal choice of the procedure was decided upon the merit of each case and the intraoperative nding. the issue of placing a drain in the peritoneal cavity was left to the discretion of the operating surgeon. postoperative period was monitored; intake output charts and vital charts were maintained. patients were followed up for a period of one month post surgery to assess for development of complications. results the study was conducted in a population of 50 patients who had been diagnosed as having peritonitis secondary to hollow viscous perforation. it was observed that perforated appendix was most common cause of peritonitis in our study accounting for 26 percent of the cases. this followed by perforation of peptic ulcer which was 20% of the cases. trauma was found to be a signicant cause of gastrointestinal perforation accounting for 16% of the cases in our study. enteric illness, inammatory bowel disease, ischemia, malignancy and tuberculosis were each found to constitute 4 per cent of the cases. cholecystitis, colonic diverticulum, gists, perforation following bowel obstruction, each formed 1 percent of the cases. no identiable cause of perforation could be found in 10 percent of the cases. the study was conducted in patients over 15 years of age. it has been found that perforation peritonitis is more common among the elderly population. 44 percent of cases occurred in patients who were aged 50 and above. 38 per cent of cases were seen in the middle aged (25-50 years of age). only 18 percent of cases were seen to occur in the age group of 15-25 years. it is seen that with increasing age, there is an increase in the morbidity rate. the average mpi score also shows an increase with increasing age. the average mpi scores for the age groups 15-25 years, 25 -50 years and >50 years were found to be 14.66, 17.26 and 21.50 respectively. 80 percent of patients in the study were found to be males. females accounted for 20 percent of the cases. the morbidity rate in men was found to be 53.84 percent where as in women it was 30/33.33 percent. table 1: etiology. table 2: site or perforation. fourteen percent of patients presented within a day of onset of symptoms. these patients had a morbidity rate of 28.5 percent and the average mpi score for these groups of patients was 13.2. 68 percent of patients presented within 24 to 72 hours after onset of symptoms. the morbidity rate in these patients was 43.75 percent and the average mpi scores 18.58. the percentage of patients who presented after 72 hours was 18. these patients had a morbidity rate of 88.88 percent and the 11average mpi score was higher than the other two groups at 23. in the study population 18 percent presented with organ failure at admission. these patients had a morbidity rate of 57.14 % and average mpi score of 25. both the patients who had mortality in the study presented with organ failure on admission. 82 percent of patients did not have any organ failure at the time of presentation. the patients had a morbidity rate of 48.78 and the average mpi score was 17.26. the p value is 0.008. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra etiology number of patients percenta ge morbidi ty avg mpi score appendicitis 13 26 2 13.0769 cholecystitis 1 2 1 20.0000 colonic diverticulum 1 2 1 21.0000 enteric 2 4 2 20.5000 gist 1 2 1 18.0000 inammatory bowel disease 2 4 2 21.0000 ischaemia 2 4 1 24.5000 malignancy 2 4 2 22.5000 non specic 5 10 5 25.2000 obstruction 1 2 0 31.0000 peptic ulcer 10 20 2 17.9000 trauma 8 16 4 18.2500 tuberculous 2 4 1 22.5000 total 50 100 24 18.6600 site of perforation number percentage morbidity avg mpi score appendix 14 28 3 13.5000 colon 7 14 6 23.8571 duodenum 9 18 3 17.7778 gall bladder 1 2 1 20.0000 ileum 10 20 7 22.5000 jejunum 6 12 4 20.8333 stomach 3 6 0 15.6667 total 50 100 24 18.6600 x 49gjra global journal for research analysis in our study, it was found that 40 percent of the patients presented with localized peritonitis. the patients had a morbidity rate of 25 percent and a low average mpi score of 14.65. 60 percent of patients came with generalized peritonitis. these patients had a higher average mpi score of 21.33 and the morbidity rate was 67.85 percent. the p value is 0.007. 62 percent of patients in our study had purulent peritoneal uid. these patients had a morbidity rate of 58.06 percent and an average mpi score of 18.70. 10 percent of patients had faecal peritonitis. these patients had a high average mpi of 27.80 and the highest morbidity rate. twenty eight percent of patient had no pus or faecal contamination of the peritoneal uid. these patients had a morbidity rate of 15.38 percent. the p value is 0.004. in nality, it was found that 64 percent of patients had mpi score of less than 21. these patients had a morbidity rate of 34.37. 30 percent had mpi score within 21 to 29. these patients had a morbidity rate of eighty percent. there were three patients who had mpi score of above 29. two of these patients died and the remaining one had post op morbidity. the mortality rate was 66.66 percent in this group. there was no mortality in the other two groups. the association of increasing mpi score with mortality and morbidity is found to be signicant. the p value is <0.001. discussion peritonitis resulting from perforation of the gastrointestinal 1,12tract is a common surgical emergency in india.. in our study a group of 50 patients who have been diagnosed to have perforation peritonitis, it was found that appendicular perforation was the most common cause of perforation 13peritonitis. patients out of the study population of 50 patients had appendicular perforation. the next most common was perforation due to peptic ulcer disease. trauma was the third 13most common cause of perforation peritonitis. during observation appendicular perforation was the most common. this was followed by gastro-duodenal perforation. in the elderly age group perforation peritonitis were more in common. also, it was noted that these patients had a higher mortality rate compared to patients of younger age. the average mpi score for patients over 50 years of age was also found to be higher than those patients less than 50 years. the lowest morbidity rate was seen in patients between 15 to 25 years of age. the mortality rate in our study is to increase with increase in age. the average mpi score has a linear relationship with increasing age. the mpi scoring system attributes a higher risk for the female sex. in our study, it was found that 80 percent of the patients were males and only 20 percent were females. the morbidity rate among male patients was found to be higher than in female patients. however, this was found to be not signicant statistically. the digression could be from the fact that there was lesser number of female patients in the study. in supervising the admitted patients, it was found the lowest morbidity rate within 24 hours of onset of symptoms. a majority of the patients in the study presented between 1 to 3 days after onset of the symptoms. it was found that the morbidity rate was higher with more delay in presentation. the morbidity rate is only 28.5 percent in patients presenting within 24 hours and increases to 88.88 percent in those patients who presented after 3 days. the rise in morbidity correlates with higher mpi 6,14score in those who have delayed presentation. in this study, it was found that those patients who had organ failure at the time of presentation had a higher morbidity rate. there were two mortalities noted in the study. both the patients had organ failure at the time of presentation. that the mpi scoring system accords a higher risk to those with organ 10,15failure seems justied. even though appendicular perforation was found to be the most common cause of perforation peritonitis in our study, it was found that the number of patients with diffuse peritonitis numbered more than those with localized peritonitis. the mpi scoring system attributes a higher risk to those with generalized peritonitis and likewise these patients were found to have a higher morbidity rate. according to the mpi scoring system patients with faecal contamination had a poorer prognosis. in our study, we found this to be justied since patients with faecal peritonitis had a hundred percent morbidity rate. one of the mortalities in the study also had faecal contamination of the peritoneal cavity. the correlates with the fact that colonic perforations carried a high morbidity rate as compared to gastro duodenal 5,16-18perforations. patients with purulent peritoneal exudate had a higher morbidity rate than those with clear peritoneal exudate, justifying the scores accorded to peritoneal uid exudates as per the mpi system. the mannheim peritonitis index is a peritonitis specic index which is easily applicable. it is based on clinical parameters that are routinely assessed. it also allows for intra operative evaluation of the patient to provide a better assessment of the nal prognosis. numerous studies have been done which have validated its accuracy and applicability in predicting the prognosis in patients with peritonitis. higher mannheim index score has a strong 6,19association with increased mortality. over the years, there has been a fall in the mortality rates in cases of peritonitis. this has been attributed to better intensive care support, a better understanding of the patho-physiology of the peritonitis. more appropriated surgical techniques have been devised in the 7management of peritonitis. in high risk cases, denitive procedures are deferred and the focus is on clearance of source of infection. the concept of staged laparotomy has gained popularity in recent times in the management of severely ill patients in whom re20exploration is expected. in our study a total of 50 patients with perforation peritonitis were followed. only two mortalities were noted in the study. it has been found that the mannheim peritonitis index has been a good predictor of mortality as well morbidity in patients with peritonitis. the patients were grouped as those having score less than 21, score between 21 and 29 and those with score greater than 29. it was found that morbidity rate was the least in those with scores less than 21. patients whose score was between 21 and 29 had a higher morbidity rate, but no mortalities were noted in this group. those patients whose mpi score was more than 29 had the highest morbidity rate. both the mortalities that occurred during the study had scored more than 29.it was also found in our study that with the exception of sex based risk assessment, all other parameters of the mannheim peritonitis index were closely associated with the prognosis of the 6patients. conclusion despite advancements in the realm of medical science, the management of patients with peritonitis continues to be demanding. in our study it was found that appendicular perforation was the most common cause followed by gastro duodenal perforation. trauma was found to be a signicant cause of perforation peritonitis. it was found that ileal perforations constitute a major proportion of cases of secondary peritonitis and the causes of ileal perforations to be varied. more males were found to present with perforation peritonitis than women. it was found that perforation of the gastrointestinal tract is more common among the elderly and that these patients also have a poorer prognosis. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 50 x gjra global journal for research analysis the mortality rate over the years have come down due to better supportive care and by implementing appropriate operating protocols in these patients. nevertheless, the challenges presented remain remarkable. a specic scoring system which is easy to apply, simple to calculate and accurate in prediction will be of great use in the management of patients with peritonitis. it has been found that the mannheim peritonitis index duly fulls these criteria. the individual parameters of the index with the exception of sex based risk assessment were found to positively correlate with the prognosis in our study. references 1. dorairajan ln, gupta s, deo svs, chumber s, sharma l. peritonitis in india a decades experience. tropical gastroenterology. 1995;16(1):33-8. 2. sharma l, gupta s, soin as, sikora s, kapoor v. generalised peritonitis in india-the tropical spectrum. japanese j surg. 1991;2:272-7. 3. altemeier wa, culbeston wr, fulln w, shock c. intra-abdominal abscess. american journal of surgery. 1973;125:70-9. 4. blot s, de waele jj. critical issues in the clinical management of complicated intra-abdominal infections. drugs. 2005;65(12):1611-20. 5. bohnen j, boulenger m, mackin jl. prognosis in generalized peritonitis, relation to cause and risk factors. arch surg. 1983;118:285-90. 6. wacha h, linder mm. mannheim peritonitis indexprediction of risk of death from peritonitis; construction of a static and validation of an empirically based index. theoritical surg. 1987;1:169-77. 7. durham h. the mechanism of reaction to peritoneal infection. j pathol bacteriol. 1897;4:338-82. 8. kaltarentzos fe, dougenis dv, cristopolus dc. prognostic criteria in intraabdominal sepsis. international surg j. 1987;72:185-7. 9. knaus wa, draper ea, wagner dp. prognosis in acute organ system failure. annals surg. 1985;202:685-93. 10. notash ay. evaluation of mannheim peritonitis index and multiple organ failure score in patients with peritonitis. indian j gastroenterol. 2005;24(5):197. 11. fugger r, rogy m. validation study of the mannheim peritonitis index. chirurg. 1988;59:598601. 12. hiyama dt, bennion r. peritonitis and intraperitoneal abscess. zinner mj, schwartz cs. maingot’s abdominal operations, 1, 10th edition, usa, new york: appleton and lange; 2001:663651. 13. verma gr. gastro-intestinal injuries in abdominal trauma. tropical gastroenterol. 1990;11(4):206-10. 14. vincent jl, weil mh, puri v, carlson rw. circulatory shock associated with purulent peritonitis. american j surg. 1981;142:262-70. 15. goris rj, te boekhorst tp, gimbrere js, nuytinck jk. multiple organ failure: generalized auto destructive inammation. archives of surg. 1985;120:1109-15. 16. kohli v. evaluation of prognostic factors in perforated peptic ulcer. indian j surg. 1988;50:184. 17. melaney fl, olip j. peritonitis: ii. synergism of bacteria commonly found in peritoneal exudates. archives surg. 1932;25:709. 18. last m, kutz l, stein ta. effect of peep on the rate of thoracic duct lymph ow and clearance of bacteria from peritoneal cavity. american j surg. 1983;145:126. 19. rodolfo l, bracho-riquelme mc, m en c, armando melero-vela mc, aidee torres-ramírez mc. mannheim peritonitis index validation study at the hospital general de durango (mexico). cirugía y cirujanos. 2002;70:217-25. 20. farquharson m, moren b. emergency laparotomy, farquharson’s text book of operative general surgery, 9th edition, edward arnold publishers, london, england; 2005:233. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 51gjra global journal for research analysis 34.tabish maqbool.cdr introduction: the word laser is an acronym for light amplication by stimulated emission of radiation. the main stay of lasers in otorhinology and head and neck surgeries is co2 laser. co2 1laser was rst developed by patel et all in 1964 , and was 2,3,5introduced for medical use in early 1970's . it was the rst laser to be used clinically in otorhinology by strong and 4,5jako . co2 lasers produce light with a wavelength of 10.6 microm in the infrared (invisible) range of the electromagnetic spectrum. a second, built-in, coaxial helium neon laser is necessary to indicate with its red color the site where the invisible co2 laser beam will impact the target tissue. this laser, then, acts as an aiming beam for the invisible co2 laser beam. the radiant energy produced by the co2 laser is strongly absorbed by pure, homogeneous water and by all biological tissues high in water content. the extinction length of this wavelength is about 0.03 mm in water and in soft tissue; reection and scattering are negligible. because absorption of the radiant energy produced by the co2 laser is independent of tissue color and because the thermal effects produced by this wavelength on adjacent nontarget tissues are minimal, the co2 laser has become extremely versatile for use in otolaryngology head and neck surgery. co transoral 2 laser microsurgery (tlm) is an emerging technique for the management of laryngeal cancer and other head and neck malignancies. the co laser is coupled to a micromanipulator 2 and microscope, which provides enhanced tumor visualization and the ability to perform precise tissue cuts, obtain excellent hemostasis, and avoid damaging the surrounding tissues and structures that are transected during open surgical procedures.this study was done in department of otorhinolaryngology and head and neck surgery gmc srinagar, to check efcacy of transoral co2laser in treatment of early head and neck cancers. material and methods: t h i s s t u d y w a s c o n d u c t e d i n d e p a r t m e n t o f otorhinolaryngology and head and neck surgery gmc srinagar for 2 years ( 2016, 2017). 34 patients who had early head and neck cancers(18 laryngeal cancers,4tongue cancers )were treated with co2 laser.in all patients relevant history was taken. personal history about any addiction( smoking,tobacco chewing,alcohol) was taken. proper examination was done in all patients. oral cavity and oropharynx were examined. site of lesion was palpated for any induration in tongue . indirect laryngoscopy was done. fol was done in all patients of laryngeal lesions. excision biopsy of all lesions was taken and sent for hpe. neck was examined for any cervical lympadenopathy.all baseline investigations were done. mri tongue was done in patients with ca tongue , and cect neck was done in all patients with ca larynx. mri tongue and cect neck was done before taking the biopsy. during the procedure all laser precautions were taken.recommended power settings were kept . in laryngeal surgeries power of 3 to 5 w, depth of 1mm was taken, while in oral surgeries power of 4 to 8 watts was used , depth of 1 mm. spot size was kept between 0.3 to 0.7 mm. mode was kept repeat superpulse in all surgeries. results: from january 2016 to december 2017, 22 patients with early head and neck cancers ( t1 and t2) were treated in our department with co2 laser . . among 22 patients ,18 were having laryngeal cancers,4 were having tongue cancers.all patients were above 45 years of age. all 18 patients with laryngeal ca were males while all 4 patients with ca tongue were females. majority of patients were from rural areas ( 64%).all patients with ca larynx presented with change of voice. on fol , vocal cord mass was present in all patients . table 1; stage wise distribution of malignant lesion in larynx treatment of early head and neck malignancies using co2 laser : our experience original research paper prof rauf ahmed ms ent and hns gmc srinagar (professor and head) x 37gjra global journal for research analysis ent introduction: since 1970s,co2laser has been an effective method of treatment of several types of head and neck lesions. because of the precise cutting and supercial well delineated effect of the co2 laser, it is widely used in laryngology for delicate phonatory surgery,benign lesions, precise excision of carcinoma in situ or early (t1) tumors, and vaporization of bulky obstructing carcinoma of the upper airway. objective: to check efcacy of transoral co2laser in treatment of early head and neck cancers. material and method: total of 197 patients with both malignant and non malignant lesions were treated with co2 laser from january 2016 to december 2017 .out of these, 22 patients who had early hncancers(18laryngeal cancers,4tongue cancers were treated with co2 laser.in all patients history,examination and relevant investigations were done for tnm staging of the tumor and were treated with transoral co2laser .type of procedure,any intraoperative or postoperative complication was documented. result: out of 18 patients of carcinoma larynx,4 underwent type1 cordectomy,9 underwent type2 cordectomy and 4 underwent type3 cordectomy and 1 patient underwent type 4 cordectomy depending on depth of lesion. all 4 patients of carcinoma tongue underwent wide local excision with supra omohyoid neck dissection. hpe of all cases showed tumor free margins..all patients are under regular followup . 2 patients with ca larynx had reccurence. conclusion: our study showed that co2laser is treatment of choice for early hncancers. abstract keywords : co2 laser , early head and neck cancers. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr tabish maqbool* ms ent and hns gmc srinagar *corresponding author t stage number of patients n=18 percentage t1 8 44.4% t2 10 55.6% total 18 100% dr ihsan ali ms ent and hns gmc srinagar (associate professor) 38 x gjra global journal for research analysis table 2; type of malignancy in larynx table 3; type of laser cordectomy patients with ca tongue presented with lesion on border of tongue . on examination all patients with ca tongue were having tongue ulcer with induration. neck nodes were absent in all patients. table 4; stage of malignant lesions in oral cavity (tongue) all 4 patients underwent wide local excision of tongue using co2 laser with supraomohyoid neck dissection. table 5, recurrence: recurrence was seen in two patients of ca larynx (1.68%). in both the patients the recurrence site was subglottis. one patient among these underwent salvage laryngectomy while another patient underwent palliative chemotherapy, due to comorbid conditions. no recurrence was seen in patients who were operated for ca tongue. there was not any laser related intraoperative or postoperative complication. discussion: this prospective study was conducted rst time in the department of otorhinolaryngology head and neck surgery, government medical college and associated smhs hospital srinagar. the study included 22 patients with head and neck malignancies. among the patients studied 18 patients were having laryngeal malignancy while 4 patients were having tongue malignancy. t1 laryngeal ca was seen in 44.4% of pts while t2 lesions was present in 55.6%(table 1). moderately differentiated ca was seen in majority of patients with laryngeal ca(table 2). cordectomy was done in 18 patients with ca larynx. as shown in table 3 among these 4 patients underwent type 1 cordectomy all of which were having t1 lesions, 9 patients underwent type ii cordectomy, 4 underwent type iii and 1 patient underwent type iv codectomy. patients who underwent type ii cordectomy either had t1 or t2 lesions while all patients who underwent type iii or type iv cordectomy were having t2 lesions while all patients with ca tongue underwent wide local excision with supraomohyois neck dissection. according 6to study by c bocciolini et al, a cohort of 79 patients with previously untreated early glottic carcinoma, subjected to endoscopic co laser excision between january 1993 and 2 october 2000, was retrospectively examined . the population comprised 75 males (95%) and 4 females (5%), age range 4093 years (mean 66.5). . eight (10.1%) patients experienced local recurrence within periods varying from 4 to 55 months (mean 14.5). according to another the study by vijay k 7sharma et al on evaluation of co2 laser surgery for early carcinoma larynx where (n=40) patients underwent trans oral laser surgery or radiotherapy as primary modality of treatment . this study revealed local recurrence rate 10% in co2 laser treated arm which was not statistically signicant. in our study ,2 patients had recurrence (4.44%). in one patient recurrence was seen after 9 months of surgery , in another patient it was seen after 11 months of tole. rest all patients are disease free. the recurrence rate in our study is less than the above mentioned studies, which may be due to the short study period.(table 5) 4 patients in our study were having ca tongue. among these 3 patients were having t2 lesion while 1 was haiving t1 lesion (table 4). hpe results showed squamous cell carcinoma in all patients.thirty-seven consecutive patients with cancer of the anterior two-thirds of the tongue without clinical neck lymph nodes or distant metastasis were treated with transoral co 2 [8]laser microsurgery. wang et al. resected the tumour under surgical microscope. of the 28 patients in the t1/t2 group, 26 patients did not receive postoperative radiotherapy. the local control rate in all 37 patients at 5 years was 93.6 %. no local recurrence occurred in the t1 or t2 cases. in our study , none of the patients had recurrence which may be due to the less number of patients studied (table 5). conclusion: it is concluded that co2 laser surgery is a preferable surgery for early head and neck cancers. references 1. patel ckn,tien pk, mc fee jh(1965): cw high power co2-n2-he laser.appl phys lett 7:290-292 2. tg, laser physics, otolaryngo clinic of north america 1983; 16: 753774 3. matschke rg, experiences with laser surgery in bening and malignant ndings of the oro and hypopharynx. adv otorhinolaryngol 1995; 49: 153-157 4. jako fg. laser surgery of the vocal cord; an experimental study with carbondioxide laser on dogs. laryngoscope 1972; 82: 204-211 5. strong ms, jako gj (1972): laser surgery in the larynx. ann otorhinolaryngol 81:791-798 6. c bocciolini, l presutti,1 and p laudadio . oncological outcome after co2 laser cordectomy for early stage glottic carcinoma acta otorhinolaryngol ital. 2005 apr; 25(2): 86–93 7. chiesa f, sala l, costa l, iglo k. excision of oral leukoplakias by co2 laser on an outpatient: a useful procedure for prevention and early detection of oral carcinomas. tumori 1986; 72: 307–312. 8. wang cp, chang sy, wu jd, tai sk. carbon dioxide laser microsurgery for tongue cancer: surgical techniques and long-term results. j otolaryngol. 2001;30(1):19–23. doi: 10.2310/7070.2001.20897.[pubmed] [cross ref] volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra type of malignancy in larynx number of patients n=18 percentage well differentiated sq.cell carcinoma 7 38.88% moderately differentiated sq.cell carcinoma 11 61.11% total 18 100% type number of patients(n=18) percentage type i 4 22.2% type ii 9 50% typeiii 4 22.2% type iv 1 5.5% stage of malignant lesions number of patients n=4 percentage t1 1 25% t2 3 75% total 4 100% site of recurrence no. of patients percentage (n= 119) procedure done post recurrence. subglottis 2 1.68% patient 1) salvage laryngectomy patient 2)palliative chemotherapy total 2 1.68% introduction neoplasms constitute the most important lesions of the breast. commonest are the neoplasms arising from the epithelial component, which constitute the glandular element of the breast. the most common type of carcinoma is inltrative ductal carcinoma (70%). lobular carcinoma is the second most common histological group of breast carcinoma followed by smaller groups such as medullary, mucinous, comedo carcinoma, paget's disease, papillary, tubular and [1]inammatory carcinoma (berg and hutter 1995 ). many prognostic factors have been identied in breast carcinoma. the most commonly used indicators for prognosis include the clinical stage of the disease, tumour size (galea et [2] [3]al 1992 ), lymphnode metastasis (pisansky et al 1993 ), tumour grade, estrogen or progesterone receptor status of the tumour . nuclear grade is an important prognostic factor in breast carcinoma and many studies of the nuclear grade have been performed on the histological section. fine needle aspiration smears are also well suited for nuclear grading. when combined with histological tumour type and race of the patient, nuclear grade is a most powerful predictor of tumour [4]aggressiveness (fisher et al 1990 ). while nuclear grading has been traditionally used, tumour angiogenesis as a prognostic marker is a latest issue. current studies of tumour angiogenesis rely on the concept that endothelium proliferates 30-40 times faster in tumours than in normal tissue. a number of studies have found that highly vascular carcinomas have a poorer prognosis than those of low vascularity. angiogenesis is found to be a key event in the metastatic growth. angiogenesis is dened as the process of new blood vessel formation. the neovascularization may be stimulated by factor from tumour cells (autocrine) or by tumour associated inammatory cells or by extra cellular matrix. tumour angiogenesis refers to the growth of new vessels towards and within the tumour. in present study an attempt has been made to correlate nuclear grading with microvessel density due to angiogenesis so as to develop a new criteria for assessing the prognosis of different histomorphological types of carcinoma breast. aims and objectives: 1. to establish histomorphological type of breast lesion. 2. to carry out nuclear grading of malignant breast lesions. 3. to assess angiogenesis: quanti tat ion of mvd (microvessel density) in malignant breast lesions. 4. to correlate the nuclear grading with angiogenesis. materials and methods: the tissue material for the study was obtained from the patients admitted in nehru chikitsalaya, brd medical college, gorakhpur over a period of 14 months (september 2006 to november 2007). the tissue specimens preserved in the department of pathology, brd medical college, gorakhpur were also utilized in the study. 51 cases of breast surgery for malignant lesions were taken and the lesions were classied according to the who classication. sections from the lesions were taken and then stain with h & e stain & examined microscopically nuclear grading of breast carcinomas: the nuclear grading was done on tissue sections. for more objectivity four criteria were selected – nuclear size, nuclear margin, chromatin pattern and nucleolar characteristics and to each criteria scores were allotted and these scores were nally summed up to assign grade. correlation of nuclear grading and angiogenesis in breast malignancy original research paper dr. vikas goyal lecturer, department of pathology, maharani laxmi bai medical college, jhansi x 31gjra global journal for research analysis pathology neoplasms constitute the most important lesions of the breast. commonest are the neoplasms arising from the epithelial component, which constitute the glandular element of the breast. the most common type of carcinoma is inltrative ductal carcinoma followed by lobular carcinoma and then other smaller groups. many prognostic factors have been identied in breast carcinoma. the grading of breast carcinomas is one of the most useful prognostic indicators. when combined with histological tumour type and race of the patient, nuclear grade is a most powerful predictor of tumour aggressiveness. tumour angiogenesis as a prognostic marker is a latest issue. a number of studies have found that highly vascular carcinomas have a poorer prognosis than those of low vascularity. in present study an attempt has been made to correlate nuclear grading with microvessel density due to angiogenesis so as to develop a new criterion for assessing the prognosis of different histomorphological types of carcinoma breast. nuclear grading of the lesions was done according to the nottingham modication of bloom richardson system (1991). all sections were assessed for angiogenesis by calculating mvd. the mvd increased from grade i to grade ii to grade iii lesions. on statistical analysis there was a positive high correlation between nuclear grade and microvessel density. present study reveals that microvessel density correlate positively with nuclear grade. abstract keywords : breast carcinoma, nuclear grading, angiogenesis, microvessel density volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. abhijat kulshreshtha* lecturer, department of pathology, maharani laxmi bai medical college, jhansi *corresponding author criteria score 1 2 3 nuclear size 1-2 times the size of rbc 3-4 times the size of rbc >5 times the size of rbc nuclear margin smooth slightly irregular/ folds or grooves buds and clefts chromatin pattern vesicular/ reticular granular clumping/ clearing nucleoli indistinct noticeable abnormal 32 x gjra global journal for research analysis score 4 6 grade 1 score 79 grade 2 score 10-12 grade 3 counting procedure for vessels: in all cases of breast malignancy most discrete blood vessels which appeared as lumen lined by endothelial cells were counted in high power lens using 40x objective and 10x eyepiece in 200 elds in h & e stained sections. in small bits, only maximum possible elds were seen. simultaneously the morphology of microvessels in the form of size, shape and thickening of vessel wall was observed. to avoid bias, counting was done by two different observers. the microvessel density for each group of lesions was correlated with the nuclear grade. results: in the present study fty one formalin xed and parafn embedded surgical specimens of various malignant disease of breast were studied to grade the lesions by bloom richardson's nuclear grading system (1991) along with density, morphology and localization of blood vessels. for this routine staining method (h&e) was employed. in h&e stained sections the lesions were graded according to the nottingham modication of bloom and richardson system (1991), along with nuclear grading. for microvessel counting only well formed vessels were identied in which endothelial cells were also present. capillaries were identied with the help of contained red blood cells within the lumen. a statistical analysis has been done between microvessel density and nuclear grading to establish a relationship between the above two. the study group consisted of 51 malignant breast lesions which were categorized according to who classication. out of total 51 cases studied maximum 50(98.04%) cases were invasive carcinoma, in which maximum 42(82.35%) cases were invasive ductal carcinoma (nos), followed by 7(13.73%) cases of invasive lobular carcinoma and 1(1.96%) case of idc(nos) scirrhous type. only 1(1.96%) case was non invasive tumour, which was papillary carcinoma in situ among the 51 cases studied, maximum patients were in age group 40-50 years (41.17%) followed by 35.3% patients from 50-60 years.17.64% patients were from above 60 years and 5.89% patients from 30-40 years of age group. only one case of ductal carcinoma in situ, papillary type showed nuclear grade i, with nuclear size being thrice of a red blood cell, and smooth nuclear margin with granular chromatin and indistinct nucleoli. maximum 20 (46.5%) cases of present study belong to nuclear grade ii with score 7-9 followed by grade iii 15(34.9%) cases with score 10-12. only 8 cases (18.6%) were of grade i with score 4-6. out of the four criteria employed for nuclear grading the assessment of nucleoli was difcult in the histological sections specially if the tumour cells were crowded and overlapped, however in these cases the slides were carefully scanned for the thin areas and the nucleoli assessed. all 7 cases of lobular carcinoma studied showed nuclear grade i with nuclear size thrice a red blood cell size having granular chromatin, smooth margins and inconspicuous nucleoli with scores 4-6, belonging to grade-i. on analysis of nuclear grading scores of all the 51 cases, nuclear grade-ii is the commonest grade in idc where as grade i in lobular carcinoma. maximum 20(39.2%) cases of present study belong to nuclear grade-ii followed by grade-i 16(31.4%) cases & 15 cases (29.4%) were of grade-iii. mvd in invasive lesions with nuclear grade-i was varied from 1-25 with an average of 3.66. the mvd in invasive lesions with nuclear grade-ii varied from 1-25 and the mean was 4.26. in most cases of idc the blood vessels were identied in the brous septa. in cases with extensive desmoplasia identication of vessels was difcult. in invasive lesions with nuclear grade-iii the mvd ranged from 1-30 with a mean of 5.47. it was noticed that extensive desmoplasia and necrosis have altered the blood vessel count. table-1 correlation of mvd in grade i, ii and iii lesions a statistically signicant increase in mean mvd was observed in breast carcinoma cases with nuclear grade i to grade ii and grade ii to grade iii, though range may overlap. on statistical analysis there was a positive high correlation between nuclear grade and microvessel density in h&e (r value = +0.98) (table-1) discussion: lesions of the breast constitute a very important chunk of the causes of morbidity and mortality in women worldwide. the large number and variety of papers published on carcinoma of the breast, the treatment, prognosis and associated factors, are an index of the complexity of the problem and indeed of [5]the study of any tumour (chervallier et al 1993 ). recently there has been increasing interest in the early detection of the malignant breast lesions as early therapeutic intervention improves survival. the efcacy of any particular treatment can only be assessed if the inuence of pretreatment clinical and pathological factors is known. here in lies the importance of the search of new prognostic factors which are described relentlessly in [6]various studies worldwide (murray pa et al, 1993 ). one of the most fundamental aspects of oncologic pathology has been the recognition that the morphologic appearance of tumour can be correlated with their degree of malignancy. the principal methods currently used fall into two groups, the majority have followed the original concept of using multiple cellular factors while others have concentrated on nuclear characteristics. angiogenesis is one of the recently discovered prognostic [7]criteria (magennis dp, 1998 ). it is a key step in breast cancer growth and metastasis. it has been found that metastasis from breast carcinoma can be initiated as early as the point at which the primary tumors becomes vascularized at a size of less than 0.125 cm². in the present study 51 cases of malignant lesions of the breast were included. among the 51 cases studied, maximum patients were in age volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra s.n. grade of malignant lesions mvd in h&e (mean±s.d.) 1. grade i 3.66±0.72 2. grade ii 4.26±0.86 3. grade iii 5.47±1.42 r = +0.98 group 40-50 years (41.17%) followed by 35.3% patients from 50-60 years.17.64% patients were from above 60 years and 5.89% patients from 30-40 years of age group. this is in [8]accordance with study of (hussain m a et al 1994 ). among these 51 cases, 50 cases (98.04%) were invasive carcinomas while only one case (1.96%) was non invasive carcinoma and that was papillary carcinoma in situ. all the cases were epithelial tumour. these ndings are in [8]accordance with the study of hussain m a et al (1994 ). out of these 50 invasive carcinomas (epithelial), 42 (84.0%) were idc (nos), 1 (2.0%) idc (nos) scirrhous type and 7 cases (14.0%) of ilc. similar ndings were noted by (berg and [1] [8]hutter 1995 and hussain m a et al 1994 ). all invasive epithelial tumours were graded according to the nottingham modication of bloom richardson of the 43 cases of invasive ductal carcinomas including scirrhous type-46.5% were grade-ii, 34.9% were grade-iii while 18.6% were gradei. the inltrating lobular carcinomas were also graded similarly. all the 7 cases were grade-i. only non invasive case papillary carcinoma in situ was grade i. our results closely [9]matched those of a study of (le doussal et al 1989 ). in nottingham system, histologic grading of all invasive breast carcinoma is carried out regardless of the histological type. whilst recognizing that histological grading of breast cancer will always have an underlying subjective element, the authors devised modications to the bloom & richardson method in order to introduce greater objectivity. evaluation of nuclear pleomorphism is the least satisfactory element of any tumour grading system and the only way is which differences can be identied accurately is by use of morphometry or [10]image analysis (c.w. elston et al 1991 ). [11](i.a. robinson et al 1994 ) in a study graded breast carcinomas cytologically using six criteriadissociation, cell size, cell uniformity, nucleoli, nuclear margin & chromatin pattern. multiple regression analysis showed that extent of cell dissociation and appearances of nucleoli were the most inuential features. but nucleoli are not used in assessing histological grade unless multiple nucleoli are present.the presence of nucleoli in their histological nuclear grading system which includes the regularity of nuclear outline, the delicacy of the chromatin strands, presence or absence of nucleoli, and the number of mitotic gures. this system is as [12]valid as the original bloom & richardson method . recent interest in nuclear characteristics such as dna content, cell cycle analysis, ploidy analysis, morphometry data and oncogenes has involved complicated and expensive procedures with specic tissue and equipment requirement. if routine histological nuclear analysis shows some of these sophisticated nuclear data, this would be an advantage for most clinical situations when the complex procedures cannot [9]be done (le doussal et al, 1989 ). for each group of lesions [non invasive and invasive (epithelial) grade i, ii and iii] angiogenesis was studied using h&e stain in all cases. in low grade carcinomas (nuclear grade i) 1 case of papillary carcinoma in situ, 8 cases of idc (nos) & 7 cases of ilc were studied. the mvd varied from 1-25 with an average of 3.66. in intermediate grade lesions (nuclear grade ii), 20 cases of idc (nos), the mvd varied from 1-25 and the mean was 4.26. 15 cases were assigned high grade (nuclear grade iii). the mvd varied from 1-30 with a mean of 5.47. the number of microvessels is higher in grade ii lesions than grade-i lesions and in grade-iii lesions than grade-ii. on statistical analysis there was a positive high correlation between nuclear grade and microvessel density (table-1). in a number of studies a positive correlation was found between microvessel density (mvd) and tumour grade. [13](nakopolou et al in 1999 ) in a study 140 cases of invasive primary breast cancer compared angiogenesis (fviii ra & cd31 staining) with various classic clinicopathologic prognosticator (histologic type, nuclear grade, tumour size, s t a g e , l y m p h n o d e s t a t u s a n d s t e r o i d r e c e p t o r immunoexpression) by univariate and multivariate analysis. fviii ra immunoreactivity was signicantly affected only by nuclear grade (p= 0.041) in logistic regression analysis. similar positive correlation were found in studies by [14] [15]gasparani et al 1994 ; horak et al, 1992 and weidner et [16]al, 1991 . on comparing grades obtained by various methods bloom & [12]richardson 1957 found that there was a wide variability in results in their methods having predominance of grade-ii lesions, while others having majority of grade-iii lesions [17] [10](fisher et al 1980 , elston et al 1991 ). different results are obtained by different researchers regarding correlation between angiogenesis and various prognostic indicators, large number of these discrepancies can be attributed to differences in the methods employed. the choice of antibody to detect endothelial cells is a compromise between the sensitivity and specicity of those available and number of different antibodies have been used with no [7]universal agreement on which is best (d.p. magennis, 1998 ). the number of cases in present study is small and long follow up is required to reach any denitive conclusion. further studies with larger number of cases, with the antibodies specic to proliferating endothelium, together with the development of automated image analysis may improve the accuracy and value of measuring angiogenesisinduced microvessel density. mvd measurements may prove to be of value in assessing patients for antiangiogenic therapy, either alone or more likely in combination with chemotherapy. the ultimate goal of each study is how it can be benecial to the society. any research by itself on breast carcinoma is useful because of the sheer numbers of women worldwide who suffer morbidity & mortality due to this disease. hence there is relevance of search for new prognostic markers which may help in stratifying patients. also the fact that growth of tumours and their metastasis required angiogenesis brings to the fore relevant importance of antiangiogenic therapy. ongoing research in this direction world over has shown promising results. thus the role of angiogenesis as a prognostic marker and the role of antiangiogenic therapy both require more research & critical evaluation. conclusions the present study entitled “correlation of nuclear grading and angiogenesis in breast malignancy” is a comparative study carried out for nuclear grade and angiogenesis. the mvd increased from grade i to grade ii to grade iii lesions. on statistical analysis there was a positive high correlation between nuclear grade and microvessel density. thus it was concluded from present study that microvessel density correlate positively with nuclear grade. this study was conducted with a small number of cases and denite conclusions were not possible. however results of present x 33gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra study did show concurrence with those of other researchers. references: 1. berg jw, hutter rv. breast cancer. cancer. 1995 jan 1;75(1 suppl):257-69. pubmed pmid: 8001000. 2. galea mh, blamey rw, elston ce, ellis io. the nottingham prognostic index in primary breast cancer. breast cancer res treat. 1992;22(3):207-19. pubmed pmid: 1391987. 3. thomas m. pisansky m.d. james n. ingle m.d. daniel j. schaid ph.d.patterns of tumor relapse following mastectomy and adjuvant systemic therapy in patients with axillary lymph node-positive breast cancer. impact of clinical, histopathologic, and ow cytometric factors.volume72, issue4 15 august 1993 pages 1247-1260. 4. fisher b, brown am, dimitrov nv, poisson r, redmond c, margolese rg, bowman d, wolmark n, wickerham dl, kardinal cg, et al. two months of doxorubicin-cyclophosphamide with and without interval reinduction therapy compared with 6 months of cyclophosphamide, methotrexate, and uorouracil in positive-node breast cancer patients with tamoxifennonresponsive tumors: results from the national surgical adjuvant breast and bowel project b-15. j clin oncol. 1990 sep;8(9):1483-96. pubmed pmid: 2202791. 5. chevallier b, roche h, olivier jp, chollet p, hurteloup p. inammatory breast cancer. pilot study of intensive induction chemotherapy (fec-hd) results in a high histologic response rate. am j clin oncol. 1993 jun;16(3):223-8. pubmed pmid: 8338056. 6. murray pa, barrett-lee p, travers m, luqmani y, powles t, coombes rc. the prognostic signicance of transforming growth factors in human breast cancer. br j cancer. 1993;67:1408–1412. 7. magennis dp, mcnicol am. vascular patterns in the normal and pathological human adrenal cortex. virchows arch. 1998 jul;433(1):69-73. pubmed pmid: 9692828. 8. hussain ma, ali s. tyagi sp, reza h. incidence of cancer breast at aligarh. j indian med asso, 1994 sep, 92(9): 296-7. 9. doussal v, tubiana m, friedman s, hace k, burnet m. prognostic value of histologic grade nuclear components of scarf bloom richardson (sbr) an improved score modication based on multivariate analysis of 1262 idcs. cancer 64: 1914-1921, 1989 10. elston cw, ellis io. pathological prognostic factors in breast cancer. the value of histological grade in breast cancer: experience from a large study with long term follow up. histopathology, 1991; 19.403-410. 11. robinson ia, mckee g, nicholson a, d’acry j, jackson pa, cook mg, et al. prognostic value of cytological grading of ne-needle aspirates from breast carcinomas. lancet. 1994;343:947–9 12. bloom h j, richardson w w. histological grading and prognosis in breast cancer. br j cancer 11, 1957: 359-77. 13. nakopolou, l., stefanaki, k., panayotopoulou, e., giannopoulou, i., athanassiadou, p., gakiopoulou-givalou, h., and louvrou, a. expression of the vasscular endothelial growth factor receptor-2/fikl in breast carcinomas: correlation with proliferation. hum pathol. 1994; 33: 863–870 14. giampietro gasparinipatrizia boracchipierantonio bevilacquamaura mezzettifranco pozzanoel weidner.a multiparametric study on the prognostic value of epidermal growth factor receptor in operable breast carcinoma.january 1994, volume 29, issue 1, pp 59–71. 15. horak er, leek r, klenk n, lejeune s, smith k, stuart n, greenall m, stepniewska k, harris al. angiogenesis, assessed by platelet/endothelial cell adhesion molecule antibodies, as indicator of node metastases and survival in breast cancer. lancet. 1992 nov 7;340(8828):1120-4. pubmed pmid: 1279332. 16. weidner n, semple jp, welch wr, folkman j. tumor angiogenesis and metastasis--correlation in invasive breast carcinoma. n engl j med. 1991 jan 3;324(1):1-8. pubmed pmid: 1701519. 17. fisher er, redmond c, fisher b. histological grading of breast cancer. pathol annu 1980, 15(l):239-51. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 34 x gjra global journal for research analysis introduction: cardiovascular disease (cvd) is the principal cause of death worldwide. according to world health organization (who) cardiovascular diseases contribute to 20% of mortality and is estimated to have caused over 15 million deaths comprising more than one third of all deaths in the year 2001.(1) there are various risk factors which promote the development of cardiovascular disease. hypertension is a major indepe ndent risk factor for coronary artery disease & its attendant complications like infarction, cardiac failure and sudden cardiac death & also responsible for increased incidence of stroke and blindness. ththe joint national committee (7 jnc2003) on hypertension advocates non pharmacological therapy to be an important component of treatment of all patients with hypertension and prehypertension. lifestyle changes play important role in control of hypertension and these are to be continued for lifetime. (3) whole grain like wheat (tritium aestivum linn.) nds a place in the recommended dash diet and is an important component of human diet, particularly in developing countries. epidemiological studies reveal that consumption of whole grain and its products are protective against chronic diseases such as cardiovascular diseases, diabetes and cancer. wheat when harvested as young green shoots germinated over a period of 6-10 days is generally called 'wheat grass' and it is known as 'functional food' during which vitamins, minerals and phenolic compounds such as avonoids are synthesized in wheat sprouts reaching maximum antioxidant potential.(4) herbal products are highly acceptable and used 70 to 80% of the world population for their primary health care, especially in developing countries, due to their easy access, lesser side effects and low cost. it is also known to possess antioxidant as proven in several studies. (5,6) this property might protect the heart and preventing the most important cardiovascular complication. this study will denitely help and add knowledge in scientic exploration of cardio-protective potential of this promising herb in animal models. with this study, we had tried to nd out the cardio-protective potential of triticum aestivum linn. by observing its effect on isoproterenol induced myocardial infarction in rats. subjects and methods: this was a longitudinal study done on thirty healthy albino rats weighing between 100-200gms. prior to the dietary manipulation, all rats were fed standard rat chow, containing 60% vegetable starch, 11% fat and 29% protein, water ad libitum and maintained on 12 hours light/dark cycle. simultaneously rats were acclimatized to the procedure of blood pressure measurement daily for one week. drugs & chemicals: the drugs selected for the study were obtained in pure powder form from the following sources. 1triticum aestivum powder –girmes wheat grass, pune 2carvediliol – alkem company, mumbai, maharastra, 400013 3isoproterenol (iso) – get well pharmaceuticals, new delhi myocardial infarction was induced in rats by intraperitoneal injection of isoproterenol hydrochloride at a dose of 20mg/100g body weight, dissolved in normal saline for 2 consecutive days. thirty albino rats were grouped into ve groups of six rats in each, and housed in separate cages group-wise, as follows. group 1 (control) : rats were administered normal saline 0.5ml orally for 15 day followed by normal saline 5ml s.c. on th th14 & 15 day, at an interval of 24 hr. group 2 (iso) : rats were administered normal saline 0.5 ml orally once daily for 15 days followed by iso 20mg/100g body th thweight subcutaneously on the 14 & 15 day, at an interval of 24 hr. group 3 (tr low dose + iso) : rats were pretreated with triticum aestivum low dose 200mg/kg orally for a period of 15 days followed by subcutaneous injection of isoproterenol th th20mg/100g body weight on 14 & 15 day at an interval of 24 hr. group 4 (tr high dose + iso): rats were pretreated with triticum aestivum high dose 250mg/kg orally for a period of 15 cardio protective effect of wheat grass (tritium aestivum linn) in albino rats original research paper dr annapoorna sahoo tutor, pharmacology department, bhima-bhoi medical college and hospital, balangir, odisha pharmacology context: cardiovascular disease (cvd) is the principal cause of death worldwide. whole grain like wheat (tritium aestivum linn.) may have cardioprotective effect. aims: this study was carried out to nd out the cardio-protective potential of triticum aestivum linn by observing its effect on isoproterenol induced myocardial infarction in rats. settings and design: this was a longitudinal study done on thirty healthy albino rats methods and material: thirty albino rats were grouped into ve groups of six rats in each, and housed in separate cages groupwise. all groups except control received isoproterenol. in addition to isoproterenol, two groups were given wheat grass at different dosage and one group received carvediliol. cardiac parameters and histopathological study was done. statistical analysis used: anova test and post hoc dunnett test using spss version 16, unpaired t test results: signicant reduction in cardiac parameters was seen. conclusions: triticum aestivum prevented the isoproterenol induced cardiotoxicity. wheatgrass extract can be a good alternative or primary therapy in treating cardiovascular diseases myocardial infarction in future. abstract keywords : tritium aestivum linn, myocardial infaraction dr pravin dhone* professor and head, bhima-bhoi medical college and hospital, balangir, odisha *corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 48 x gjra global journal for research analysis days followed by subcutaneous injection of isoproterenol th th20mg/100g body weight on 14 & 15 day at an interval of 24 hr. group 5 (carvedilol + iso): rats were pretreated with carvedilol 5mg/kg orally for a period of 15 days followed by subcutaneous injection of isoproterenol 20mg/100g body th th weight on 14 and 15 day at an interval of 24hr. biochemical studies : at the end of the experimental period (after 24hr of the last dose of isoproterenol), orbital blood samples were collected from all the rats and the serum was used for estimation of biochemical parameters (cardiac biomarkers) like creatine phosphokinase (ck) and lactate dehydrogenase (ldh), aspartate aminotransferase (ast), alanine transaminase (alt) and alkaline phosphatise (alp). histopathologicalstudies : at the end of the experiment, three rats of each group were sacriced and the heart was isolated to measure its weight. the myocardial tissues from all groups were subjected to histopathological studies. the tissues were xed in 10% formalin, routinely processed, embedded in parafn wax and sectioned. parafn sections were then dewaxed,cut in glass slides, stained in hematoxylin and eosin and examined under light microscope. statistical analysis– the comparison were done using anova test and post hoc dunnett test using spss version 16, unpaired t test and p<0.05 was considered as statistically signicant. results: effect of triticum aestivum linn. on various cardiac biomarkers is shown in in isoproterenol induced myocardial infarction in albino rats. as evident in the table, it is having comparable effect to that of carvedilol. (table 1) effect of triticum aestivum linn. on histomorphology is shown.(table 2) carvedilol has a more protective effect compared to what grass. group i revealed cardiac bers with normal architecture and regular morphology and showed muscle bers with striations in cytoplasm and elongated nuclei. group ii showed large areas of infarcted cardiac muscle tissue with extensive loss of muscle bers, scattered inammatory cells and isolated residual muscle bers. group iii showed very small infracted cardiac muscle tissue, although it showed loss of muscle bers, occasional inammatory cells and isolated residual muscle bers. group iv revealed very small infarcted cardiac muscle tissue, although it showed loss of muscle bers, scattered inammatory cells in the infracted area. group v revealed almost normal cardiac bers and regular morphology and showed muscle bers with striations in cytoplasm and elongated nuclei. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra group drug dose duration induction of mi 1 distilled water 0.5 ml for 15 days no treatment 2 distilled water 0.5 ml isoproterenol 20mg/100gbwt. sc inj on 14th& 15th day. 3 triticum aestivum extract 200mg/kg 4 triticum aestivum extract 250mg/kg 5 carvedilol 5mg/kg table 1: effect of triticum aestivum linn. on various cardiac biomarkers. parameters (mmhg) group1 control (distilled water) group2 control iso 20mg/100gbwt group3 wg200mg/kg +iso 20mg/100gbwt group4 wg250mg/kg +iso 20mg/100gbwt group5 carvedilol 5mg/kg+ iso 20mg/100gbwt ck-mb ± se 75.34 ± 2.08 400.5 ±6.87 203.16 ±2.91 142.16 ±2.27 115.83 ±1.69 sgot ± se 31.567 ± 1.35 48.375*** ±0.93 39.49* ±0.81 34.82*** ± 0.54 31.40*** ± 0.63 sgpt ± se 19.253 ± 0.64 67.22*** ± 1.59 52.117* ±1.69 38.133*** ± 2.86 22.96*** ± 1.25 alp ± se 92.59 ± 2.7 129.45** ±2.85 184.102* ±2.51 155.25** ±1.97 98.84 ±2.09 ldh ± se 588.34 ±0.645 940.83*** ±3.64 740.16* ±3.42 691.5*** ±4.45 630.67*** ± 4.98 table 2:effect of triticum aestivum linn. on histomorphology of frontal section of heart in isoproterenol induced myocardial infarction in albino rats group1 control (distilled water) group2 control iso 20mg/100gbwt group3 wg200mg/kg +iso 20mg/100gbwt group4 wg250mg/kg +iso 20mg/100gbwt group5 carvedilol 5mg/kg+ iso 20mg/100gbwt grade-0 grade-4 grade-3 grade-2 grade-2 grade-0 grade-4 grade-3 grade-2 grade-1 grade-0 grade-4 grade-3 grade-2 grade-1 figure 1:photomicrograph in various group of rats group1 control (distilled water) group2 control iso 20mg/100gbwt x 49gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra group 3 wg200mg/kg +iso 20mg/100gbwt group4 wg250mg/kg +iso 20mg/100gbwt group5 carvedilol 5mg/kg+ iso 20mg/100gbwt discussion: this study was carried out to nd out the cardio-protective potential of triticum aestivum linn. by observing its effect on isoproterenol induced myocardial infarction in rats. wheat grass refers to the young grass of wheat (triticum aestivum) germinated for a period of 6 to 10 days. it contains vitamin c and e, ß carotene, ferulic acid, vanilic acid and phenols, especially avonoids. wheat grass juice is found to have healing properties in various degenerative diseases and is known to benet blood cells, bones, glands, kidney and other parts of the body. (7,8,9) since little or no work has been done on cardio-protective effects of wheat grass, the present study was designed to analyse its role on isoproteronol induced myocardial insufciency. histopathological observations were in correlation with our biochemical results. wheat grass treatment effectively reduced the pathological abnormalities and showed inammatory cell inltration, which is a positive immune response. this proves that wheat grass is very effective in lowering the lipid levels induced by isoproteronol. in the cardioprotective study, rst myocardial-infarction was induced with a �-adrenergic agonist isoproterenol, which caused severe stress in the myocardium causing coagulative necrosis (i.e. infarct like) of heart muscle. cardiac markers are biomarkers measured to evaluate the heart function. they are creatine phosphokinase, lactate dehydrogenase, aspartate aminotransferase etc. the present study showed development of oxidative cardiac injury induced by iso by the myocardial cell damage, the alteration in oxidative stress markers and the signicant decrease in sod as well as the levels of reduced gsh in the heart tissue. cardioprotection was conrmed by the decrease level of serum markers of heart damage and elevated levels of gsh, sod. (10) pre-treatment of triticum aestivum was able to reduce the iso induced cardiotoxic manifestations in multiple ways. increase in the level of plasma triglycerides, total cholesterol, ldls in the iso treated group indicate that iso may be interfering with metabolism or biosynthesis of lipids. heart tissue injury induced by iso in rats was indicated by elevated level of the marker enzymes such as serum. the increase of ldh level in serum suggests an increased leakage of this enzyme from mitochondria as a result of toxicity induced by treatment with iso. (11) treatment with iso increased serum marker of heart damage, ast, alt, alp. the pre-treatment with triticum aestivum attenuated this increase in ast, alt and alp level. serum level of ast, alt and alp were signicantly reversed by treatment with triticum aestivum extract was found to be more effective. light micrograph of iso injected rats showed necrosis of muscle bers, inammatory cell inltration and oedema with fragmentation of muscle bers as compared with the control group. treatment with triticum aestivum linn in iso treated rats (triticum aestivum linn.+ iso) showed moderate degree of edema, necrosis and inammatory cells compared to iri injected rats. to conclude, the present result suggests that triticum aestivum prevented the iso induced cardiotoxicity. wheatgrass extract can be a good alternative or primary therapy in treating cardiovascular diseases myocardial infarction in future. references: 1. world health organisation. world health organisation epidemiology and burden of disease unit.geneva, 2003. 2. pierdomenico sd , di nicola m,esposito al,di mascio r,ballone e,lapenna d, et al. prognostic value of different indices of blood pressure variability in hypertensive patients .am j hypertension .2009;22;842-7. 3. chobanianav, bakris gl, black hr ,cushman wc, greeen la,izzo jl,jr,et al. seventh report of the joint national committee on prevention ,detection, evaluation, and treatment of high blood pressure.hypertension,2003; 42:1206-52.[pubmed :14656957] 4. pickering tg. pathology of exercise hypertension.herz .1987;12:11924.[pubmed :2953661] 5. kyrou i, chrousos gp, tsigos c. stress, visceral obesity, and metabolic complications. ann n y acad sci.2006;1083:77-110.[pubmed :17148735] 6. wofford mr, hall je. pathophysiology and treatmengt of obesity hypertension. curr pharma design . 7. kulkarni sd, tilak jc, acharya r, rajurkar ns, devasagayam tpa, reddy avr. evaluation of the antioxidant activity of wheatgrass (triticum aestivum l.) as a function of growth under different conditions. phytother res 2006; 20: 218–227. 8. padalia s, drabu s, raheja i, gupta a, dhamija m. multiple potential of wheatgrass juice (green blood): an overview. chron young scientist 2010; 1: 23-28. 9. sri jaya m, gayathri s. antioxidant activity of wheatgrass & impact of supplementing grass extract anaemics. biomed 2009; 4: 262-268. 10. othman ai, el-missiry ma, amer ma, arafa m. melatonin controls oxidative stress and modulates iron, ferritin, and transferrin levels in adriamycin treated rats. life sci. 2008;83:563–8. 11. koti bc, vishwanathswamy ah, wagawade j, thippeswamy ah. cardioprotective effect of lipistat against doxorubicin induced myocardial toxicity in albino rats. indian j exp biol. 2009;47:41–6. 50 x gjra global journal for research analysis introduction peutz-jeghers syndrome (pjs) is rare with an estimated prevalence of 1:8000 to 1:200,000 births. males and females are equally affected. autosomal dominant disorder (1 per 200,000) with variable penetrance, usually diagnosed at age 20 – 30. hamartomatous polyps in small bowel (100%), stomach and colon (25%) polyps may occur without other features of syndrome, may cause intussusception and bleeding. polyps are benign but adenocarcinoma may arise from associated adenomatous lesions. h&e slides of peutz jegher's polyp low (left) and high (right) power views of the normal villous architecture of the small intestine. the high power view shows the enterocytes and interspersed goblet cells (arrows). a duodenal peutzjeghers polyp shows a tree-like proliferation of smooth muscle lined by normal small intestinal epithelium; the overlying epithelium is normal case report ÿ a 24 years old hindu male patient came in our emergency with chief complain of :generlised abdominal pain since 2 days, vomiting since 2 days, abdominal pain, was generalised, moderate in intensity, aggravated with taking meal and was not relieved with medication, not radiating to any other site. also vomiting, 2-3 episodes in 2 days ,non projectile, non billious, containing food particles ,occurs after 1-2 hours after meal. no c/o fever, diarrhoea, bleeding p/r,malena,constipation,burning micturition. no history suggestive of dm, htn, tb, jaundice, previous surgeries, blood transfusions. patient had no addictions. no signicant family history. on general examination, ÿ pulse-92/min ÿ bp100/60 mm hg ÿ rr-22/min on per abdomen examination: ÿ patient had generalised tenderness present all over the abdomen on per rectum examination: ÿ no e/o anal fissures or fistulas ÿ no bleeding per rectum investigations ÿ complete blood count, viral screening, coagulation prole, renal and liver function tests and serum electrolytes found to be normal. ÿ abdomen xray –s/o multiple air fluid levels ÿ chest xray – no abnormality detected ÿ usg abdomen + pelvis : ÿ approx 30*44 mm size target like lesion(bowel within bowel apperance) seen in pelvis. ÿ large bowel and messentry act as intussuceptum and large bowel act as intusuccepient. ÿ length of involved segment is 75mm and findings suggest p/o colo-colic intussuception. ÿ patient had outside cect abdomen with pelvis report which was suggestive of :ÿ dilatation of large bowel with a maximum diameter of 5.5cm with fat stranding in mesentery. ÿ rest of the abdomen had no signitcant abnormalities. plan of management ÿ after initial assessment, resuscitation and investigations, pt was taken for exploratory laparotomy in our emergency operation theatre. operative procedure ÿ exploratory laparotomy through midline incision was done. ÿ an 8 cm skin incision was placed on the lower midline of abdomen. ÿ after incising through the anterior abdominal layers, peritoneum was opened and bowel was evacuated out and approximately 40cm from the duodenojejunal junction, jejunojejunal intussusception was found. small bowel intussusception a case report: a rare case of peutz jegher polyp presenting as small bowel intussuception. original research paper dr rajesh d patel ms assistant professor, department of general surgery, b .j medical college, ahmedabad. general surgery keywords : dr jigarkumar j modi* mbbs 3rd year resident, department of general surgery, b .j medical college, ahmedabad. *corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 60 x gjra global journal for research analysis cut section of resected bowel showing multiple polyps in the bowel loop intussusception was manually reduced and a palpable mass was found at the lead point. enterotomy was done and multiple poypoidal lesions were found in the 10 cm segment of the jejunum. the segment was resected and end to end anastomosis was done in two layers using silk 2-0. approx 5cms free margins were kept on either side of the lesion. a 32fr romo adk was placed in the pelvis and fixed to skin. adequate wash given with normal saline. closure was done after instrument tally and mop count. post operative period ÿ patient was monitored for 24 hours and was then shifted to the wards. ÿ nil by mouth regime was employed. anitbiotics and fluids were given intravenously. rd ÿ sips were started on the 3 post operative day after patient passed stool and flatus. ÿ followed by liquids and then to soft diet subsequently. th ÿ abdominal drain was removed on 5 post operative day. ÿ pt was discharged after 5 days of observatory period. th ÿ skin stitches were removed on 15 post operative day discussion ÿ small bowel intussusception is a case of grave urgency as it will lead to intestinal obstruction and can cause ischemia and subsequent gangrene of the involved bowel loop. ÿ the intra enteral mass was the causation of intussuscception and acted as a lead point which caused obstruction of the proximal bowel. ÿ hpe examination of the resected segment of the small bowel with polyps revealed well differentiated adenocarcinoma inltritating into submucosa and reaching upto muscularis propria with no serosal breach. ÿ tumor staging was done which was t1nxmx ÿ modied duke's stage: b1 ÿ ajcc stage : group:1 ÿ in this case the patient was referred to the gcri( g u j a r a t c a n c e r a n d r e s e a r c h i n s t i t u t e ) fo r adenocarcinoma of small bowel. ÿ a review of the hpe slides were done at the gcri which was s/o peutz-jegher's polyp. ÿ no evidence of malignancy was found. ÿ patient is kept under regular 6 monthly follow up at gcri. references: 1. bailey and love’s short practice of surgery. 2. sabiston textbook of surgery. 3. devita,hellman and rosenberg’s cancer principles and practice of surgery. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 61gjra global journal for research analysis introduction microorganisms which persists and multiply inside the root canal system is the main causative factor in pulpal and peri radicular lesions .because endodontic infections are polymicrobial, many microorganisms take part in constitution ofbiolms and become more resistant to endodontic procedures. candida albicans and enterococcus faecalis are considered the most resistant species microorganisms which are responsible for root canal treatment failures(hancock, sigurdsson, trope, & moiseiwitsch, 2001) .consequently, antimicrobial agents can be combined to be effective against these polymic robialora. using this idea, different vehicles used to carry the medicaments can have adirect inuence on the release, time of onset of action of the medicament, penetration of the intracanal medicaments into dentinal tubules, and also the dissociation of drugs(athanassiadis, abbott, george, & walsh, 2009). calcium hydroxide(ch) is the most commonly used medicament in endodontics with signicant antibacterial effects on intracanal microorganisms. the efcacy of this material depends on the penetration ofhydroxyl ions into the dental tubules and accessory canals, where bacteria and their products accumulate. (siqueira & lopes, 1999), ch can prevent reinfection of the canal and impair nutritional supply of the residual microorganisms in the root canal system by forming a physical barrier. in order to have optimal efcacy in the root canal system, ch should be spread all over the canal walls to be in close contact with them(haapasalo, shen, wang, & gao, 2014). so calcium hydroxide powder is mixed with different vehicle for the continuous release of hydroxyl ions. so in this study we have combined ch with chlorhexidine, chitosan, glycerin which have proven antimicrobial action. different studies have shown controversial results over the antimicrobial efcacy of calcium hydroxide mixed with chx. therefore, thepurpose of the present study was to assess antimicrobial activity of ch when mixed with different vehicles against e.faecalis and c. albicans by agar diffusion method and to examine the invitrosusceptibilityof these microorganisms to amixture of ch and chx. materials and methods this in vitro study was conducted in the department of microbiology, kannur medical college, anjarakandy, kannur. calcium hydroxide(ch) powder was mixed with 2% chlorhexidine digluconate chx (rc prep), glycerin (100%), 0.5% chitosan and saline to form a slurryat 1.5:1(vol/wt). freshly prepared pastes of ch and a vehicle were used for each test. standard e.faecalis (atcc 29212) and c. albicans (atcc 60193) strains were used for this study. in the present study ch+chx(group1),ch+glycerine (group2),ch+chitosan(group3) andch+saline(group 4)as the positive control group. agar diffusion test hundred microliters of test organisms e.faecalis and c albicans suspensions were obtained from prepared culture and inoculated in a culture plate with previously set layers of muller hinton agar and sabouraud dextrose agar in vitro study of antimicrobial activity of calcium hydroxide mixed with different vehicles against e.faecalis and candida albicans original research paper dr. noushad m. c, professor ,department of conservative dentistry and endodontics ,anjarakandy, kannur dental college, anjarakandy, kannur,kerala x 81gjra global journal for research analysis dental science objective. : the purpose of this in vitro study was to investigate antimicrobial activity of calcium hydroxide (ch) in combination with chlorhexidine gluconate (chx),glycerine, chitosan and saline against enterococcus faecalis and candida albicans. study design: antimicrobial activity was determined using agar diffusion test. standard well in the cultivated agar plates were lled with one of the calcium hydroxide preparations and control agents. the zones of microbial inhibition were measured after incubation period. the combination of calcium hydroxide with chlorhexidine demonstrated most antibacterial activity of all results. : other preparations. all the tested groups had signicant antimicrobial action against e faecalis and c albicans. conclusion : antimicrobial activity of calcium hydroxide may change with the type of the vehicle. abstract keywords : calcium hydroxide, chitosan, chlorhexidine, glycerine, antimicrobial activity, vehicles dr. rakhi r* senior lecturer, department of conservative dentistry and endodontics ,anjarakandy, kannur dental college, anjarakandy, kannur, kerala *corresponding author dr. shaheen abootty senior lecturer, department of conservative dentistry and endodontics ,anjarakandy, kannur dental college,anjarakandy,kannur,kerala dr. suneetha m. p post graduate student, department of conservative dentistry and endodontics, kannur dental college,anjarakandy, kannur, kerala dr. kavya maheesan post graduate student, department of conservative dentistry and endodontics, kannur dental college,anjarakandy, kannur, kerala dr ashraf. k post graduate student, department of conservative dentistry and endodontics, kannur dental college ,anjarakandy ,kannur ,kerala volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra respectively for each organism. the strains were inoculated in brain heart infusion and incubated at 37°c for 24 hours. microbial cells were resuspended in saline to give a nal 8concentration of 1.5 10 cells/ml, similar to that of tube #0.5 of the mcfarland scale. for agar diffusion test, petri plates with 20 ml muller hinton agar (merck) were inoculated with 0.1 ml of one of the microbial suspensions. holes (4 mm in depth, 6 mm in diameter) were punched in the cultivated agar plates and lled with one of the ch preparations or control agents. each agar plate contained only one medicament. nystatin (antifungal; mycostatin; bristol-myers squibb, nj) and cefotaxime (antibacterial; fortum; glaxosmith kline) were the control agents. the plates were re incubated aerobically at 37°c for 24 hours. then the diameter of microbial inhibition zones around each well was measured and recorded in millimeters. statistical analysis was performed with one way anova and post hoctukey test. result analysis of variance (one way anova) was performed as parametric test to compare different groups for both e faecalis and c albicans. fig 1:zone of inhibition fig 2:zone of inhibition formed against e faecalis formed against c albicans 82 x gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra table 1: one way anova with post hoc tukey test graph 1: inhibiton of each agent agaisnt e faecalis table 2:one way anova with posthoc tukey test agaisnt candida albicans graph 2: inhibiton of each agent agaisnt e faecalis number of values minimum 25% percentile median 75% percentile maximum mean std. deviation std. error chlorhexidine-ch 5 16 16.25 17 17.75 18 17 0.7906 0.3536 glycerine-ch 5 12.5 13.25 14.5 15 15 14.2 1.037 0.4637 chitosan-ch 5 11 11.25 12 12.75 13 12 0.7906 0.3536 saline-ch 5 9 9.25 10 10.75 11 10 0.7906 0.3536 f 61.2 p value <0.0001 number of values minimum 25% percentile median 75% percentile maximum mean std. deviation std. error chlorhexidine-ch 5 20 20.75 22 23.25 23.5 22 1.369 0.6124 glycerine-ch 5 16.5 16.5 17 18 19 17.2 1.037 0.4637 chitosan-ch 5 17 17.25 18 18.75 19 18 0.7906 0.3536 saline-ch 5 14 14.25 15 15.75 16 15 0.7906 0.3536 f 40.68 p value <0.0001 utilizing abiocompatible intracanal medicament between appointments,help to diminish or eradicate bacteria in the root canal system and it enhance the success of root canal therapy(el karim, kennedy, & hussey, 2007). as e. faecalis is the commonly seen organism in infected root canals ,it was chosen as the test organism. virulency of e. faecalis in failed endodontically treated teeth may be related to its ability maintain the capability to invade dentinal tubules and adhere to collagen in the presence of human serum(love, 2001).in addition to this, different fungal speciesare also given special attention in failure of endodontic treatments. almost all the isolated species of fungi belong to the candida clade, predominantly candida albicans(mozayeni, hadian, bakhshaei, & dianat, 2015); which is the culprit responsible for development of pulpal and periapical infections.c.albicans promotes colonization the root canal by its collagenolytic activity and also it uses dentin as a nutrient source leading to its high virulence(yadav, chaudhary, saxena, talwar, & yadav, 2017). calcium hydroxide is the most commonly used intracanal medicament and its antibacterial effect is mainly due to thehigh ph by release of hydroxyl ions (sjogren, figdor, spangberg, & sundqvist, 1991).this hydroxyl ions diffuse through the dentin and reach sufcient levels to be lethal 3against the bacteria located inside the dentinal tubules . because of the buffering property of dentin, ph value of ca(oh) may be insufcient to kill some bacterial strains, 2 particularly e. faecalis, which can survive at a ph value of 11.5(kim & kim, 2014). although calcium hydroxide can effectively eliminate most of the root canal pathogens, e. faecalis and c. albicans are resistant to calcium hydroxide according to turkbt and ballalv et al(turk, sen, & ozturk, 2009).its resistance is due to the basic ph of calcium hydroxide,which in a basic medium ,proton pump activity occurs inside the microorg anismwhich acidies the environment and forms a biolm(maekawa et al., 2013). candida albicans is also resistant to calcium hydroxide. according to ballal v et al ch showed higher efcacy against candida albicans at the rst 24 hours and its effect was reduced after 72 hours. its resistance mechanism has yet to be fully understood but it seems that c. albicans due to biolm formation has a strikingly biphasic killing pattern in response to antibacterial agent(delattin, cammue, & thevissen, 2014). in this study all experimental groups were found to be effective against e faecalis and c albicans. group1 chx-ch combination showed the largest inhibition zone against e. faecalis and c.albicans compared to all other group. chlorhexidine has a broad spectrum antimicrobial activity and substantivity effect, and its optimal antimicrobial activity is achieved at ph range of 5.5-7.0.(athanassiadis et al) . therefore it is likely that alkalinizing the ph by adding ch to chx will lead toprecipitation of chx molecules and thereby . decreases its effectiveness (mohammadi & abbott, 2009).but it has been demonstratedthat ,there is no change in alkalinity of ch when mixed with chx. nevertheless, chx alone does not act as a physical barrier in solution or gel form, but combination of chx with ch paste act as a barrier in the root canal system long enough to e l iminate exis t ing (microorganisms and to stop recontamination ballal, kundabala, acharya, & ballal, 2007)another factor which explain antimicrobial synergism consist of production of more reactive oxygen species (ros), by combination of chx and ch.(turk et al., 2009) valera et al stated that although 2% chx gel signicantly decreased the microbial count, intracanal medicaments including ch and ch+chx completely eliminated the microorganisms from the canals(pavaskar et al., 2012). their ndings conrmed the synergistic effects of ch and chx. however, delgado et al ,found no signicant difference in terms of antibacterial properties of chx gel with and without ch. such controversy in the results may be attributed to the different culture techniques, root canal irrigating solutions, type of microorganisms and root canal anatomy.(saatchi, shokraneh, navaei, maracy, & shojaei, 2014)ina study by lin et al. chx alone and in combination withch showed . antibacterial efcacy greater than that of ch alone (saatchi et al., 2014) study conducted by c. maniglia-ferreira et al on the evaluation of the antimicrobial effects of different intracanal medications in necrotic immature teeth showed that ca(oh)2 paste in combination with 2 % chx gel was devoid of any antimicrobial activity against e faecalis which is in contradiction to the present study(maniglia-ferreira et al., 2016).systemic review and meta analysis by saatchi et al showed thatchx does not have synergetic antibacterial effect with ch. this may be due to deprotonation of chx at high ph, which reduces its solubility and alters its interaction with bacterial surfaces as a result of the altered charge of the .( )molecule saatchi et al., 2014 chitosan is a natural unbranched homopolymer obtained from chitin, an abundant by-product of seafood processing, via a de acetylation reaction with alkali.positivelycharged +nh groupof glucosamine present in chitosan, interact with 3 negatively charged surface components of bacteria, resulting in extensive cell surface alterations, leakage of intracellular substances and ultimately causing damage of vital bacterial activities.(raafat& sahl, 2009) chitosan binds to dna and inhibits mrnas ynthesis by penetrating toward the nuclei of microorganisms and interfering with the synthesisof mrna andproteins .consequently, it is possible that ca(oh) 2 combined with chitosan inhibits the growth of e. faecalis and subsequently it may inhibit bacterial re-entry and recolonization(elsaka& elnaghy, 2012). a synergistic antibacterial effect was found in ca(oh) combined with 2 chitosan against e. faecalis. another tested vehicle was 100% glycerin which is a sweet, syrupy liquid obtained from animal fats and oils or by the fermentation of glucose. glycerol consists of a propane molecule attached to three hydroxyl (oh) groups. recently glycerine has been recommended for use as vehicle as they possess better therapeutic and handling properties. according to this study, glycerin-ch combinations had potential antifungal effects and antibacterial effect. this activity can be due to continued dissociation of ch by imbibitions of water into paste, by hygroscopic nature of glycerine thus ensuring a continued therapeutic effect. sylvia et al have reported this combination have extensive gradual and sustained release of ca and hydroxyl x 83gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra tukey's multiple comparison test mean diff. q signicant? p < 0.05? summary 95% ci of diff chlorhexidine-ch vs glycerine-ch 4.800 10.47 yes *** 2.946 to 6.654 chlorhexidine-ch vs chitosan-ch 4.000 8.729 yes *** 2.146 to 5.854 chlorhexidine-ch vs saline-ch 7.000 15.28 yes *** 5.146 to 8.854 glycerine-ch vs chitosan-ch -0.8000 1.746 no ns -2.654 to 1.054 glycerine-ch vs saline-ch 2.200 4.801 yes * 0.3459 to 4.054 chitosan-ch vs saline-ch 3.000 6.547 yes ** 1.146 to 4.854 discussion lion.rivera and williams showed that glycerin help in easy placement of ch in the root canals. according to sudeep et al chglycerine combination showed a gradual increase in the zone of inhibition upto 7 days of incubation. the negative results which is obtained in other studies with glycerine may be due to their inability to diffuse through agar due to their viscous nature more than absence of any antimicrobial activity.(liu, wei, ling, wang, & huang, 2010) safavi and nakayama concluded that higher concentrations of glycerin reduce the conductivity of ch that would decrease the antibacterial activity of ch which is in contrast to our 30study . because of the ph of glycerin-ch combination would not be high enough to eliminate e. faecalis, because it could tolerate very high ph values with the durability of cell membrane and by using specic proton pumps and enzymatic systems. (portenier, waltimo, orstavik, & haapasalo, 2005)unlike other invitro tests, agar diffusion method, mainly depend upon the molecular size, solubility and diffusion of the materials through the aqueous agar medium, the sensitivity of the drug, bacterial source (wild strains or collection species), the number of bacteria inoculated, ph of the substrates in plates, agar viscosity, storage conditions of the agar plates, incubation time and the metabolic activity of the microorganisms. therefore, the inhibition zones may be more related to the materials' solubility and diffusabilityin agar than to their actual efcacy against the microorganisms which might be a limitation in our study. conclusion in summary the antimicrobial effect of ca(oh) is related to 2 the hydroxyl ions released in an aqueous environment, which affects cytoplasmic membranes, proteins, and the dna of microorganisms. theaddition of vehicles or other agents might contribute to the antimicrobial effect of ca(oh) . 2 although it remains controversial, the antimicrobial activity of ca(oh) can be increased with a mixture of ca(oh) with 2 2 chx. references 1. athanassiadis, b., abbott, p. v., george, n., & walsh, l. j. (2009). an in vitro study of the antimicrobial activity of some endodontic medicaments and their bases using an agar well diffusion assay. aust dent j, 54(2), 141-146. doi:10.1111/j.1834-7819.2009.01107.x 2. ballal, v., kundabala, m., acharya, s., & ballal, m. (2007). antimicrobial action of calcium hydroxide, chlorhexidine and their combination on endodontic pathogens. aust dent j, 52(2), 118-121. doi:10.1111/j.18347819.2007.tb00475.x 3. delattin, n., cammue, b. p., & thevissen, k. (2014). reactive oxygen speciesinducing antifungal agents and their activity against fungal biolms. future med chem, 6(1), 77-90. doi:10.4155/fmc.13.189 4. el karim, i., kennedy, j., & hussey, d. (2007). the antimicrobial effects of root canal irrigation and medication. oral surg oral med oral pathol oral radiol endod, 103(4), 560-569. doi:10.1016/j.tripleo.2006.10.004 5. elsaka, s. e., & elnaghy, a. m. (2012). antibacterial activity of calcium hydroxide combined with chitosan solutions and the outcomes on the bond strength of realseal sealer to radicular dentin. j biomed res, 26(3), 193-199. doi:10.7555/jbr.26.20110136 6. haapasalo, m., shen, y., wang, z., & gao, y. (2014). irrigation in endodontics. br dent j, 216(6), 299-303. doi:10.1038/sj.bdj.2014.204 7. hancock, h. h., 3rd, sigurdsson, a., trope, m., & moiseiwitsch, j. (2001). bacteria isolated after unsuccessful endodontic treatment in a north american population. oral surg oral med oral pathol oral radiol endod, 91(5), 579-586. doi:10.1067/moe.2001.113587 8. kim, d., & kim, e. (2014). antimicrobial effect of calcium hydroxide as an intracanal medicament in root canal treatment: a literature review part i. in vitro studies. restorative dentistry & endodontics, 39(4), 241-252. doi:10.5395/rde.2014.39.4.241 9. liu, h., wei, x., ling, j., wang, w., & huang, x. (2010). biolm formation capability of enterococcus faecalis cells in starvation phase and its susceptibility to sodium hypochlorite. j endod, 36(4), 630-635. doi:10.1016/j.joen.2009.11.016 10. love, r. m. (2001). enterococcus faecalis--a mechanism for its role in endodontic failure. int endod j, 34(5), 399-405. doi:10.1046/j.13652591.2001.00437.x 11. maekawa, l. e., valera, m. c., oliveira, l. d. d., carvalho, c. a. t., camargo, c. h. r., & jorge, a. o. c. (2013). effect of zingiber ofcinale and propolis on microorganisms and endotoxins in root canals. journal of applied oral science : revista fob, 21(1), 25-31. doi:10.1590/1678-7757201302129 12. maniglia-ferreira, c., de almeida-gomes, f., pinto, m. m., de sousa barbosa, f. t., de farias filho, d. m., & albuquerque, n. l. (2016). in vitro evaluation of the antimicrobial effects of different intracanal medications in necrotic immature teeth. eur arch paediatr dent, 17(4), 251-255. doi:10.1007/s40368016-0236-x 13. mohammadi, z., & abbott, p. v. (2009). the properties and applications of chlorhexidine in endodontics. int endod j, 42(4), 288-302. doi:10.1111/j.13652591.2008.01540.x 14. mozayeni, m. a., hadian, a., bakhshaei, p., & dianat, o. (2015). comparison of antifungal activity of 2% chlorhexidine, calcium hydroxide, and nanosilver gels against candida albicans. journal of dentistry (tehran, iran), 12(2), 109-117. 15. negi, p. s., jayaprakasha, g. k., jagan mohan rao, l., & sakariah, k. k. (1999). antibacterial activity of turmeric oil: a byproduct from curcumin manufacture. j agric food chem, 47(10), 4297-4300. doi:10.1021/jf990308d 16. pavaskar, r., de ataide ide, n., chalakkal, p., pinto, m. j., fernandes, k. s., keny, r. v., & kamath, a. (2012). an in vitro study comparing the intracanal effectiveness of calcium hydroxideand linezolid-based medicaments against enterococcus faecalis. j endod, 38(1), 95-100. doi:10.1016 /j.joen.2011.09.031 17. portenier, i., waltimo, t., orstavik, d., & haapasalo, m. (2005). the susceptibility of starved, stationary phase, and growing cells of enterococcus faecalis to endodontic medicaments. j endod, 31(5), 380-386. 18. raafat, d., & sahl, h. g. (2009). chitosan and its antimicrobial potential--a critical literature survey. microb biotechnol, 2(2), 186-201. doi:10.1111/j.17517915.2008.00080.x 19. saatchi, m., shokraneh, a., navaei, h., maracy, m. r., & shojaei, h. (2014). antibacterial effect of calcium hydroxide combined with chlorhexidine on enterococcus faecalis: a systematic review and meta-analysis. journal of applied oral science : revista fob, 22(5), 356-365. doi:10.1590/1678775720140032 20. siqueira, j. f., jr., & lopes, h. p. (1999). mechanisms of antimicrobial activity of calcium hydroxide: a critical review. int endod j, 32(5), 361-369. doi:10.1046/j.1365-2591.1999.00275.x 21. sjogren, u., figdor, d., spangberg, l., & sundqvist, g. (1991). the antimicrobial effect of calcium hydroxide as a short-term intracanal dressing. int endod j, 24(3), 119-125. doi:10.1111/j.1365-2591.1991.tb00117.x 22. turk, b. t., sen, b. h., & ozturk, t. (2009). in vitro antimicrobial activity of calcium hydroxide mixed with different vehicles against enterococcus faecalis and candida albicans. oral surg oral med oral pathol oral radiol endod, 108(2), 297-301. doi:10.1016/j.tripleo.2009.03.029 23. yadav, p., chaudhary, s., saxena, r. k., talwar, s., & yadav, s. (2017). evaluation of antimicrobial and antifungal efcacy of chitosan as endodontic irrigant against enterococcus faecalis and candida albicans biolm formed on tooth substrate. j clin exp dent, 9(3), e361-e367. doi:10.4317/jced.53210 84 x gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: 1 diabetes mellitus is the most common metabolic disorder. the incidence of cardiovascular diseases in patients with type 2 diabetes mellitus is increasing nowadays. assessment of cardiovascular risk in patients with type 2 diabetes mellitus is the primary concern in managing these patients. microalbuminuria is a known important risk factor for kidney disease. recent studies have highlighted micro albuminuria as an independent marker for endothelial dysfunction and 2 cardiovascular diseases. microalbuminur ia is a consequence of vascular diseases. albumin leakage into 3 urine is a reection of widespread vascular damage. microalbuminuria is dened as the excretion of 30-300 µg of albumin per mg creatinine excreted in a spot urine sample or 30-300mg of albumin excreted per day in a 24 hours urine 4 sample. microalbuminuria is highly prevalent in patients with 4diabetes mellitus, its prevalence ranging from 10 to 40 % . in india, the prevalence of microalbuminuria varies from 19.7 to 128.5 % in patients with type 2 diabetes mellitus. a duration of more than 6 years may have existed before the patients are diagnosed with type 2 diabetes mellitus, due to its insidious onset. as a result, patients often present with 5microalbuminuria at the time of diagnosis. microalbu minuria leads to increased risk of cardiovascular diseases 6and death. studies have reported that the risk factors for cardiovascular disease such as the fasting lipid prole varied signicantly between type 2 diabetes mellitus patients with and without microalbuminuria. this study is to evaluate the prevalence of microalbuminuria in recently diagnosed cases of type 2 diabetes mellitus and to study the correlation of the parameters of fasting lipid prole and microalbumin excretion in these patients, so that microalbuminuria can be used as an independent marker for early prediction of cardiovascular complications and can be used as a screening procedure in all patients diagnosed with type 2 diabetes mellitus. review of literature: microalbuminuria is dened as excretion of low levels of albumin in urine about 30 to 300 mg/dl. the prevalence of 7,8,9, 10,11microalbuminuria varies from 10 to 40% . it is urinary excretion of albumin that is persistently increased above normal levels, but below the sensitivity of conventional semi12quantitative test strips . microalbuminuria has been proposed as a strong and independent indicator of increased cardiovascular risk in subjects with and without diabetes. endothelial dysfunction and chronic low-grade, subclinical inammation has been implicated as a common pathophysiologic process in the association between microalbuminuria and cardiovascular 13,14,15,16,17,18disease . physiologically, the glomerular lter forms a barrier to prevent macromolecules from reaching the urinary space. the proximal tubule has an effective albumin reabsorption system that metabolizes albumin, so that urine contains no or only small quantities of albumin. increase in albumin excretion reects the loss of ltration power of glomerulus due to 4,10,19damage of glomerular endothelial cells (podocytes) . the incidence of subclinical atherosclerosis is increased in type 2 diabetic patients with microalbuminuria, insulin 20,21,22resistance and hyperglycemia . the pathophysiological process of atherosclerosis is mainly due to endothelial dysfunction. impaired endothelium leads to increased susceptibility to thrombus formation, increased adhesion of platelets and increased transmigration of leukocytes. the normal blood ow maintenance is by prostacyclin and nitric oxide which inhibits platelet activation. people with dm have reduced prostacyclin and no, due to a chronic impairment of endothelial no synthase activity. this also has been proposed as a mechanism of atheroma microalbuminuria – an increasingly recognized cardiovascular risk factor original research paper dr. s. aruna, m.d.* assistant professor, department of biochemistry, karur govt. medical college, karur *corresponding author x 1gjra global journal for research analysis biochemistry aim: the aim of the study is to determine the prevalence of microalbuminuria in newly diagnosed patients with type 2 diabetes mellitus and to compare the effectiveness of microalbuminuria with the fasting lipid prole in detecting cardiovascular risk in these patients in terms of atherogenic index. material &methods: the study group includes 100 patients with type 2 diabetes mellitus. patients with urinary tract infection, macro albuminuria, renal failure and heart failure are excluded from the study. fasting and post-prandial blood sugar, fasting lipid prole, atherogenic index, creatinine and urine albumin are measured in all the patients. the patients were divided in to two groups: group a without microalbuminuria and group b with microalbuminuria. results: bmi, fbs, ppbs, total cholesterol, tgl, atherogenic index, creatinine and urine albumin are found to be higher in group b compared to group a patients and serum hdl is found to be lower in group b compared to group a patients. pearson correlation coefcient of atherogenic indices with urine albumin excretion of group b patients shows that there is a signicant positive correlation (r = 0.5981). conclusion: microalbuminuria can be used as an independent marker for early prediction of cardiovascular complications and can be used as a screening procedure in all patients diagnosed with type 2 diabetes mellitus. abstract keywords : microalbuminuria, atherogenic index, cardiovascular diseases, diabetesmellitus. dr. j. sowndharya, m.d. tutor, department of biochemistry, karur govt. medical college, karur dr. r. s. monish anand, m.b.b.s. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 2 x gjra global journal for research analysis 22formation in patients with type 2 diabetes mellitus . the endothelial function in type 2 diabetes mellitus patients 23has a negative correlation with microalbuminuria .the leakage of albumin through glomerulus reects a widespread atherosclerosis-mediated capillary vascul 24opathy .angiographic studies proved that the extent of endothelial dysfunction correlates with the degree of albumin 10excretion .microalbuminuria is an index of vascular 25,26damage . urinary excretion of large amounts of proteins may lead to increased serum levels of total cholesterol and ldl27cholesterol .the number of patients attending cardiology outpatient setting is increasing, indicating that cardiov ascular high risk is common and possibly underes 23timated .microalbuminuria can be used as a prognostic factor for morbidity and mortality due to cardiovascular 25,28,29diseases in type 2 diabetes patients . there is evidence that reduction of albuminuria leads to improvement in the risk 11proles of patients with type 2 diabetes mellitus . lipid prole and atherogenic index have been shown to be 30,31signicant predictors for metabolic disturbances . atherogenic index was calculated by the formula = log (tg/hdl-c). friedewald formula is used for calculating ldl and vldl. 30,31vldl = tg/5, ldl = total cholesterol-(vldl+hdl). atherogenic index has been found to be an independent determinant of chronic subclinical inammation in patients 32with type2 diabetes mellitus .the atherogenic index of plasma has been positively correlated with cholesterol, tg, ldl, vldl and negatively correlated with hdl and the 33correlation is found to be statistically signicant .compared to conventional lipid levels, ratios such as tg/hdl-c have a better statistical link with the prevalence and severity of 34coronary artery disease . aims & objectives: 1. to determine the prevalence of microalbuminuria in newly diagnosed patients with type 2 diabetes mellitus. 2. to compare the effectiveness of microalbuminuria with the fasting lipid prole in detecting cardiovascular risk in these patients in terms of atherogenic index. materials & methods: the current study is a cross-sectional study and carried out for a period of two months. the study group includes 100 patients with type 2 diabetes mellitus. the patients are selected from those attending diabetic out patient department. informed written consent was obtained from all the 100 participants. inclusion criteria: patients with recently diagnosed type 2 diabetes mellitus (within 2 years of diagnosis) and age less than 40 years. exclusion criteria: patients presenting with 1. urinary tract infection 2. macro albuminuria 3. renal failure 4. heart failure of any stage. methodology: bmi (body mass index) is calculated and it is expressed as 2. (35)kg/m . fasting and postprandial blood samples and early morning urine samples are collected from the selected patients. in the fasting blood sample, plasma glucose, serum lipid prole and serum creatinine are measured. in the post prandial blood sample, plasma glucose is measured. in the early morning collected urine sample, microalbumin is measured. the parameters are determined using semi-auto analyzer. plasma glucose is measured by glucose oxidase peroxidase enzymatic method, serum creatinine by alkaline picrate method, serum total cholesterol by cholesterol oxidaseperoxidase method, serum triglycerides by enzymatic colorimetric method, serum hdl – cholesterol by phosphotungstate/magnesium precipitation method and urine microalbumin by turbidimetric immunoassay method. ldl is calculated by the friedewald formula. vldl is (30)calculated by the formula tgl/5 . observation & results: the patients were divided into two groups: group a, without microalbuminuria and group b, with microalbuminuria. atherogenic indices were calculated by using the following 35,30,31equation log (triglycerides / hdl cholesterol) . statistical analysis: all values are presented as mean ± standard deviation. the results were statistically analyzed by using student's 't'test and by pearson's correlation coefcient using microsoft excel worksheet. 'p' value <0.05 is considered as signicant. the study consisted of 100 patients out of which 54 patients had no microalbuminuria and 46 patients had microalb uminuria. the prevalence of microalbuminuria is 46% in newly diagnosed cases of diabetes mellitus. table-1: shows the biochemical characteristics of the study mean, standard deviation and unpaired t test correlation between group a and group b. table-2: shows the pearson correlation of atherogenic indices with urine albumin excretion of group b patients. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra s.no. bmi fbs ppbs t.chol tgl hdl group a 27.2±1.74 100.9±16.52 234±104.61 183.8±36.49 97.4±16.91 38.6±2.35 group b 27.6±1.39 115.7±16.85 288.5±104.8 200.3±28.21 140.5±27.63 35.6±4.93 p value <0.5 signicant <0.001 signicant <0.005 signicant <0.05 signicant <0.001 signicant <0.001 signicant table 1: table 2: discussion: the results show that bmi, fbs, ppbs, total cholesterol, tgl, atherogenic index, creatinine and urine albumin to be higher in group b compared to group a patients and serum hdl is found to be lower in group b compared to group a patients. s.no. creat a.i. m.alb. group a 27.2±1.74 100.9±16.52 234±104.61 group b 27.6±1.39 115.7±16.85 288.5±104.8 p value <0.001 signicant <0.001 signicant <0.001 signicant 1. 0.5981 (signicant positive correlation) s.no. pearson correlation coefcient x 3gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra pearson correlation coefcient of atherogenic indices with urine albumin excretion of group b patients shows that there is a signicant positive correlation (r = 0.5981). so, from the results obtained it is clear that the lipid prole is deranged in a signicant manner in type 2 diabetes mellitus patients with microalbuminuria (group b) compared to those with type 2 diabetes mellitus without microalbuminuria (group a). and from the pearson correlation, it is clear that there is a signicant positive correlation between atherogenic index and microalbuminuria as found in group b patients. endothelial dysfunction in the vascular wall has been proposed to play a pivotal role in the development and progression of subclinical atherosclerosis. the excretion of albumin into the urine is also due to a disturbance in the barrier function of endothelial glomerular cells (podocytes). so, the pathogenesis is systemic endothelial dysfunction and is common for both atherosclerosis and albumin excretion in urine. so the two parameters can be related. hence, microalbuminuria can be used as an independent biochemical marker for early prediction of cardiovascular risk factors and for primary prevention from cardiovascular diseases. albuminuria being a modiable risk marker and studies of secondary prevention have shown that blood pressure– lowering drugs effectively reduce the albumin excretion rate, ace inhibitors seem to be particularly effective. the current observation may lead to new therapeutic strategies in the prevention of cv disease. albumin excretion levels may represent the primary marker for success of such therapies. conclusion: microalbuminuria can be used as an independent marker for early prediction of cardiovascular complications and can be used as a screening procedure in all patients diagnosed with type 2 diabetes mellitus. periodic screening for microal buminuria could allow early identication of vascular disease and help stratify overall cardiovascular risk, especially in patients with risk factors such as diabetes. a positive test for urinary albumin excretion could signify the need for an intensive multifactorial intervention strategy, including behavior modication and targeted pharmacotherapy, aimed at preventing further renal deterioration and improving the overall cvd risk factor prole. in our study, the measurement of urinary albumin excretion is based on a single early morning urine sample. the urine albumin values of rst void sample are close to the 24 hours urine protein values than spot urine as found in previous other studies. but, a 24 hour urine sample would have been 36preferable . this study is cross-sectional, and without control participants. so, new studies are needed in this topic rectifying these limitations. suggestions: the american diabetes association recommends that patients with type 2 diabetes be tested for albuminuria at the time of initial diagnosis of diabetes mellitus and every year 25,11thereafter . physicians should measure urinary albumin excretion in patients with type 2 diabetes and hypertension routinely and be aggressive in treating this modiable risk factor. references: 1. dr. kedam. durga prasad, dr. perumalla rajaseker (2012) study of microalbuminuria as a cardiovascular risk factor in type 2 diabetes mellitus, asian j pharm clin res, 2012, vol 5, issue 2, 42-43. 2. coen d.a. stehouwer, yvo m. smulders, 2006, microalbuminuria and risk for 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bhattacharjee1, m.k bhatnagar, s. tyagi, atherogenic index of plasma, castelli risk index and atherogenic coefcientnew parameters in assessing cardiovascular risk, ijpbs |volume 3| issue 3 |julsep|2013|359-364. 36. subinaydatta, mrinal pal, comparison between different methods of urine collection for estimation of albumin-creatinine ratio in patients with type-2 diabetes mellitus, advances in biological chemistry, 2013, 3, 403-407. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 4 x gjra global journal for research analysis introduction hypertension is more prevalent in patients with chronic kidney disease (ckd) and has a strong risk of cardiovascular disease. elevated blood pressure leads to decline the kidney function in ckd patients. therefore, treatment of hypertension plays a central role in the management of ckd. hypertension accelerates vascular aging which leads to aortic stiffening. increased arterial stiffness (pulse wave velocity [pwv]) is associated with increased systolic blood pressure (sbp). however antihypertensive drug has achieved better controlling effect on diastolic blood pressure (dbp) than sbp. pwv may remain same or not after the antihypertensive drug therapy, which directly implies sbp response to the treatment [1]. antihypertensive regimens commonly include angiotensinconverting enzyme (ace) inhibitor and angiotensin receptor blocker (arb), calcium channel blocker (ccb), and beta blockers [2]. the mechanism of action of ccb, including amlodipine which inhibits n-type calcium channel and cilnidipine which inhibits both l and n-type calcium channels, in hypertension is due to its inhibition of calcium inux into vascular smooth muscle cells (vmc) that causes relaxation of vmc, decreased after load and systemic blood pressure. both amlodipine and cilnidipine have signicant impact on blood pressure and arterial stiffness [3-5]. however, amlodipine associated with higher incidence of adverse events like pedal edema leads to discontinuing the treatment. studies have reported the similar antihypertensive action between amlodipine and cilnidipine [6, 7]. however, cilnidipine is superior in terms of improving articial stiffness and central aortic pressure [8, 9] with greater antiproteinuric effect [10, 11]. there is still a scarcity of clinical trials comparing effects of amlodipine and cilnidipine on arterial stiffness and vascular aging in patients with ckd associated hypertension. therefore, the present study aimed to assess and compare amlodipine with cilnidipine on hemodynamic parameters of central blood pressure and arterial stiffness in patients with ckd on dialysis and with associated hypertension. methods and materials study design: the present prospective study was conducted in the department of nephrology of grant government medical college and sir j. j. group of hospitals, mumbai, maharashtra, india from october 2018 to october 2019. patients of either sex with ckd on dialysis and with associated hypertension were included in the study. patient with any known drug allergy, or with any history of systemic illness and presence of pre-existing edema, nephritic syndrome, anaemia was excluded from this study. study procedure: the complete medical history and demographic details (age, sex, body mass index (bmi), bp) were collected for each patient. central blood pressure (cbp) and as were measured ®using the mobil-o-graph pwa (i.e.m. gmbh, stolberg, germany). a common cuff was centered on the left upper arm. cuff size was chosen according to the circumference of the ®mid-upper arm. mobil-o-graph pwa provides information about peripheral bp, vascular age, augmentation index (ai) and pwv. patients who were taking either amlodipine or cilnidipine were categorised into group 1 and group 2, respectively. bp and pulse rate value were analysed and the average value was recorded. statistical analysis: statistical analysis was performed using statistical package for the social sciences (spss) version 23.0. analysis of categorical variables using chi-square test and continuous variables using independent sample t-test was done for the assessment of the level of signicance. a p value <0.05 was considered statistically signicant. results a total of 87 patients were included and majority of patients were men (n=55). the demographics of enrolled patients are summarized in table 1. comparison of hemodynamic and vascular parameters between patients with ckd and associated hypertension treated with amlodipine and cilnidipine original research paper dr. geeta sheth* associate professor, department of nephrology, grant government medical college and sir j. j. group of hospitals, mumbai, maharashtra, india *corresponding author x 9gjra global journal for research analysis nephrology background: hypertension is more prevalent in patients with chronic kidney disease (ckd) and has a strong risk of cardiovascular disease. this study was aimed to assess and compare amlodipine with cilnidipine on hemodynamic parameters of central blood pressure and arterial stiffness in patients with ckd on dialysis and with associated hypertension. methods: this was a prospective study conducted between october 2018 and october 2019. patients of either sex with ckd on dialysis and with associated hypertension and receiving either amlodipine or cilnidipine were included in the study. mobil-o®graph pwa was used assess peripheral bp, vascular age, augmentation index (ai) and pulse wave velocity (pwv). results: a total of 87 patients were included (group 1, amlodipine, n=55; group 2, cilnidipine, n=22). the majority of patients were men (n=55). proportion of patients with normal, average and abnormal vascular age and arterial stiffness was comparable between the treatment groups. however, in amlodipine group, frequency of patients with normal vascular age (42.2% vs 31.8%) was comparatively higher and frequency of patients with average vascular age (32.8% vs 40.9%) was comparatively lower, compared to cilnidipine group. conclusion: both amlodipine and cilnidipine showed equal efcacy on hemodynamic parameters of central blood pressure and arterial stiffness in studied population. abstract keywords : augmentation index, blood pressure, cardiovascular, pulse wave volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. shahid ansari senior registrar, department of nephrology, grant government medical college and sir j.j. group of hospitals, mumbai, maharashtra, india 10 x gjra global journal for research analysis the patients were divided into group 1, patients treated with amlodipine (n=65) and group 2, patients treated with cilnidipine (n=22). table 1: demographic and clinical characteristics of participants the mean age of patients from group 1 was 53.66 years while the mean age of patients from group 2 was 50.36 years with male predominance in both the groups (60% vs 72.7%). antihypertensive efcacy of amlodipine and cilnidipine drug therapy was found to be comparable (figure 1). sbp, systolic blood pressure; dbp, diastolic blood pressure. figure 1. antihypertensive efcacy of amlodipine and cilnidipine treatment proportion of patients with normal, average and abnormal vascular age was comparable between the treatment groups (p=0.675). however, in amlodipine group, frequency of patients with normal vascular age (42.2% vs 31.8%) was comparatively higher and frequency of patients with average vascular age (32.8% vs 40.9%) was comparatively lower, compared to cilnidipine group. frequency of patients from both the treatment groups was similar when categorized according to small and large arterial stiffness (p = 0.945 and 0.850, respectively). majority of patients had normal small arterial stiffness in both the groups while average and abnormal levels of large arterial stiffness were commonly observed in both the groups. mean peripheral bp was comparable between both the groups. the average pulse pressure was slightly higher in patients from cilnidipine group than those from amlodipine group without any signicant difference (p=0.093). augmentation index was comparatively higher in patients taking cilnidipine (p=0.411) compared to those taking amlodipine (p=0.411). pulse wave velocity was similar between both the group (p=0.565) (table 2). discussion this study assessed and compared vital hemodynamic parameters of central blood pressure and arterial stiffness measured by oscillometric methods in patients with ckd on dialysis and with associated hypertension treated with two types of calcium channel blockers; amlodipine, a l-type ca channel blocker and cilnidipine, n/l-type ca channel blocker. overall observations demonstrated no signicant difference in any of the pulse wave analysis parameters between the two treatment groups indicating similar effect of l-type and n/ltype calcium channel blockers on these patients. to our knowledge, there is no similar study conducted to compare these observations with amlodipine and cilnidipine. however, several past studies have compared amlodipine with cilnidipine on antihypertensive efcacy and incidence of pedal edema in hypertensive individuals. two studies from southern part of india demonstrated equal efcacy of cilnidipine and amlodipine in reducing blood pressure in hypertensive individuals [6, 7]. however, cilnidipine being n-type and l-type calcium channel blocker, associated with lower incidence of pedal edema compared to only l-type channel blocked by amlodipine. table 2: comparison of parameters between the treatment groups there are few studies which reported cilnidipine is more effective than amlodipine at improving renal function and arterial stiffness [8] and albuminuria and uric acid metabolism [12] in patients with essential hypertension and in hypertensive patients with ckd, respectively. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra characteristics total (n= 87) age (years) 52.83 (12.64) sex male, n (%) 55 (63.20) female, n (%) 32 (36.80) bmi (kg/m2) 22.72 (3.33) peripheral bp (mmhg) systole 128 (86-201) diastole 86 (58-130) pulse pressure (mmhg) 40 (19-79) heart rate (bpm) 85.49 (17.30) arterial bp (mmhg) 105 (76-159) augmentation index (%) 25.83 (11.25) pulse wave velocity (m/s) 7.84 (1.65) vascular age normal 34 (39.5) average 30 (34.9) abnormal 22 (25.6) central bp (mmhg) systole 119.08 (16.89) diastole 88 (59-132) arterial stiffness small arteries 26.19 (10.36) large arteries 7.84 (1.65) data shown as media (sd), unless otherwise specied. bmi, body mass index; bp, blood pressure parameters group 1 (n=65) group 2 (n=22) p value age 53.66 (12.24) 50.36 (13.77) 0.293 sex, n (%) male female 39 (60) 26 (40) 16 (72.7) 6 (27.3) 0.319 bmi 22.44 (3.33) 23.55 (3.28) 0.177 vascular age, n (%) normal average abnormal 27 (42.2) 21 (32.8) 16 (25) 7 (31.8) 9 (40.9) 6 (27.3) 0.675 small arterial stiffness, n (%) 37 (56.9) 23 (35.4) 5 (7.7) 13 (59.1) 7 (31.8) 2 (9.1) 0.945normal average abnormal large arterial stiffness, n (%) normal 18 (27.7) 7 (31.8) average 25 (38.5) 7 (31.8) 0.850 abnormal 22 (33.8) 8 (36.4) peripheral bp systole diastole 128.35 (20.81) 87.92 (14.15) 132.77 (15.50) 86.31 (10.20) 0.364 0.626 pulse pressure 41.41 (12.49) 46.45 (10.39) 0.093 heart rate 89.94 (17.11) 90.09 (17.42) 0.150 arterial bp 106.32 (15.70) 107.63 (11.95) 0.721 augmentation index 25.24 (11.63) 27.54 (10.12) 0.411 pulse wave velocity 7.88 (1.64) 7.70 (1.69) 0.656 central bp systole 118.68 (18.29) 120.27 (12.15) 0.704 diastole 86.48 (25.50) 88.54 (10.52) 0.713 data shown as mean (sd), unless otherwise specied. bmi, body mass index; bp, blood pressure malleshappa p. revealed that urinary albumin excretion was signicantly reduced by administration of the cilnidipine in hypertensive ckd patients [13]. he also suggested that early treatment of cilnidipine in hypertensive ckd patients with lowgrade albuminuria may prevent cardiovascular disease. a prospective randomized trial demonstrated by zaman et al. compared the effects of amlodipine and cilnidipine on blood pressure, heart rate, proteinuria, and lipid prole in hypertensive patients [10]. both the drugs showed signicantly reduced sbp and dbp. unlike amlodipine, pulse rate and urinary protein excretion were decreased in cilnidipine group. also, in cilnidipine group patients with diabetes showed reduce serum triglyceride. a multi-centre study at japan demonstrated that cilnidipine had greater antiproteinuric effects than amlodipine when used in combination with a renin-angiotensin system (ras) inhibitor to treat hypertensive patients [14]. therefore, cilnidipine showed higher antioxidant activity than amlodipine when used in combination therapy. similar study done by fujita et al. showed superior effect of cilnidipine in preventing progression of proteinuria more potently than that with amlodipine in hypertensive ckd patients concomitantly with ras therapy [11]. a randomized trial conducted in hypertensive patients with ckd reported reduction of ambulatory blood pressure and heart rate in the cilnidipine group compared with the control ccbs group. furthermore, the results showed that cilnidipine is superior to the control ccbs in improving left ventricular hypertrophy [15]. one open labeled study evaluated the effects of amlodipine and cilnidipine on pwv and augmentation pressures in hypertensive patients [9]. cilnidipine showed signicantly higher improvement in aortic blood pressure and aortic augmentation pressure as well as markers of arterial stiffness including pwv and augmentation index compared with amlodipine. however, this study showed that the cilnidipine has a similar antihypertensive action to the amlodipine, but is superior in terms of improving arterial stiffness and central aortic pressures. the present study assessed hemodynamic parameters of central blood pressure and arterial stiffness in ckd patients associated with hypertension using cilnidipine and amlodipine. however, there was no signicant difference in the markers of arterial stiffness and central blood pressure between both the groups. both cilnidipine and amlodipine have shown similar effect in reducing blood pressure in patients with ckd and associated with hypertension. the present study has several limitations. firstly, small sample size which may limit the determination of signicant effectiveness of drugs. secondly, this study could not evaluate the levels of hemodynamic and vascular parameters before and after the antihypertensive drug treatment in the patients with ckd and associated with hypertension which could have added a value to the study. studies with large sample size are required to conrm above results. conclusion both amlodipine and cilnidipine have shown equal efcacy in terms of hemodynamic parameters of central blood pressure and arterial stiffness in patients with ckd on dialysis and with associated hypertension. references 1. protogerou, a., blacher, j., stergiou, g. s., achimastos, a., & safar, m. e. (2009). blood pressure response under chronic antihypertensive drug therapy: the role of aortic stiffness in the reason (preterax in regression of arterial stiffness in a controlled double-blind) study. j am coll cardiol, 53(5), 445-451. https://doi.org/ 10.1016/j.jacc.2008.09.046 2. nguyen, q., dominguez, j., nguyen, l., & gullapalli, n. (2010). hypertension management: an update. am health drug benets, 3(1), 47–56. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4106550/ 3. safar, m. e., pannier, b., laurent, s., & london, g. m. (1989). calcium-entry blockers and arterial compliance in hypertension. j cardiovasc pharmacol, 14(suppl 10): s1-6, discussion s59-62. https://doi.org/ 10.1097/00005344198906151-00002 4. kim, k. h., jeong, m. h., cho, s. h., moon, j.y., hong, y. j., park, h. w., kim, j. h., ahn, y., cho, j. g., park, j. c., & kang, j. c. (2009). clinical effects of calcium channel blocker and angiotensin converting enzyme inhibitor on endothelial function and arterial stiffness in patients with angina pectoris. journal of korean medical science, 24(2), 223-231. https://doi.org/ 10.3346/ jkms. 2009.24.2.223 5. takahara, a. (2009). cilnidipine: a new generation ca channel blocker with inhibitory action on sympathetic neurotransmitter release. cardiovasc ther, 27(2), 124-139. https://doi.org/10.1111/j.1755-5922.2009.00079.x 6. babu, k. a. (2017). assessment of efcacy of amlodipine with cilnidipine in hypertensive patients: a comparative study. int j contemporary med research, 4(4), 956-958. https://www.ijcmr.com/ uploads/ 7/7/4/6/ 77464738/ ijcmr_1416_may_20.pdf 7. adake, p., somashekar, h. s., mohammed rafeeq, p. k., umar d., basheer, b., & baroudi, k. (2015). comparison of amlodipine with cilnidipine on antihypertensive efcacy and incidence of pedal edema in mild to moderate hypertensive individuals: a prospective study. j adv pharm technol res, 6(2), 81-85. https://doi.org/10.4103/2231-4040.154543. 8. morimoto, s., yano, y., maki, k., & iwasaka, t. (2007). renal and vascular protective effects of cilnidipine in patients with essential hypertension. j hypertens, 25(10), 2178-2183. https://doi.org/10.1097/hjh.0b013e3282c2fa62 9. pathapati, r. m., rajashekar, s. t., buchineni, m., meriga, r. k., reddy, c. b., & kumar, k. p. (2015). an open label parallel group study to assess the effects of amlodipine and cilnidipine on pulse wave velocity and augmentation pressures in mild to moderate essential hypertensive patients. j clin diagn res, 9(11), fc13-6. https://doi.org/10.7860/jcdr/2015/12702.6754 10. zaman, z. a., & kumari, v. (2017). comparison of the effects of amlodipine and cilnidipine on blood pressure, heart rate, proteinuria and lipid prole in hypertensive patients. int j basic clin pharmacol, 2(2), 160-164. https://doi.org/10.5455/2319-2003.ijbcp20130308 11. fujita, t., ando, k., nishimura, h., ideura, t., yasuda, g., & takahashashi, k. (2007). antiproteinuric effect of the calcium channel blocker cilnidipine added to rennin angiotensin inhibition in hypertensive patients with chronic renal disease. kidney int, 72(2), 1543-1549. https://doi.org/ 10.1038/ sj.ki.5002623 12. uchida, s., takahashi, m., sugawara, m., saito, t., nakai, k., fujita, m., mochizuki, k., shin, i., morita, t., hikita, t., itakura, h., takahashi, y., mizuno, s., ohno, y., ito, k., ito, t., & soma, m. (2014). effects of the n/l-type calcium channel blocker cilnidipine on nephropathy and uric acid metabolism in hypertensive patients with chronic kidney disease (j-circle study). j clin hypertens (greenwich), 16(10), 746-753. https://doi.org/10.1111/jch.12412 13. malleshappa, p. (2013). cilnidipine effectively reduces low-grade albuminuria in hypertensive chronic kidney disease patients. dial traspl, 34(1), 2-6. https://doi.org/ 10.1016/j.dialis.2012.04.001 14. soeki, t., kitani, m., kusunose, k., yagi, s., taketani, y., koshiba, k., wakatsuki, t., orino, s., kawano, k., & sata, m. (2012). renoprotective and antioxidant effects of cilnidipine in hypertensive patients. hypertens res, 35(11), 1058-1062. https://doi.org/10.1038/hr.2012.96 15. kanaoka, t., tamura, k., wakui, h., ohsawa, m., azushima, k., uneda, k., kobayashi, r., fujikawa, t., tsurumi-ikeya, y., maeda, a., yanagi, m., toya, y., & umemura, s. (2013). l/n-type calcium channel blocker cilnidipine added to renin-angiotensin inhibition improves ambulatory blood pressure prole and suppresses cardiac hypertrophy in hypertension with chronic kidney disease. int j mol sci, 14(8), 16866-16881. https://doi.org/10.3390/ijms140816866. x 11gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction job satisfaction is dened as the worker's attitude towards his or her job (peiró, 2000), which is based on the worker's beliefs and values. herzberg says there are factors that generate satisfaction and others that avoid job dissatisfaction. satisfaction or intrinsic generators include job content, accomplishments, and responsibility. and among those who only avoid dissatisfaction, it places company policies, the physical environment and safety at work (smerek and peterson, 2007). other authors such as cook and spector refer that job satisfaction is generated by: 1) characteristics of work (nature of work, autonomy, responsibility, rewards, payment, promotions, recognition), 2) interpersonal relationships (colleagues, bosses, supervisors), 3) organizational factors (policies, promotional opportunities, procedures, working conditions), and 4) personal aspects (internal motivation, moral values) (cuadra & veloso, 2007). studies on job satisfaction generally refer to "typical" determinants of work, i.e. labour law (with salary, guarantees and social protections established and inherent in a contract). thus, quantitative studies present satisfactories such as the amount of salary (mahendran and devanesan (2013); promotional opportunities (delgado, inzulza and delgado (2012) and involvement with the company (rico, 2012). and the results of qualitative studies, they afrm that job satisfaction varies with the hierarchical level of workers: at the bottom, they value more the amount of wages; at the middle level, professional development; and in the superior, the status (galanou, georgakopoulos, sotiropoulos and vasilopulos, 2011). also, they present work as "satisfactory, fun and fantastic", because they have variety in the tasks and recognition of their work (navarro, roche & fuentes, 2012), and as a result of working conditions such as comfort at work, (stability and schedules); sufcient remuneration and freedom or autonomy to work (lopez-garcía, 2016). on the other hand, the concept of precariousness in terms of work, is started to be used in france since the 70-80s, referring mainly to those "atypical" works that do not have a contract of indeterminate duration (bouffartigue and busso, 2009). however, there are a wide variety of atypical jobs with signicant differences (louie, ostry, quinlan, keegel, soveller & lamonagne, 2006). castillo (2012) mentions that it refers to wage-earning and non-employee occupations characterized by low quality, instability in employment and poor income or remuneration security. for its study, esope (2005) proposes four dimensions: 1) temporary, that is, the degree of certainty that the employee has about his work, that is what type of contract he has, and how long it is expected to last. 2) organizational, the control that can had at the individual and / or collective level of their working conditions, schedules, shifts and calendars, intensity of work, salary, health and safety. 3) economic: sufcient and progressive wage. 4) social: legal protection against unfair dismissals, discrimination and unacceptable working practices, and social protection (social security benets, health, accidents, unemployment insurance). finally, mora and oliveira (2009) take up these dimensions and build a synthetic index of precariousness: stability (determined time contract), salary and social protection. studies related to this type of work mention that the factor that generates the greatest stress in this type of work is insecurity at work (inoue, tsurugano, nishikitani & yano, 2010). precariousness in mexico is catalogued within informal work. mexico's national occupational and employment survey (enoe) notes that the informally occupied population is the workplace vulnerable by the nature of the economic unit in which it works and/or whose employment link or dependence does not give it access to social security or is not recognized by its source of work. includes the independent working mode (employers and self-employed). this survey shows that, during the rst quarter of 2019, 30.8 million people with informal work were registered in our country, or 56.9% of the occupied population (inegi, 2019). as for the independent artists participating in this research are part of this informal working group. studies such as guadarrama-olivera, hualde-alfaro & lópez-estrada (2012) already refer to the work of musicians in mexico as a precarious job, since they mostly perform multiple jobs, transient and without some kind of performance or social security. garcía-canclini (2012) refers that it is young people who have taken on the role as producers and consumers of culture. they consume, create, and communicate over unconventional networks. all this through self-employment, covering the inability of the current economic model to incorporate new generations into the labour market. that is why this research is presented, in order to establish the theoretical construction that according to their "precarious work", have been developed by independent artists from mexico city. method it was chosen to address this study to the qualitative methodology of grounded theory. its basic concepts are: theoretical sampling and theoretical saturation; the constant job satisfaction and precariousness in independent artists of mexico city original research paper maría del carmen lópez-garcía escuela nacional de medicina y homeopatía, instituto politécnico nacional, méxico medicine the objective of this study was to analyze the construction of the concept of job satisfaction through the perception of their working conditions in independent artists. we will consider all those occupations characterized by instability, insecurity in remuneration, and lack of social security within the concept of job precariousness. as a method it was applied grounded theory. the sample was integrated with independent artists from mexico city. in-depth interviews were applied and the data obtained were analyzed with atlas-ti software. the results reveal that the participating artists, although they perceive their precarious working conditions, like their work and assume their shortcomings as something necessary to what they must face in order to work in mexico, within that eld. abstract keywords : job satisfaction, grounded theory, precarious work. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 96 x gjra global journal for research analysis comparative method; open, axial and selective coding; memos and theoretical sensitivity (vivar et al., 2010). in-depth interviews were conducted for the collection of information, with open, generating questions, which allowed participants to respond on their own terms and for their answers to serve as the basis for deepening. the atlas.ti program was used for the analysis of the data. with the help of it, the appointments were codised and the categories were integrated with the form of job satisfaction. the selection criteria that were considered for the participants are: that they were artists, without some kind of employment contract greater than three months, who lived predominantly from their creative work, and lived in mexico city. finally, the exhibition was integrated with ten artists: ve of the male sex and ve, of the female. none of them have a stable partner. only one refers to an economic dependent. your socio-demographic data is presented in table 1 table – 1 socio-demographic data of participants source: direct it is interesting that all but two, have bachelor's level and that it is women, who have the highest academic level. however, even those without bachelor's degree, have extensive preparation in their area that they have acquired as apprentices with the experts of the area, as in the old cultures. results below are the emerging categories related to their working conditions and their resulting job satisfaction. working conditions was the emerging category of this research, which is decisive in the theoretical construction of the satisfaction of participating independent artists. working conditions jointly the perceptions that participants have of their employment situation. integrate the resulting codes of the categories: work by projects, you must diversify, i do not have xed schedule, i take care of myself and my house my workplace. the results are shown in figure 1. fig 1: job satisfaction categories they are then reviewed and presented by each of the built-in categories. category 1. work by projects (29 codes) this category highlights the temporality of its activities. in general, they claim that their income is very uctuating. they refer to funding or having received at some point in their lives, government grants with a maximum duration of three years. also, for the scholarships offered when undergoing graduate studies. they also say they work for orders, with payment informally, without xed contract. they only have a contract when their services are required for a festival, although payment in these cases is for fees. painters also work with dealers or gallerists, who require up to 50% of their work payment. in some cases there is family support, for maintenance costs. although they say they are used to it, they generally lament, "on a creative level, it is a burden the lack of xed income". and they claim that their success as artists, does not assure them that they will win well. category 2. you must diversify (28 codes) they say that, in order to be an artist, they must diversify and perform multiple activities. among the basic ones are musical performance and composition, dance, singing, sculpture, painting, drawing, animation for short lms and advertising. and they perform complementary tasks such as acting, modeling, university teaching and in workshops, carpentry, drawing design and curatorship for cultural events. all these for maintenance and to be able to nance their artistic project. category 3. i do not have xed hours (19 codes) in this sense, they like to be freelance, because they say they can accommodate their schedules, since they need rest periods, which say "they are part of the creation process". they explain: "sometimes, i spend time just watering plants, reecting and waiting for the idea…" or: "i spend days and nights working and then... nothing." and they say, "sometimes i don't even realize that i'm still working and i'm still working and i forget that i have to rest.” category 4. i take care of myself (9 codes) in this category it is clear that its lack of benets in terms of social security and health at work. they refer to health effects as a result of their work such as "i feel stressed because i'm on many projects," or when they narrate, "we have to set up scenarios in very different forums and we have to improvise and multiply, but if something happens, there is no insurance... one is responsible for our own actions and their consequences on health.” 5. my house and workplace (9 codes) also, some said to have a workshop, almost always a house or department enabled for it. others ensured that the same place where they lived, served as a house, workshop, and even as a winery where to store all their implements. despite all this, they said, "i love my job, it has to do with ideas coming out of me", "i love to share". and; "i'm grateful to do what i do, but it's hard, although it could be very easy in other circumstances.” conclusions in general, these workers perform "atypical" work without contract or benets. scholarships for funding are temporary and do not provide them with any health care or social security services in case of illness or accident. so, neither, a space to work according to your needs. according to herzberg's twofactor theory, it is observed that these workers value their intrinsic factors such as labour content and achievements, more than extrinsic ones, which are signicantly diminished. this, in obvious disregard with the results of job satisfaction studies carried out with those who perform a "typical" work. this because, the satisfactory of the participating independent artists are more related to their autonomy and self-realization, they like to share theself and give up their ideas. although there is agreement on satisfactories such as safety at work and wages, mentioned in investigations of mahendran and devanesan (2013), galanou et al. (2011) and lópez-garcía (2016). volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 97gjra global journal for research analysis we consider that this is a precarious work according to the dimensions of esope (2005) of temporality, organizational, economic and social. and it is consistent with guadarramaolivera, hualde-alfaro and lópez-estrada (2012), as to the need to carry out multiple activities, of a temporary nature and little remuneration that these art workers have, despite the high preparation who is required of them to carry out their activities. however, despite their precarious conditions these young people like not to be subject to a xed schedule, since their work rate is also not xed and goes according to their creativity. they also believe that if they wish to engage in this work, they must agree to do so within informality, with their "atypical" aspects. references: 1. castillo, d. (2001). the new precarious, women or men? trends in the urban labour market in panama, 1982–1999. papeles de población, 27 (enero–marzo): 99–145. 2. cuadra, a. & veloso, a. (2007). leadership, climate and job satisfaction in organizations.. revista universum,22 (2), 40 -56. 3. delgado, d., inzulza, m., delgado, f. (2012). quality of life at work: health professionals from río blanco clinic and medical specialty center. medicina y seguridad en el trabajo (internet), 58 (228), 216 – 223. 4. inegi. (2019). national survey for occupation and employment (enoe). retrieved from https://www.inegi.org.mx/programas/enoe/15ymas/ 5. esope. (2005). precarious employment in europe. a comparative study of labor market related risks in flexible economies. informe nal. bruselas: european commission. 6. guadarrama-olivera, r. hualde-alfaro, a. & lópez-estrada, s. (2012). job p r e c a r i o u s n e s s a n d o c c u p a t i o n a l h e t e r o g e n e i t y : a theoretical–methodological proposal. revista mexicana de sociología 74 (2). issn: 0188-2503 (versión impresa) 7. galanou, e., georgakopoulos, g., sotiropoulos, i.& dimitris, v. (2011). the effect of reward system on job satisfaction in an organizational chart of four hierarchical levels: a qualitative study. international journal of human sciences, 8 (1). 8. garcía-canclini, n., cruces, f. & urteaga, m. (2012). youth, urban cultures and digital networks. buenos aires: editorial ariel. 9. inoue, m., tsurugano, sh., nishikitani,m. & yano, e. (2010).effort-reward imbalance and its association with health among permanent and xed-term worker. (2010). biopsychosocial medicine, 4 (16). retrieved from http://www.bpsmedicine.com/content/4/1/16 10. lópez-garcía, m.c. (2016). theoretical construction of job satisfaction in occupational health physicians of companies in mexico, 2014. phd thesis. cucs, university of guadalajara, mexico 11. louie, a., ostry, a., quinlan, m., keegel, t., soveller, j. & lamonagne, a. (2006). empirical study of employment arrangementes and precariousness in australia. relations industrielles/industrial relations, 61(3), 465-489. 12. mahendran, m. & devanesan, p. (2013). job stress and job satisfaction among employees of insurance companies. golden research thoughts, 3 (issue 3). 13. mora, m. &, y de oliveira,o. (2009). the degradation of wage employment at the dawn of the 21st century: costa rica and mexico . papeles de población (universidad autónoma del estado de méxico), 15 (61), 195–231. 14. navarro, e., roche, h. & fuentes del burgo, j. (2012). do we know who we're working with? qualitative study on the work and job satisfaction of building ofcers. xvi valencia international project engineering congress,1113 de j u l i o , 2 0 1 2 . r e t r i e v e d f r o m h t t p : / / a e i p r o . c o m /  l e s / congresos/2012valencia/ciip12_0368_0378.3721.pdf 15. oit. (2014). informal employment in mexico: current situation, policies and challenges. 16. peiró, j. m. (2000). psicología de la organización. universidad nacional de educación a distancia, madrid 159, 165 – 170. 17. rico, p. (2012). job satisfaction of employees in spain. revista de métodos cuantitativos para la economía y la empresa, 14, 137-158. 18. vivar, c., arantzamendi, m., lópez-dicastillo, o. & gordo, c. (2010). the theory based as a qualitative research methodology in nursing. index de enfermería: 19 (4). 19 – 27. doi 10.4321/s1132-12962010000300011 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 98 x gjra global journal for research analysis black skin lightening usage and duration, hiv status, haart, and hypovitaminosis in kinshasa hospitals, dr congo (central africa) original research paper mandina ndona madone department of internal medicine, infectious diseases and parasaries service, university clinics in kinshasa, faculty of medicine, university of kinshasa, dr congo medicine background: the articial lightening of the skin is a social phenomenon in sub-saharan africa, most practiced by women using hydroquinone products, topical corticosteroids and mercury. vitamin d is synthesized in the skin and represents the main source of the body. the use of these lighteners that determine specic skin lesions is therefore likely to cause hypovitaminosis d. hiv infection and its treatment are also a recognized risk factor for hypovitaminosis d. objective: this study aimed to evaluate the inuence of the use and duration of lightening cosmetics, skin lesions, demographics factors, hiv status, and haart on vitamin d concentrations. design: the plasma level of 25-hydroxyvitamin d [25(oh)d] (25 [oh]d < 30 ng / l= hypovitaminosis d) was measured in a cross-sectional approach, and the use and duration of use of lightening cosmetics, as well as some socio-demographic, therapeutic, and biological variables were collected from hiv infected patients and non-hiv patients in 8 hospitals from kinshasa province, dr congo (drc). results: 506 participants (80.2% n = 406 hiv+ and 19.8% n = 100 hiv-), were examined with 66.7% (n= 337) of hypovitaminosis d. hypovitaminosis d was estimated 21% in hiv-, 100% in hiv+ not on haart, and 76,5% in hiv+ not on haart. 76.1% (n = 385) of the study population used lightening cosmetics whose 47.6% were for more than 5 years. hypovitaminosis d was more frequent (p <0.0001) among users of lightening cosmetics (73.3% n = 297/405) than among none users of lightening cosmetics (39.6% n = 40/101). there was a very signicant positive and linear association with biological gradient (p <0.0001) between increasing duration of use of cosmetics and hypovitaminosis d (39,6% in none users, 58% in 1-4 year-duration of use, 77,4% in 5-9 year-duration of use and 86,4% in ≥ 10 year-duration of use). in logistic regression, cosmetics use (or = 3.3 95% ci 1.9-5.7, p <0.0001), advanced age (or = 4.4 95% ci 2.7-7.2; p <0.0001), low socioeconomic status (or = 2.2 95% ci 1.2-4, p <0.009), and hiv+ on haart were identied signicant and independent determinants of hypovitaminosis d. conclusions: the proportions of hypovitaminosis d and use of lightening cosmetics are epidemic in urban congolese patients in general. the most important determinants of hypovitaminosis d were aging, lightening cosmetics, efv and zdv use and lower socio-economic status in these central africans. abstract volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra longo-mbenza benjamin* department of internal medicine, cardiology and physiopathology service, university clinics in kinshasa, faculty of medicine, university of kinshasa; faculty of health sciences, walter sisulu university, mthatha, private bag xi, mthatha 5117, eastern cape, south africa, university president joseph kasavubu, dr congo. biostatistics unit, lomo medical center and heart of africa center of cardiology, dr congo. *corresponding author renzaho andre school of social sciences and psychology, western sydney university, australia lepira mbompaka françois department of internal medicine, infectious diseases and parasaries service, university clinics in kinshasa, faculty of medicine, university of kinshasa, dr congo voumbo matoumona yolande university of marien ngouabi, brazzaville, republic of congo mokondjimobe etienne university of marien ngouabi, brazzaville, republic of congo francine ntoumi university of marien ngouabi, brazzaville, republic of congo wumba-di-mosi roger department of tropical medicine, infectious diseases and parasitaries, parasitology service, university clinics in kinshasa, faculty of medicine, university of kinshasa ; dr congo apalata teke ruphin department of internal medicine, cardiology and physiopathology service, university clinics in kinshasa, faculty of medicine, university of kinshasa; faculty of health sciences, walter sisulu university, mthatha, private bag xi, mthatha 5117, eastern cape, south africa, university president joseph kasa-vubu, dr congo kayembe ntumba jean marie department of internal medicine, infectious diseases and parasaries service, university clinics in kinshasa, faculty of medicine, university of kinshasa, dr congo mambueni thamba christophe biostatistics unit, lomo medical center and heart of africa center of cardiology, dr congo 74 x gjra global journal for research analysis introduction the involvement of the skin in the metabolism of vitamin d is well established. indeed, the endogenous synthesis of vitamin d takes place at the level of the skin from 7-dehydrocholesterol present in the membranes of the cells of the dermis and the epidermis, under the effect of the energy provided by ultraviolet b (uvb) (1, 2). the endogenous supply of vitamin d is more important than the exogenous supply of vitamin d (1, 2). the main factors inuencing this endogenous production are the seasons, the time of day, latitude, skin phototype, sun exposure duration, type of clothing and the use of sunscreens (3). it is also known that a higher pigmentation of the skin reduces the endogenous synthesis of vitamin d because melanin constitutes a natural sunscreen (4). not only, its major role in the growth and mineralization of bone, vitamin d has also numerous extra-bone effects on immunity (5), infections (6), cardiovascular risk (7, 8), renal damage (9, 10) and some cancers (11, 12). hypovitaminosis d is now reported more among hiv infected patients than among not infected people (13, 14). a general review of hypovitaminosis d in hiv infection, reports high rates of prevalence of hypovitaminosis d between 70.3% and 83.7% (15). the articial lightening of black skin is a social phenomenon in sub-saharan africa (ssa), and among immigrant populations in europe or the united states of america (16). this phenomenon, called "xessal" in senegal, "tcha" in mali, "tshoko" in the drc, emerged after african independences in the 1960 (17). prevalence rates of articial lightening of skin vary from 25% to 67% in sub-saharan africa (17). this skin lightening is more practiced by women using hydroquinonebased pharmacological components, dermocorticoids and mercury (16-18). the median duration of the use of lightening cosmetics is 4 years in senegal (18). the skin lesions are observed after at least 2 years of use lightening cosmetics in abidjan (19) and lomé (20). hiv infection (21), highly active antiretroviral therapy (haart) (22, 23), the use of lightening cosmetics (16, 24) and hypovitaminosis d itself (25) induces specic skin lesions (kaposi's disease, prurigo , chronic herpes simplex for hiv; toxidermia for arvs, dyschromia, exogenous ochronosis, increased mycosis and bacterial infections for cosmetics, skin cancer, autoimmune skin diseases, photodermatoses and psoriasis for vitamin d deciency) likely to compromise the penetration of uvb rays and lead to or aggravate a hypovitaminosis d. however, the epidemiology of the relationship between the use of cosmetics, the duration of use (toxicity) and hypovitaminosis d are not well understood in kinshasa hospital. what justies the initiation of the present study whose objective was to evaluate the inuence of the use and duration of lightening cosmetics, skin lesions, demographics factors, hiv status, and haart on vitamin d concentrations. materials and methods study design and sites this was a descriptive, comparative and analytical crosssectional study, conducted between 1 october 2015 and 30 november 2017. it was a multicentric study from hospitals in kinshasa province, drc. the study sites were characterized by the following four health levels of patient management with the use of antiretroviral treatment (art): community art station or level 1; referral health center or level 2; general referral hospital or level 3; university hospital or level 4. of the 1,315 art facilities scattered across drc, 335 (25.7%) are located in kinshasa which were eligible for this study. the inclusion criteria for the health settings were as follows: ÿ level 2-4 health settings that provide art, dened based on available resources (health center, general referral hospital, university hospital); ÿ level 2-4 health settings that provide art for adults. of the 335 health settings of the capital kinshasa, 114 (34%) were not excluded, including maternities, pediatric services and community art station. 8 health settings were randomly selected by simple random random draw (centre hospitalier boyambi, hôpital central de la police nationale congolaise, centre bomoi de n'djili, centre hospitalier kimbanguiste, hôpital général de makala, centre médical de kinshasa, hôpital général de n'djili, cliniques universitaires de kinshasa). study population and sampling the study population consisted in hiv-infected and noninfected patients taken care in the art centers selected for the study that met the following inclusion criteria: age ≥15 years, hiv status (positive not on art, positive on art and negative); conrmed by a rapid serological test, art naïve patient, patient having a medical record that contains information on study variables of interest, voluntary participation and provision of informed consent. the criteria for exclusion were as follows: vitamin d supplementation, treatment for osteoporosis, treatment for a kidney condition, severe liver disease, and refusal to participate in the study. laboratory data hiv rapid serological test (alere determine™ hiv-1/2, abbott) was used in all participants to conrm the presence of hiv specic antibodies. determine test is one of the three hiv-tests used at rst-line for hiv/aids screening in drc (26). total 25-oh vitamin d (d2 and d3) was measured by the elisa (enzyme linked immunosorbent assay) method, which is an enzymatic colorimetric assay (27). operational definitions of outcome variables aging, marital status, churches and socio-economic status (ses) were the demographic factors. advanced age was dened by an age ≥ 60 years. marital status has been dened by single / non married and married. ses was respectively dened by the low (unemployed, housewives, state ofcials) and high (traders, executives, legislators) levels. participants were belonging to reveal-charismatic/muslim churches or to traditional churches (catholic, protestant, salvation army and kimbaguisme churches). the use and the no-use of lightening cosmetics including the steroids, hydroquinone, mercury-based soap and lotions were considered. skin lesions comprised of hyperchromic spot dermatologic lesions. vitd status was dened normal or optimal status by a serum level of vitd ≥ 30ng/ml (28). hypovitaminosis d was dened by a serum level of vitd < 30 ng/ml, vitd insufciency for vitd = 20–29 ng/ml and vitd deciency for vitd ≤ 20 ng/ml (29, 30). ethical considerations research approval was obtained from the ethics committee of the kinshasa university school of public health (no esp/ce/062/2016) on 29 june 2016. all research procedures volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra keywords : vitamin d, hiv infection, lightening cosmetics, aging, efv, zdv kinshasa, central africa. x 75gjra global journal for research analysis were undertaken according to the helsinki. the participation in the study was voluntary, upon provision of a written informed consent form. additionally, condentiality of the information obtained from the participants was guaranteed and access to the study data was allowed only to the investigators. data analysis for categorical variables, data were presented as frequencies and proportions (%), whereas mean and standard deviations were used to present continuous variables. in univariate analysis, pearson's chi-square test was used to compare proportions between groups for large sample. student's t-test was used to compare means between 2 groups for normally distributed variables. however, the analysis of variance (anova) was performed to compare means for ≥ 3 groups. after excluding confounding factors, a multivariable binary logistic regression analysis was performed to identify independent and signicant determinant of hypovitaminosis d. a p-value < 0.05 was considered as the threshold of statistical signicance. all analysis were performed using the statistical package for social sciences (spss) for windows version 19 (spss inc chicago, il,usa). results table 1. characteristics of the study participants general characteristics in total, 506 persons were examined, including 406 hivinfected patients and 100 non infected (comparative group). the mean age of participants was 57.1 years; the distribution of the proportions of participants by age-group was as follows: 15 – 39 years (18.6%; n=94), 40-59 years (22.5%; n=114), 60-69 years (32.2%; n=158) and 70 years or older (27.7%; n=140). the majority of participants was female, 75.9% (384/506) (vs. 24.1% for males); the sex ratio between women and men was 3:1. out of hiv+, 5,6 % n=23 were not on art. whereas, 94,3% (n=383) were on art (51,4% n=197 on zdv+3tc+nvp, 40 ,2% n=154 on tdf+3tc+efv, 4 ,4% n=17 on zdv+3tc+efv, 2,3% n=9 on tdf+3tc+nvp, 0,8% n= 3 on tdf+3tc+lpv/r, 0,52% n=2 on zd v+3tc+lpv/r, and 0,3% n=1 on abc+ddi+lpv/r) proportions and means of general characteristics were compared between hiv+ and hiv(table 1). various of sex and age were comparable (p>0,05) between hiv+ and hiv-. however, a proportion of low ses, married status and traditional churches were signicantly (p<0,0001) higher among hiv+ than among hiv-. prevalence of hypovitaminosis d, vitamin d insufficiency, and deficiency the overall prevalence of hypovitaminosis d was estimated 66.6 % (n=337/506). out of patients with hypovitaminosis d, 54.6% (n= 273) had vitd deciency, and 12% (n=64) had vitd insufciency. frequency of use of artificial lightening of the skin more than three-quarters of participants (76.1% n = 385) used lightening cosmetics. figure 1 characterizes the study population by use and stratied duration of lightening cosmetics with 23.9%, 28.5 %, 25.7% and 21.9% respectively without use, use for 1-4 years, 5-9 years, and ≥ 10 years. figure 1. use and stratied duration of lightening cosmetics in the study population. univariate association between demographics factors and hiv infection, and hypovitaminosis d there was univariate association between females, aging, reveal/muslim church, married status, low ses, hiv infection and hypovitaminosis d. table 2. association between demographics factors, hiv infection, and hypovitaminosis d univariate associations between the use of lightening cosmetics, dermatological lesions and hypovitaminosis d hypovitaminosis d was more frequent (p<0.0001) when volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra variables all (n=506) hiv + (n=406) hiv – (n=100) p sex, % (n) men women 24,1 (122) 75,9 (380) 23,4 (95) 76,6 (311) 27 (27) 73 (73) 0,451 age, % (n) > 60 yrs < 60 yrs 58,9 (298) 41,1 (208) 59,6 (242) 40,0 (164) 56 (56) 44 (44) 0,512 ses % (n) low high 75,5 (382) 24,5 (124) 87,2 (354) 12,8 (52) 28 (28) 72 (72) < 0,0001 marital status, % (n) married none married 70,2 (355) 29,8 (151) 79,6 (323) 20,4 (83) 32 (32) 68 (68) < 0,0001 churches, % (n) reveal/muslim traditional churches 26,9 (136) 73,1 (370) 32,8 (133) 73,8 (273) 3 (3) 97 (97) < 0,0001 variables hypovitaminos is d % (n) or (95% ic) p sex ÿ women ÿ men age ÿ ≥ 60 yrs ÿ < 60 yrs churches ÿ reveal/muslim ÿ traditional churches marital status ÿ married ÿ none married ses ÿ low ÿ high hiv status ÿ hiv+ ÿ hiv69,3 (266/384) 58,2 (71/122) 76,8%(229/298) 51,9%(108/208) 82,4 (112/136) 60,8 (225/370) 74,1 (263/355) 49 (74/151) 76,4 (292/382) 36,3 (45/124) 77,8 (316/406) 21 (21/100) 1,6 (1,1 2,5) 1 3 (1,9 4,9) 1 3,1 (2,1-4,5) 1 3 (2 4,4) 1 5,7 (3,78,8) 1 13,2 (7,7-22,6) 1 0,024 <0,0001 <0,0001 <0,0001 <0,0001 <0,0001 76 x gjra global journal for research analysis lightening cosmetics were used (73.3% n=297/405) than when not used (39.6% n=40/101). in addition, there was a very signicant biological gradient (p<0.0001 trend) between increasing the duration of use of cosmetics and hypovitaminosis d in the study population (figure 2). figure 2. relationship between the duration of use of lightening cosmetics and hypovitaminosis d in the study population. there was a positive and very signicant association (p <0.0001) between hyperchromic spot dermatologic lesions and hypovitaminosis d: hypovitaminosis d more common in hyperchromic lesions (90% n = 45 / 50) in the absence of dermatological lesions (64% n = 292/456). the use of cosmetics was more (p<0.001) reported by women (82.3% n=299/355, p=0.038) than by men (68.9% n=84/122). aging was more associated with the use of cosmetics (83.9% n=250/298, p=0.009) than was the young age (74.5% n=155/208). reported more use of cosmetics (83.6% n=321/384) than did singles (74.8% n=113/151). cosmetics use was more reported (p<0.0001)) by women of low socioeconomic status (84.3% n=322/382) only by high ses participants (66.9% n=83/124). independents determinants of hypovitaminosis d two multivariable models (logistic regression and multiple linear regression) were used to identify independent determinant of hypovitaminosis d and vitamin d variation in the study population. after adjusting for confounding factors (marital status and gender) using the binary logistic regression model, cosmetics use, low socioeconomic status, advancing age, art regimens zdv + 3tc + nvp, tdf + 3tc + efv, zdv + 3tc + efv, and tdf + 3tc + nvp or lpv / r were identied as independent and signicant determinants of hypovitaminosis d in the study population (table 3). table 3. independent associations between the use of cosmetics, sociodemographic factors, therapeutic modalities and hypovitaminosis d in the study after adjusting for the confounding variables using multiple linear regression model according to the antiretroviral molecules, 13.5% of variation (r2 adjusted) of the decrease in vitamin d concentrations (towards hypovitaminosis d) were predicted (explained) signicantly and independent by increased viral load, increased duration of cosmetic use, aging, and female sex (table 4 and figure 3). table 4. independent role of viral load, duration of use of cosmetics, age advancement and sex on the prevalence of hypovitaminosis d figure 3. straight lines and partial regression equations of serum vitamin d concentrations explained by sex, age, viral load and duration of use of cosmetics. discussion this study sought to demonstrate potential associations between the use and duration of lightening cosmetics, skin lesions, demographic factors, hiv status, and haart on vitamin d concentrations among patients managed for hiv infection and for absence of hiv infection with inammation (comparative group) in kinshasa province, drc, central africa. hypovitaminosis d varied according to geotype (geographic origins) in this study and in the literature (31, 32). indeed vitamin d concentrations are impacted by latitude and seasons (3, 33). the rate of hypovitaminosis d was closed to 70% in this study as also as within the interval of 5 90% in the general population from middle east (35), north africa (34, 35) and sahel regions (36), hypovitaminosis d is also widespread in middle eastern countries, probably because of heavy dress habits (34, 37). furthermors, the average of hypovitaminosis d rate in kinshasa megacity, drc, was high from the present study in hospital (66,6%), 62,1% ilanga and al (38), and 95,2% kabengele and al (39) in hospital studies. mvitu and al (40) in both community and the hospital, and m'buyamba-kabangu and al (41) in the general population was also reported high frequencies. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra b es wald adj or (95% ci) p value independents variables use of cosmetics ÿ yes ÿ no 1,181 0,247 16,854 refere nce 3,3 (1,9-5,7) 1 <0,00 01 ses ÿ low ÿ high 0,787 0,302 6,772 refere nce 2,2 (1,2-4) 1 0,009 advancing age ÿ yes ÿ no 1,483 0,247 36,112 refere nce 4,4 (2,7-7,2) 1 <0,00 01 art regimens ÿ zdv+3tc+nvp ÿ tdf+3tc+efv ÿ zdv+3tc+efv ÿ tdf+3tc+ nvpou lpv/r 2,379 2,241 2,001 1,384 0,364 0,371 0,638 0,713 42,648 36,570 9,832 3,875 10,8 (5,3-22) 9,4 (4,6-19,5) 7,4 (2,1-25,8) 4(1,002-16,1) <0,00 01 <0,00 01 0,02 0,05 constant 3,459 0,420 67,669 <0,00 01 independents variables coefcients non standardizes coefcients standardizes beta p value b es viral loads (copies/ml) -3,847 4,36 -0,224 < 0,0001 duration of cosmetics use (yrs) -2,235 0.00 -0,146 0,003 age (yrs) -0,33 0,75 -0,134 0,006 female sex -4,726 0,05 -0,123 0,012 constant 39,68 1,86 < 0,0001 x 77gjra global journal for research analysis out of hiv-infected patients in this study, 83% had hypovitaminosis d, whereas only 21% of hypovitaminosis d was reported in the comparative group conrming (14, 42) and not conrming (43, 44). indeed, hypovitaminosis d rates from the present results were similar to those reported in some studies among hiv-infected patients versus the general population (14, 42), while other studies did not nd difference between hiv-infected patients versus the general population (43, 44). the proportion of hypovitaminosis d found in this study among hiv-infected patients was in the range reported by mansueto et al, in their review of hypovitaminosis d in hiv infection, where almost all of studies did nd a high prevalence of hypovitaminosis d ranging from 70.3% to 83.7% in hiv-infected patients worldwide (15). in sub-saharan africa, including the present kinshasa study reported frequencies appear to be lower than those reported by most european and us studies (15). thus, the prevalence of hypovitaminosis d varies from 35% to 75% in most studies in warmer tropical africa in hiv-infected adults (43-45) in comparison studies from colder tempered european (13, 42) and north america (46, 47). more than 3/4 (76.1%) of the participants in this study used lightening cosmetic products. this proportion was close to that found by hardwick et al (69%) in south africa (48), slightly higher than that found by wone et al (67%) in senegal (49), but much higher than that of 25 % reported in mali (18). the risk of toxicity related to the use of corticosteroids, hydroquinone, and the mercury salts contained in these products was estimated to be real in 47.6% of the participants in the present study with a duration of use of more than 5 years, well above the onset of lesions observed after the start of the use of lightening cosmetics (≥ 2 years) in abidjan (19) and lomé (20). as reported in senegal (49) and mali (18), female sex, adulthood, being married, low socioeconomic status, were identied as signicant contributing factors to the use of cosmetics in this study. in contrast to the data in this study,that from côte d'ivoire reports the use of cosmetics for skin depigmentation among young urban women between the ages of 20 years and 30 years, single, educated and professionally active, wanting to be more beautiful (19). the relationship between the use of cosmetics, the duration of use (toxicity), hyperchromic dermatological lesions and hypovitaminosis d are not yet specically explained in the literature whereas the results on cosmetics issues in the present study could be explained by several complex physiopathological mechanisms: skin application of hydroquinone / corticosteroid-based products leads to premature aging of the skin with a decrease in the concentration of 7-dehydrocholesterol in the deep layers of the epidermis which reduces the rate of vitamin d (50); exogenous ochronosis (blackish reticulate layers), which is the most typical complication associated with prolonged application of hydroquinone, occurs mainly in exposed photo areas and results from a cumulative photo-toxic reaction leading to the alteration of melanocytes and elastic tissue (24); with the inhibition of melanin production, the skin loses its natural protection against the uva and uvb rays of the sun and uv light can lead to dna damage, inammatory responses, skin cell apoptosis (programmed cell death), skin aging, and skin cancer (50, 51) that may compromise the skin synthesis of vitamin d. vitamin d deciency has been associated with skin lesions including skin cancer, autoimmune skin diseases, photodermatoses, atopic dermatitis and psoriasis (52). this study also showed that the use of cosmetics among elderly hiv patients with a low socio-economic status under antiretroviral therapy with efv and zdv were at high risk of hypovitaminosis d. it should be recalled that in sub-saharan africa, 60% of hiv infected persons are women (53, 54), most of female users of cosmetics live in precarious situations (55). the advanced age as well as the use of lightening cosmetics are both responsible for an aging of the skin that can explain the hypovitaminosis d. indeed, the concentration of 7dehydrocholesterol in the deep layers of the epidermis decreases with age (75% reduction in skin regeneration at age 70 years) (56, 57). in addition, the decrease in vitamin d concentrations was explained by the increase in the duration of use of cosmetics and the advancement in age in the present study, attesting that the appearance of the skin toxicity of these cosmetics is depending on the duration of use (17-19). implications for public health the present ndings will impact in terms of public health (prevention, education, attitude and practice) about cosmetics use in general population and among hiv infected patients. the present information will be disseminated for information, education, and change of behavior: the proscription of the use of cosmetics, the non-use (primordial prevention) and to stop use (primary prevention) of these products in general, and by hiv patients especially in the elderly, poverty reduction, improving the management of hiv patients (monitoring the efcacy of treatment and molecules at risk of hypovitaminosis d, prevention and treatment of skin lesions, promoting appropriate diet rich in antioxidants including vitamin d, and vitamin d supplementation) (58). limitations and strengths the present study was limited for some degreed because its comparative nature without times information. this nature did not establish causality for the relation of cause and effect. the measures of vitamin d might not be precise as their measures were not repeated in this study. this hospital study does not generalize the rates of hypovitaminosis d, hiv infection, and cosmetics use in congolese general population. however, the present study had the merit to obtain the rst evaluation of epidemic levels of hypovitaminosis d and cosmetics uses among a large size of hiv patients not only in drc, and also among persons with black skin in else countries. conclusion the extent of hypovitaminosis d and its severity is more marked in hiv infected patients than in non-hiv-infected individuals. the use of cosmetics, the prolongation of cosmetics use , the female sex, aging, the increase in hiv viral load, the reduction of cd4 +, the low socioeconomic status, the combination for molecules of efv and zdv were the factors associated with hospital hypovitaminosis d in kinshasa. references 1. bikle dd. vitamin d metabolism, mechanism of action, and 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hearing vj. the protectrive role of melanin against uv damage in human skin. photochem photobiol 2008; 84(3):539-549. 51. mostafa wz, hegazy ra. vitamin d and the skin: focus on a complex relationship: a review. j adv res. 2015;6(6):793–804. doi:10.1016/j.jare. 2014.01.011. 52. british association of dermatologists. the relation between skin disorders and vitamin d. british journal of dermatology 2012 ; 166 :471-473. 53. unaids data 2017 : http://www.unaids.org/en /resources/ documents/2017/ 20170720_data_book_2017. 54. unaids global aids update 2017 :http://www.unaids.org/ en/resources /documents/2016/ global-aids-update-2016. 55. g. raguin, f. sivignon. précarité et maladies infectieuses. la revue de médecine interne 2009 ; 30(2) : s3-s. 56. meehan m, penckofer s. the role of vitamin d in the aging adult. j aging gerontol. 2014;2(2):60–71. 57. michael f holick,1 tai c chen,1 zhiren lu,1 and edward sauter. vitamin d and skin physiology: a d-lightful story. journal of bone and mineral research. 2007volume 22, supplement 2. 58. arpadi sm, mcmahon d, abrahams ej, bamji m et al. effect of bimonthly supplementation with oral cholecalciferol on serum 25-hydroxyvitamin d concentrations in hiv-infected children and adolescents. pediatrics. 2009; 123: e121-e126. x 79gjra global journal for research analysis introduction adolescence is an important phase of transit ion, characterized by dramatic changes in physiological, social, emotional and cognitive aspects; which lays for future success in directions including not only academics but also different skills. self-concept is the nature and organization of beliefs about one's self. adolescence is a period of life during which self-concept takes its shape. self-concept is theorized to be multi-dimensional, such as physical, emotional, social and many other aspects of themselves. during this period adolescents develop some skills that will help them to grow into a caring and responsible citizen. world health organization (who) has dened life skills as,"the abilities for adoptive and positive behaviour that enable individuals to deal effectively with the demands and challenges of everyday 1life”. so, life skills are those essential abilities that help to grow competencies and mental power to face everyday challenges in realities. life-skills education is an educational motivation that has spread in several countries since it was introduced in mid-1980, thus showing its effectiveness. comprehensive life skills programmes developed in england, canada, australia and the united states have spread to over 30 countries. in our country, most of the 2 initiatives have come from ngo's sector. life skills based programmes are not yet adopted in policy level as government initiative though it is coming up as simple initiatives from the 4part of central board of secondary education. so, this study was planned to be conducted in the school under west bengal council of higher secondary education where such interventions are not so far observed in published form. objectives 1. to assess the self-concept among the adolescents. 2. to measure the existing knowledge on life skills of the adolescents . 3. to evaluate the effect of life skills education programme in terms of gain in post-test knowledge score. 4. to nd out the association between self concept of adolescents and the demographic variables: age, gender, religion, type of family, standard of education of parents, occupation of parents, area of living and order of birth. 5. to nd out the association between pre-test life skills knowledge of adolescents and the demographic variables: age, gender, religion, type of family, standard of education of parents, occupation of parents, area of living and order of birth. 6. to nd out the association between self concept and pretest life skills knowledge of adolescents. methodology a pre-experimental single group pre-test post-test research study was conducted at selected school of kolkata among 350 adolescents, studying class ix, x and xi, by using nonprobability purposive sampling technique. the inclusion criteria were to include the willing participants, adolescents present with parental written informed consent forms and both t hboys and girls. study duration was one month(7 thjanuary,2019-7 february,2019). the study synopsis was approved by the institutional ethics committee of apollo gleneagles hospital, kolkata. permission from selected school authority (ramkumar kamala vidyalaya, kolkata) was received. demographic data were collected from participants by background information, self-concept assessed by standardised tool-self-concept questionnaire by dr. saraswat,84, on rst day; knowledge on life skills assessed before on rst day and after conducting education programme on life skills on ninth day by structured knowledge questionnaire and. the content validity was 100 % a study to assess self-concept and effect of life skills education programme on knowledge among adolescents of a selected school in kolkata original research paper ms. manasi ghoshal assistant professor, b. m. birla college of nursing, kolkata, west bengal. x 1gjra global journal for research analysis nursing keywords : self-concept, life skills, adolescents volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra prof. ratna biswas* principal, apollo gleneagles nursing college, kolkata, west bengal. *corresponding author mrs. nirupama roy associate professor, apollo gleneagles nursing college, kolkata, west bengal. a pre-experimental research study was conducted to assess the self-concept and effect of life skills education programme on knowledge among adolescents of a selected school in kolkata. the study objectives were to assess self-concept and existing knowledge on life skills among selected adolescents and develop, validate a structured education programme on life skills and evaluate effect of that programme in terms of knowledge gain. . the conceptual framework was based on stufebeam's cipp evaluation model. methodology: non probability purposive sampling technique was used to select 350 adolescents. data were collected through self-concept questionnaire and structured knowledge questionnaire on life skills. result: the major ndings of the study showed that most of the adolescents had above average selfconcept level (78%). the mean, median of the post test knowledge score (14) were found to be higher than that of mean, median of pre-test knowledge score on life skills (7.33, 7) and the computed 't' value (44.399) was found statistically signicant at 0.001 level of signicance, [df (349 )= 3.29 ]. the chi square test showed that there is statistically signicant association with the self-concept with the demographic variable age, gender, type of family, religion, fathers' occupation and area of living, birth order but no association was found between self-concept and educational status of father and occupation of mother. the ndings also showed that pre-test life skills knowledge was strongly associate with age, gender, type of family, area of living and birth order but no association with religion, parental educational status, and parental occupation. the self-concept and pre-test life skills knowledge was found strongly associated. conclusion: the study was concluded with few recommendations to replicate on different settings, population and can be implicated in the eld of nursing education, nursing practice, nursing administration and nursing research. abstract 2 x gjra global journal for research analysis and as per suggestions of ve experts, some items were modied with structured knowledge questionnaire on life skills. reliability of self-concept questionnaire was done by test-retest method and it was found 0.89. reliability coefcient of structured questionnaire on life skills was 0.87, calculated by test-retest method. a planned and structured life skills education programme among adolescents was implied separately among 9th, 10th & 11th standards by using lecture method, group discussion method, multiple role play sessions and brain storming sessions with the help of power point presentation and chart in bengali language throughout 45 minutes teaching-learning session on second day. result in this research study, participants were different classes; from class ix, class x, class xi respectively. table 1: frequency percentage distribution of the sample characteristics n=350 data presented in the table 1 revealed that most of the adolescents (52%) were aged 13years to 15 years. the data also revealed that most (54.6%) of the adolescents were male. data also showed that majority of the adolescent school going children (50%) were from joint family. data further showed that majority (60.9%) of the adolescent school going children were from hindu family. data showed that most of the fathers (39%) had completed higher secondary level of education whereas most of the mothers (44%) had completed secondary level of education. most of the fathers' occupation were business (42.90%) whereas most of the mothers were housewife (56%).majority of adolescents were from semi-urban area (35.40%) and most (55.4%) of the adolescents were rst born by birth. figure 1: distribution of raw self-concept scores from the figure 1, it is revealed that most of the adolescents had above average self-concept (78%) followed by average self-concept 12% and high self-concept 10%, whereas no adolescent scored in below average self concept (0%) and low self-concept (0%). figure 2: rader diagram showing frequency percentage distribution of self-concept scores according to domain data presented in figure 2 showed that most of the adolescents scored above average self-concept level 60.60%, followed by average self-concept 29.40% and high selfconcept 9.40%. 0.60% adolescents scored below average selfconcept and no adolescent scored low self-concept in the physical dimension; most of the adolescents scored above average self-concept level 62.90%, followed by average selfconcept 22.20% and high self-concept 14.90%. no adolescents scored below average and low self-concept in the social dimension; most of the adolescents scored above average self-concept level (63%), followed by average selfconcept 23.60% and high self-concept 12.50%. few adolescents scored below average self-concept level (0.90%). no adolescents scored low self-concept in the tempera mental dimension; most of the adolescents scored above average self-concept level 50.90%, followed by average selfconcept 25.90% and high self-concept 23.20%. no adolescents scored below average and low self-concept in the educational dimension. most of the adolescents scored above average self-concept level 55.70%, followed by average self-concept 37.40% and high self-concept 6.90%. no adolescents scored below average and low self-concept in the moral dimension. frequency percentage of adolescents in volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra variables frequency(f) percentage (%) 1. age a. 13 years to 15 years b. 16 years to 18 years 182 168 52 48 2. gender a. boy b. girl 191 159 54.6 45.4 3. type of family a. nuclear b. joint c. extended 151 175 24 43.1 50 6.9 4. religion a. hindu b. muslim c. others 213 137 0 60.9 39.1 0 5. educational status of father a. illiterate b. primary c. secondary d. higher secondary e. graduate 14 95 71 137 33 4 27.1 20.3 39.1 9.4 6. educational status of mother a. illiterate b. primary c. secondary d. higher secondary e. graduate 24 139 153 34 0 6.9 39.7 43.7 9.7 0 7. occupation of father a. service b. business c. homemaker d. labour e. any other 96 150 24 64 16 27.4 42.9 6.9 18.3 4.6 8. occupation of mother a. service b. business c. housewife d. labour e. any other 38 44 196 42 30 10.9 12.6 56 12 8.6 9. area of living a. urban b. semi-urban c. rural 120 124 106 34.3 35.4 30.3 10. birth order a. first born b. second born c. more 194 120 36 55.4 34.3 10.3 high self-concept were 7.70%, in average self-concept were 25.40%, in above average self-concept were 66.60%, in below average self-concept were 0.30%, whereas no adolescents scored in low average self-concept (0%). figure 3: frequency percentage distribution of self-concept scores according to age data presented in figure 3 showed that, most of the adolescents of age group of 13 to 15 years (76.92%) and 16 to 18 years (79.17%) had above average self-concept. 12.09% adolescents of age group of 13 to 15 years had average selfconcept, whereas 11.31% adolescents of age group of 16 to 18 years had the average self-concept. in high self-concept, frequency percentage of adolescents of age group of 13 to 15 years was 10.99%, whereas frequency percentage of adolescents of age group of 16 to 18 years was 9.52%. data also showed that no adolescents of both age groups had below average self-concept and low self-concept. figure 4: frequency percentage distribution of self-concept according to gender frequencydata presented in figure 4 showed that, most of the boys (78.01%) and girls (77.99%) was scored in above average self-concept. 10.47% boys and 10.06% girls had high self-concept and 11.52% boys and 11.95% girls had average self-concept. data also showed that no boys and girls had below average selfconcept and low self-concept. figure 5: frequency polygon showing mean pre-test and mean post-test knowledge cores on life skills figure 5 depicted the frequency polygon of the pre-test and mean posttest knowledge scores of 350 adolescents. in the frequency curve the pre-test mean and median lies close to each other and the posttest mean and median lies at the same position. it further showed that the post-test frequency polygon lies to the right side of the pre-test frequency polygon, indicating a higher score range. in the frequency polygon of pre-test knowledge scores the mean (7.33) and median (7) lie close to each other and the mean lie at the right side of the median, indicated that the scores were positively skewed (+0.33). in the (%)frequency polygon of post-test knowledge scores are not skewed (0). the gure also shows that in the pre-test 159 adolescents' score was within the range of 6-8 and 99 adolescents' score was within range of 9-11 whereas in posttest out of 350 adolescents, 164 scored in the range of 12-14 and 136 scored within the range of 15-17 respectively. so, it is evident that the post-test scores of most of the participants fall beyond the pre-test scores, which indicate that there was a considerable gain in knowledge scores after the adminis tration of life skills education programme. figure 6: bar diagram showing the mean percentage of pretest and post-test knowledge scores on life skills key: are i is concept of life skills, area ii is core elements of life skills and area iii is importance of life skills education. the data presented in the gure 20 , showed that the mean percentage of pre-test knowledge scores ranged from 37 %39 % between the area iii and i, whereas mean percentage of post-test scores ranged from 66.4 % 90% between the area iii and i. in area i, mean percentage of pre-test knowledge scores was 39% whereas mean percentage of pre-test knowledge scores was 90%. in the area ii, mean percentage of pre-test knowledge scores was 37.8% and mean percentage of pre-test knowledge score was 67%. in the area iii, pre-test mean percentage score was 37% and post-test mean percentage score was 66.4%. so, the revealed data showed that the adolescents' knowledge gain was highest in the area i, i.e. concept of life skills. table 2: mean, mean difference, sd ,'t' value of pre-test and d post-test knowledge scores on life skills of adolescents 't' value with df (349) =3.29, p<0.001 level of signicance, * signicant data presented in the table 2 revealed that the post-tests mean (14) is higher than the pre-test mean (7.33) with the mean difference of 6.637. the standard deviation of pre-test life skills knowledge score and post-test knowledge score are respectively ±2.32 and ±2.087 with standard difference of 0.235. paired 't' test was calculated to nd out the effect of life skills education programme. the computed 't' value (44.399) is signicantly greater than the critical region 't' value (3.29) at 0.001 level of signicance. so the mean difference is true and x 3gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra knowledge score on life skills mean mean difference standard deviation sdd 't' value pre-test knowledge scores 7.33 6.637 ±2.322 0.235 44.399* post-test knowledge scores 14 ±2.087 not by chance. hence, the null hypothesis is rejected and research hypothesis is retained indicating there was signicant gain of knowledge score among the adolescents after administering life skills education programme. table 3: association of self-concept scores with demo graphic variables n=350 p˂ 0.05, * signicant from the table 3 it is observed that the obtained chi square value is less than the table value for the variable educational status of father, occupation of mother respectively. so, it can be inferred that adolescents' self-concept is not associated with educational status of father and occupation of mother. there is statistically signicant association with the selfconcept score with each of the demographic variable age, gender, type of family, religion, occupation of father and area of living, birth order, as the calculated chi square is greater than table value of chi square at 5% level of signicance. table 4: association of pre-test knowledge scores on life skills with demographic variables n=350 volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 4 x gjra global journal for research analysis variables self concept score calcula ted χ2 df χ2 (table value) ≤ median (169) >median (169) 1. age (in years) a. 13 to 15 71 91 4.60* 1 3.84 b. 16 to 18 104 84 2. gender a. boys 77 99 5.53* 1 3.84 b. girls 98 76 3. type of family a. nuclear b. joint 82 84 69 81 8.70* 2 5.99 c. extended 9 25 4. religion a. hindu 96 117 5.289* 1 3.84 b. muslim 79 58 5. educational status of father a. illiterate 4 10 b. primary 49 46 2.776 4 9.49 c. secondary 36 35 d. higher secondary 70 67 e. graduate & more 16 17 6. educational status of mother a. illiterate 12 12 b. primary 74 65 1.021 4 9.49 c. secondary 73 80 d. higher secondary 16 18 e. graduate & more 0 0 7. occupation of father a. service 49 57 21 44 4 47 93 3 20 12 b. business c. home maker 35.182* 4 9.49 d. labour e. any other 8. occupation of mother a. service b. business c. house wife d. labour e. any other 25 19 91 26 14 13 25 105 16 16 8.122 4 9.49 9. area of living a. urban b. semi urban c. rural 57 47 71 63 77 35 19.784* 2 5.99 10. birth order a. first born b. second born c. more 92 66 17 102 40 32 11.5* 2 5.99 variables pre-test knowledge scores on life skills calculated χ2 df χ2 (table value) ≤ median (7) >median (7) 1.age (in years) a. 13 to 15 103 79 5.230* 1 3.84 b. 16 to 18 115 53 2.gender a. boys 110 81 3.944* 1 3.84 b. girls 108 51 3.type of family a. nuclear 87 64 6.84* 2 5.99 b. joint 114 51 c. extended 17 17 4.religion a. hindu 126 87 2.271 1 3.84 b. muslim 92 45 5.educational status of father a. illiterate 7 7 b. primary 53 42 7.499 4 9.49 c. secondary 41 30 d. higher secondary 97 40 e. graduate & more 20 13 6.educational status of mother a. illiterate 12 12 5.490 3 7.81 b. primary 80 59 c. secondary 105 48 d. higher 21 13 variables pre-test knowledge scores on life skills calculatedχ2 df χ2 (table value) ≤median (7) �median (7) 7. occupation of father a. service b. business c. home maker d. labour e. any other 54 96 18 38 12 42 54 6 26 4 4.660 4 9.49 8. occupation of mother a. service b. business c. house wife d. labour e. any other 21 24 129 24 20 17 20 67 18 10 3.678 4 9.49 from the table 4 it is observed that the obtained chi square value is less than the table value for the variable religion, educational status of father, educational status of mother, occupation of father, occupation of mother respectively. so, it can be inferred that pre-test knowledge scores on life skills of adolescents is not associated with religion, educational status of father, educational status of mother, occupation of father and occupation of mother. there is statistically signicant association with the pre-test knowledge scores on life skills with each of the demographic variable-age, gender, type of family, area of living and birth order, as the calculated chi square is greater than table value of chi square at 5% level of signicance. table 5: chi square test of association between self-concept score and pre-test knowledge score on life skills of adolescents. p˂ 0.001, * signicant data presented in table 5 showed that there was association between pre-test knowledge scores on life skills before administering life skills education programme and selfconcept scores of the adolescents asevident from calculated chi square value (30.703) which was more than the table value(10.83) at 0.001 level of signicance. hence the null hypothesis was rejected, research hypothesis retained. thus it can be concluded that adolescents who had higher life skills knowledge, also had higher self-concept. hence, life skills knowledge certainly helps to improve their self-concept. discussion: this study showed that most of the adolescents had above average self-concept(78%) followed by average concept (14%) and high self-concept (10%). most of the adolescents had above average selfconcept on physical domain (60.6 %), social domain (62.9%), temperamental domain (63%),educational domain (50.9%), moral domain (55.7 %) and intellectual domain (66.6%).the ndings of the present study was supported by another study conducted by bharathi t a, sreedevi p. to assess the self-concept by using selfconcept scale of saraswat (1984) among 40 adolescents of twin cities of hydrabad, telengana state. the ndings of the study revealed that higher percentage of adolescents had above average levels of self-concept in dimension of temperamental (85), intellectual (77.5), physical (60) and social (52.5). about 47.5% of adolescents equally had high and above average self-concept in education and 57.5 % of adolescents had high moral self-concept. adolescents overall self-concept was found as 27.5 % in high and 72.5% had 3above average. in this study, mean post test knowledge score (14) was higher than the mean pre-test score (7.33) on life skills. the mean and median of knowledge score was same in the post test (14). standard deviation of pre-test and post-test was ±2.322 and ±2.087 respectively which indicates that the post-test knowledge score was less dispersed than the pre-test knowledge score. mean percentage of pre-test knowledge score ranged from 37%39% where as post-test knowledge score ranged from 66.4%-90%. modied gain in the area of concept of life skills, core elements of life skills and importance of life skills were 83.60%, 46.95% and 46.67% respectively. so the adolescent's life skills knowledge was gained more than 40% in all area. in this study, mean difference of pre and post test knowledge score on life skills was 6.67. it was found to be statistically signicant as evident from the calculated 't' value 44.399 at 0.001 level of signicance. so it was concluded that life skills education programme was effective in gaining knowledge on life skills among adolescents. these ndings of the present study was supported by a study conducted by parvathy v., renjith r p. on impact of life skills education on adolescents in rural school, kerala among 57 students (control group 30, experimental group 27) to assess existing knowledge on life skills and impact of life skills education programme among them. there was signicant knowledge gain through life skills education programme. 7 this study showed that there was statistically signicant association with the self-concept score with the demographic variable age, gender, type of family, religion, occupation of father and area of living, birth order, as the calculated chi square was greater than table value of chi square at 5% level of signicance whereas the obtained chi square value was less than the table value for the variable educational status of father, occupation of mother respectively. so, it can be inferred that adolescents' self-concept was not associated with educational status of father and occupation of mother. this ndings were supported by a study conducted by anuradha k. among 100 students (50 boys and 50 girls) studying in 9th standard high schools in tirupati town to assess the life skills and self-concept along with to nd out the association of selfconcept and life skills. signicant association was observed between the self-concept scores and family income whereas there was no signicant association between self-concept and gender, type of family, parental educational status. 6 in this study there was statistically signicant association with the self-concept score with the demographic variable age, gender, type of family, area of living and birth order, as the calculated chi square was greater than table value of chi square at 5% level of signicance whereas the obtained chi square value was less than the table value for the variable religion, educational status of father, educational status of mother, occupation of father, occupation of mother respectively. so, it can be inferred that pre-test life skills knowledge of adolescents was not associated with religion, educational status of father, educational status of mother, occupation of father and occupation of mother. this result was supported by a study conducted by arati c. with the objective to nd out the inuence of personal variables on core affective life skills of adolescents among 292 adolescents in kvr govt. college. in this study, order of birth, family income had signicant inuence on interpersonalrelationship dimension of life skills of adolescents. 8 in this study there was association between life skills knowledge scores before administering life skills education programme and self-concept scores of the adolescents as evident from calculated chi square value (30.703) which was more than the table value(10.83) at 0.001 level of signicance. this result was supported by a study conducted by anuradha k. on life skills and self concept of adolescents to assess the x 5gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 9. area of living a. urban b. semi urban c. rural 67 82 69 53 32 47 7.03* 2 5.99 10. birth order sta. 1 born ndb. 2 born c. more 112 84 22 82 37 13 8.68* 2 5.99 sl no. selfconcept life skills knowledge score total df calcul ated 2χ value table value of χ2 ≤median (7) (7)median > 1. ≤median (169) 120 61 181 1 30.703 * 10.83 2. (169) median> 62 107 169 total 182 168 350 life skills and self-concept along with to nd out the association of self-concept and life skills among 100 students(50 boys and 50 girls) studying in 9th standard high schools in tirupati town. signicant strong association was found between the life skills scores and self-concept scores of sample. 6 conclusion: by the ndings of the present study, it can be concluded that most of the students had above average level of self-concept. this study also indicated that life skills education programme was effective in term of knowledge gain of the adolescents. this study also concluded that self-concept and life skills were strongly associated with each other. thus, the life skills education programme will help the adolescents to enhance their psychosocial competencies for a successful adulthood. conflict of interest: none references: 1. world health organization. maternal, newborn, child and adolescent health.available from: www.who.int/maternal-child adolescent/t opic /ad olescence/dev/en 2. world health organization (who). life skills education for children and adolescents in schools. programme on mental health; geneva, 1997. available from: https://who.int/iris/handle/10665/63552 3. bharati a t, sreesevi p. a study on the self-concept of adolescents. international journal of science and research. 2016 october; 5 (10):512-516. available from: http://www.semanticscholar.org/paper/680873ee8c5168827 4. life skills education, cbse, viewed 30 november 2012. available from: www.cbse.nic.in/cce/life_skills_cce.pdf 5. searo. child and adolescent health and development: adolescent health and development. strategic directions for improving adolescent health in south-east asia region, 2018-2022. available from: www.adolescent heal th.indd-world health organization.pdf 6. anuradha k. life skills and self-concept of adolescents. international journal of science and research. 2014 november; 3(11): 600-604.available from: https://www.ijsr.net>archive 7. parvathy v, pillai r r. impact of life skills education on adolescents in rural school. international journal of advanced research. 2015 february; 3(2): 788794. available from: https://www.rtesearchgate.net>publication 8. arati c. inuence of personal variables on core affective life skills of adolescents. research journal of family, community and consumer sciences. 2016 april; 4(4): 1-6. available from: https://www.isca.in>isca-rjfccs-2016004 6 x gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: pregabalin is a structural similar drug of the inhibitory neurotransmitter γ-amino butyric acid but it is not functionally the same. it binds to the α-2-δ subunit of voltage-gated calcium channels reducing the release of several excitatory neurotransmitters and blocking the development of hyprealgesia and central sensitization. opioids deals with acute pain and tricyclic antidepressants 1(tcas) were used for chronic neuropathic conditions . pregabalin binds to the α-2-δ subunit of voltage-gated calcium channels reducing the release of several excitatory neurotransmitters and blocking the development of 2hyprealgesia and central sensitization . pregabalin has anticonvulsant anti-hyperalgesic and anxiolytic properties similar to gabapentin, but it has a more favorable pharmacokinetic prole including dose-independent 3absorption . recently the role as oral pre-emptive analgesic of 4,5pregabalin for postoperative pain relief has been reviewed . this study puts in a effort to nd the efcacy of this drug in controlling the diabetic neuropathy pain. aims and objectives: to study the efcacy of pregabalin in post-operative. materials and methods: this study was done in the department of department of general surgery, pes institute of medical sciences and research, kuppam this study was done using 60 patients. all were severely in pain according to pain numeric scale. they were given adjusted dose of pregabalin for 3 weeks and then they were checked for pain scores again and then reported. the study was done from july 2017 to june 2018. inclusion criteria 1. the patients were aged between 30-50 years exclusion criteria 1. not consented patients numeric pain scale was used: all the statistics were done using the spss software 2015 (california) results: table 1: age distribution table 2: sex distribution table 3: pain scale initially table 3: pain scale next day of adjusted dose use: table 4: unpaired t-test discussion: pregabalin has anticonvulsant anti-hyperalgesic and anxiolytic properties similar to gabapentin, but it has a more favorable pharmacokinetic prole including dose3independent absorption . recently the role as oral preemptive analgesic of pregabalin for postoperative pain relief 4has been reviewed it is advantageous due to high efcacy with less drug doses and less chances of aspiration pneumonitis. due to its limitations in the form of lesser control of block height & limited duration of analgesia researchers have used battery of drugs intrathecally like vasoconstrictors, (epinephrine) opioids, (fentanyl, buprenorphine) benzodiazepines, (midazolam) ketamine and many others as adjuvant to local anaesthetics to prolong the duration of sensory block & achieve longer 6,7perioperative analgesia . but each of this adjuvant has certain limitations of their own hence search for better options for acute postoperative analgesia research is still continuing. provision of effective pain relief is a prerequisite accelerated convalescence. previously the drugs used for acute & chronic pain were categorically different. opioids, nsaids & local anaesthetics were tools for dealing with acute pain and tricyclic antidepressants (tcas) were used for chronic neuropathic conditions. two comparative studies gabapentin v/s pregabalin using single oral pre-emptive drug for infraumbilical surgeries under sab, for evaluation of their comparative efcacy in terms of a cute postoperative analgesic benets with rescue analgesic as diclofenac have shown similar results to our 8,9study. a study to find the efficacy of pregabalin in post operative pain original research paper dr zamiruddin ahmed associate professor, department of general surgery, pes institute of medical sciences and research, kuppam general surgery pregabalin is a structural similar drug of the inhibitory neurotransmitter γ-amino butyric acid but it is not functionally the same. it binds to the α-2-δ subunit of voltage-gated calcium channels reducing the release of several excitatory neurotransmitters and blocking the development of hyprealgesia and central sensitization. this study puts in a effort to nd the efcacy of this drug in controlling the post-operative pain. abstract keywords : pregabalin, efcacy, analgesia, pain. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 0 no pain 1–3 mild pain (nagging, annoying, interfering little with adls) 4–6 moderate pain (interferes signicantly with adls) 7–10 severe pain (disabling; unable to perform adls) number mean age std deviation 60 67.27 years 17.48 years number male female 60 49 11 male female mild 41 9 moderate 07 1 severe 01 nil male female mild 07 03 moderate nil 01 severe nil nil p-value signicance mild <0.05 highly signicant moderate <0.05 highly signicant severe >0.05 not signicant 94 x gjra global journal for research analysis conclusion: pregabalin is very effective in controlling post operative pain. references: 1. shneker bf, mcauley jw. pregabalin: a new neuromodulator with broad therapeutic indications. ann pharmacother. 2005; 39: 2029-37. 2. chizh bh, gohring m, troster a, quartey gk, schmelz m, koppert w. effects of oral pregabalin and operation on pain and central sensitization in the electrical hyperalgesia model in human volunteers. br j anaesth. 2007; 98: 246-54. 3. guay dr. pregabalin in neuropathic pain: a more „pharmacetically elegant „gabapentin? am j geriatr pharmacother. 2005; 3: 274-87. 4. frampton je, foster rh. pregabalin: in the treatment of post herpetic neuralgia. drugs2005; 65: 111-8; 9-20. 5. gilron i. gabapentin and pregabalin for chronic neuropathic and early postsurgical pain: current evidence and future directions. curr opin anaesthesiol 2007; 20: 456-72. 6. sahu s, sachan s, verma a, pandey hd, chitra. evaluation of pregabalin for attenuation of postoperative pain in below umbilical surgeries under spinal anaesthesia. anaesth clin pharmacol. 2010; 26 (2): 167-71. 7. saraswat v, arora v. preemptive gabapentin vs pregabalin for acute postoperative pain after surgery under spinal anaesthesia. ind j of anaesth. 2008; 52 (6): 829-834. 8. mathiesen o, jacobsen ls, holm he, randall s, adamiec-malmstroem l, graungaard bk, holst pe, hilsted kl, dahl jb. pregabalin and dexamethasone for post-operative pain control: randomized controlled study in hip arthroplasty.br j anaesth. 2008 oct; 101 (4): 535-41. 9. tippana em, hamunen k, kontinen vk, kalso e. do surgical patients benet from perioperative gabapentin/pregabalin? a systematic review of efcacy and safety. anesth analg. 2007; 104 (6): 1545-56. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 95gjra global journal for research analysis introduction this study was conducted to compare the result of single incision laparoscopic surgery with conventional laparoscopic surgery & open – surgery & to seek the advantages & pitfall of single incision laparoscopic surgery, and to know the kinds of surgery which can be performed with single incision laparoscopy. single incision laparoscopic surgeries performed between june 2015 to september 2018 were included in this study. the advantage of single incision laparoscopic surgery for patients are less post operative pain, minimal scaring (cosmetically better), shorter – hospital stay and earlier return to normal activity.in the debate of single incision laparoscopic surgery & conventional laparoscopic surgery, it was concluded that sils is safe, feasible, cosmetically – better and probably a better option to conventional laparoscopy & open surgery. the major challenges in single incision laparoscopic surgery are crowding of instruments and crossing of instruments, which require expertise, but as surgeon becomes familiar with single incision laparoscopic surgery, sils can be performed as smoothly as conventional surgery. the pitfalls of sils include – costlier instruments, advance expertise and long learning curve. cost of the sils can be lowered with use of conventional instruments in place of sils port. study after insertion of 5mm port, put patients in antitrandelenberg position & related to left. ÿ dissection performed with electric country hook in left trocar & an endograsper roticulator in other trocar. ÿ the cystic artery & duct were rst exposed then separately clipped with standards 5mm clip applier and excised using an endoshear roticulator. ÿ the gall bladder then extracted with a standard endocatch through umbilical site. careful control of haemostasis is achieved & penrose drain was placed in the choleystectomy lodge through 2mm incision for the mini loop retraction. finally 25 mm trocar site was closed with an absorbable suture & umbilical physiological position restored. results and discussion in study of silc by pisanu-a, recia et al. post opp analgesia required up to 24 hr that is equal to conventional laparoscopy as upto 24 hr but in our study patients required post operative analgesia < 24 hr, that is less than the study of pisanu-a, racio et al & than conventional laparoscopic cholecystectomy. so earlier return to routine work. hospital stay is equal to in all three study. post operative complication rate was 5% each in study of pisanu-a & racia et al & conventional laparoscopy. but in our study post operative complication rate was much less 1.90%.as compare on the basis of scar, in our study scar was cosmetically better than conventional laparoscopy. conclusion 1. sils operation can be performed with conventional instruments. 2. advance single incision laparoscopic surgery may require special instruments eg: sils port, which increase the cost and requires expertise of operating surgeon. 3. sils is cosmetically better than conventional laparos copic surgery & open surgery. 4. sils is safe and feasible for all laparoscopic surgery. 5. sils has advantage of less pain, less intra operative and post operative complication, shorter hospital stay & earlier return to routine activity. references 1. mouret p. how i developed laparoscopic cholecystectomy. ann acad med singapore. 1996;25:744 2. litynski gs. proles in laparoscopy: mouret, dubois, and perissat: the laparoscopic breakthrough in europe (1987-1988) jsls. 1999;3:163–7. 3. litynski gs. erich muhe and the rejection of laparoscopic cholecystectomy (1985): a surgeon ahead of his time. jsls. 1998; 2: 341 4. kalloo an, singh vk, jagannath sb, niiyama h, hill sl, vaughn ca, et al. flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity.gastrointest endosc. 2004;60:114–7 5. gettman mt, lotan y, napper ca, cadeddu ja. transvaginal laparoscopic nephrectomy: development and feasibility in the porcine model. urology. 2002; 59:446–50. 6. rao gv, reddy dn, banerjee r. notes: human experience. gastrointest endosc clin n am.2008; 18:361–70. 10. 7. rattner d, kalloo a. asge/sages working group on natural orice translumenal endoscopic surgery. october 2005. surg endosc. 2006; 20:329–33. 8. pauli em, mathew a, haluck rs, ionescu am, moyer mt, shope tr, et al. single inscision laparoscopic cholecystectomy possibilities and pitfalls original research paper prof dr rajeev sinha hod surgery dept mlb medical college jhansi general surgery single incision laparoscopic surgery has only gained popularity over last few year and this technique in mainly offered at major laparoscopic centers. sils is an advance minimal invasive surgical procedure in which the surgery is done through a single entry point i.e. the navel. a 20 mm incision at the umbilicus is all that is required for the surgery. a scope is inserted that can be moved around in the body & returns images from various angles giving the surgeons a larger eld of vision for the surgery & the instruments used to performs the surgery are exible there by enabling extra reach and maneuverability. sils involves the use of exible instruments and a higher level of laparoscopic expertise. sils was mainly used for gall stone disease appendicitis & hernia but in recent year sils is using in almost every laparoscopic procedure. abstract keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr sudhanshu sharma* senior resident mlb medical college jhansi *corresponding author s. no. silc by (pisanua recia et al) conventional laparoscopy in our study 1. no of pt 465 427 368 2. site of incision umbilicus four incision as in conventional laparoscopy umbilicus 3. operative time 45.8 min 63 min 24 min 4. post operative analgesia up to 24 yr up to 24 yr < 24 yr 5. hospital stay 3 3 3 6. post operative complication 5% 5% 1.90% 12 x gjra global journal for research analysis technique for transesophageal endoscopic cardiomyotomy (heller myotomy): video presentation at the society of american gastrointestinal and endoscopic surgeons (sages) 2008, philadelphia, pa. surg endosc.2008; 22:2279–80. 9. shin ej, kalloo an. transcolonic notes: current experience and potential implications for urologic applications. j. endourol. 2009; 23:743–610. granberg cf, frank i, gettman mt. transvesical notes: current experience and potential implications for urologic applications. j endourol. 2009;23:747–52. 10. linke gr, tarantino i, hoetzel r, warschkow r, lange j, lachat r, et al. transvaginal rigid-hybrid notes cholecystectomy: evaluation in routine clinical practice. endoscopy. 2010; 42:571–5. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 13gjra global journal for research analysis introduction: local anasthetic like bupivacaine is commonly used in spinal anaesthesia. studies have shown that duration of analgesia due to bupivacaine in spinal anaesthesia can be prolonged by using adjuvants. most commonly used opioid in regional anaesthesia is fentanyl. it is highly potent drug because of its high lipophilicity. the aim of the present study was to compare the effect of intrathecal fentanyl as adjuvant to low dose bupivacaine in the subarachnoid block with regular dose of bupivacaine. need for study: the study was conducted to reduce the side effects of hyperbaric bupivacaine 0.5% given intracthecally in spinal anaesthesia by reducing the dose of it. aim: the aim of the study was to evaluate the efcacy of intrathecal hyperbaric bupivacaine 0.5% with 50mcg of fentanyl. objectives: level of block at the end of 10 minutes after giving spinal anaesthesia. time taken by sensory block regression by two segments. duration of analgesia. intraoperative hemodynmic stability adverse effects methods: type and design of study: randomised prospective study. study population: the study population included 60 patients undergoing below umbilical surgeries under spinal anaesthesia during november 2018 to december 2019. study location: mvj medical college and research hospital. ethical clearance: obtained inclusion criteria: patients of asa grade i,ii and iii patients of both sexes posted for below umbilical surgeries patients giving valid informed and written consent. exclision criteria: patients refusal and contraindications for spinal anaesthesia. patients below 35kgs and above 90kgs weight. patients with history of hypersensitivity to drug used. methodology: a randomized prospective clinical study involving 60 patients belonging to asa physical status i to iii and height from 150165cm. routine pre-anaesthetic checkup was done. valid informed written consent was obtained. patients below 35 and above 90kgs were excluded. patients were randomly divided into two groups of 30 each. group a received 1.5ml of 0.5% hyperbaric bupivacaine with 50mcg fentanyl. group b received 3ml of 0.5% hyperbaric bupivacaine, under aseptic precautions, subarachnoid block was given in lateral position at l2-l3 using a 25 g quincke's needle through midline approach and table in neutral position. patients were turned supine immediately. the following parameters were noted: onset of sensory block, onset of motor block, level of the sensory block, duration of motor block, duration of two segment sensory regression, duration of analgesia, parameters like hr, bp, spo2 were recorded every 2 mins for the rst 10 minutes and every 10 minutes till the end of surgery, any other adverse drug reactions like nausea, vomiting, urinary retention, pruritis etc were noted.there was no signicant difference in mean onset of sensory block and motor block between two groups. results: there was no signicant difference in mean onset of sensory block and motor block between two groups. there was signicant difference in mean duration of sensory and motor block between two groups. a comparative study of low dose hyperbaric bupivacine with fentanyl and hyperbaric bupivacaine in spinal anaesthesia for below umbilical surgeries. original research paper dr tahir s hatturkar post graduate mvjmc&rh dr jawabulla vazhayil post graduate mvjmc&rh x 21gjra global journal for research analysis anaesthesiology keywords : volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr nirmala b c* professor mvjmc&rh *corresponding author dr kaveti vihitha reddy post graduate mvjmc&rh 22 x gjra global journal for research analysis there was signicant difference in mean duration of analgesia between two groups(group a=178.50 ± 17.96 min,group b= 254.17 ± 24.53 min) discussion: bupivacaine is the widely used anaesthetic agent for spinal anaesthesia. it has the advantage of producing good surgical anaesthesia and longer half-life compared to other local anaesthetics, the incidence of adverse effects on haemodynamic stability like hypotension ismorecommon. perioperative hypotension will affect postoperative recovery and increases risk of coronary ischaemia. intra thecal opioids are synergistic with local anaesthetics and intensify the sensory block. the addition of fentanyl to hyperbaric bupivacaine increases the intra-operative quality of block and synergistic antinociceptive effects with local anaesthetics will increase the duration of the block. the major advantages of neuraxial opioids are the preservation of preganglionic sympathetic function, postoperative analgesia and augmentation of spinal .this study had shown that addition of fentanyl to low dose of bupivacaine provided the same level of anaesthesia as that of higher dose of bupivacaine given alone with added advantage of haemodynamic stability. this combination can be especially useful for patients having ischaemic heart disease, diabetics with end organ damage, renal failure without coagulopathy and in patients with autonomic neuropathy. results from our study shows that the baricity of the solution does not make any difference to the level of blockade or the density of blockade which is similar to 1the results of the study done by roy g soto et al. thus we conclude that adding fentanyl helps in reducing the dose of bupivacaine for spinal anaesthesia in below umbilical surgeries without showing any signicant change in sensory and motor level block. it provides better intra and postoperative analgesia, good hemodynamic stability with no incidence of complications. conclusion: thus we conclude that adding fentanyl helps in reducing the dose of bupivacaine for spinal anaesthesia in below umbilical surgeries without showing any signicant change in sensory and motor level block. it provides better intra and postoperative analgesia, good hemodynamic stability with no incidence of complications. references: 1. soto rg, paez jc, smith ra. impact of baricity of bupivacaine on intrathecal fentanyl-associated pruritus during combined spinal/epidural anesthesia for labor. the internet journal of anaesthesiol 2009;20(1):1-6 2. kotwani, m.b, rupwate, k., shivananda, p., & magar, j. comparison between high dose hyperbaric bupivacaine (12.5 mg) alone versus low dose hyperbaric bupivacaine (7.5 mg) with fentanyl (25 µg) in spinal anaesthesia for inguinal hernia surgery. international journal of clinical trials,2016,08: 3(3), 140. 3. shah s, shah b, deb c. a study of comparative evaluation of bupivacaine plain versus bupivacaine with fentanyl in spinal anaesthesia in geriatric patients. international journal of medical and health research. 2016;2:23-26. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction alkali (kshar) is described as superior among all surgical and supplementary surgical procedures in ayurveda1. the samhi ta descr ibes two types o f a lkal i – topical (pratisaaraneeya) and internal administration (paneeya)2. further, among three types mild (mridu), moderate (madhyama) and strong (teekshna), strong alkali can be used as topically but never for internal administration. strong alkali is a paste prepared by ltering ash of specic plants in water or cow's urine, then boiled with hot limestone with nal additives of specied herbal pastes. the resultant herbomineral paste, alkali, is extremely corrosive and usually strongly alkaline. for instance, the alkali prepared for this study had a ph of 12.41.3 whereas the 2n-naoh procured for this study had a ph of 11.90.4 the sharp and penetrating properties of alkali is responsible for its excision, incision, scrapping, digestion or suppuration, dissolving, purication, healing, drying, contraction and other properties6. what is notable here is that after treating a lesion with alkali separate healing measures are not required, the alkali itself induces healing. earlier studies in this topic have shown encouraging results. a study carried out in 20087 showed the following: the histological study showed on 3rd day mild inammatory inltrate comprising of polymorphs, monocytes and plasma cells are evident in deep dermis, the hair follicles shows atrophy. on 7th day the inammatory cell extends up to the subdermis with dense layout of broblasts, the broblasts are plump with spindle shapes and mature into dense collagenous bers. on 14th day there is marked healing process and regeneration of hair follicles with evacuation of inammatory cells and maturation of broblasts in to dense collagenous bers, the granulation tissue in the deeper dermis of the wound is gradually replaced by brous tissue. on 21st day marked regeneration of hair follicles evident with total replacement of the dermis, inammatory cells are very sparse and epidermis show focal feature of hyperkeratosis and mild parakeratosis. a clinical study conducted in 20128 showed the following: a clinical study of 20 patients with diabetic foot was randomly selected and achyranthus aspera alkali was applied at the site. the study shows itching and smell were reduced markedly, whereas pain and inammation reduced slightly. the wound size, discharge, and granulation tissue reduced markedly whereas tenderness and surrounding area of ulcer reduced slightly. signicant results were seen in wound. this study seeks to investigate whether an alkali, after injuring tissue, induces healing in the injured area; and whether the healing induced is quicker than other chemical injury. this study, therefore, is planned to investigate healing patterns in alkali induced tissue injury vis-à-vis its healing effect. the results will be compared with the healing pattern of chemical tissue injury and control. material and methodology objectives of study 1. to describe of vrana its nidana, purvarupa, lakshana, chikistsa and upadrava in ayurvedic literature. 2. to conduct a literature review of kshara and its preparation of tikshna pratisaaraniya kshara as described in sushrutha samhita. 3. to evaluate healing patterns of kshara dagdha vrana and compare with healing patterns in chemical induced tissue injury, using following parameters: a. biochemical changes of kshara dagdha vrana on the skin of albino rats. b. hydroxyproline estimates. c. histopathological changes of kshara dagdha vrana on the skin of albino rats. study design and methodology: this is a controlled standardized experimental study on wister albino rats. rats will be grouped into control, standard and trial. histopathological and biochemicl study of alkali burns (kshara dagdha vrana) in albino rats original research paper sharma sukrant* dr. sukrant sharma m.s (ayu) assistant professor, jammu institute of ayurveda and research nardini, jammu, india* corresponding author yadav rajesh dr. farookhahmed kamagal m.s (ayu) assistant professor, sindagi shantvereshwar ayurvedic medical college and hospital haveri. x 67gjra global journal for research analysis ayurveda acharya sushrutha mentioned alkali (kshara) as a substance which does debridement (ksharana) and cutting properties (kshanana) and mentioned its properties like excision (chedana), incision (bhedana), scrapping (lekhana), purication (shodhana), healing (ropana) , cauterization(dahana)etc. how a strong alkali, after injuring tissue, can itself induce healing needs investigation. with this objective, this experimental study on albino rats was planned to observe and measure alkali induced tissue injury and its subsequent healing. findings were compared with healing pattern of topical chemical tissue injury and healing using 2n-naoh (2normal saline sodium hydroxide). the parameters for assessing tissue injury and subsequent healing were total hematology, c-reactive protein, total protein, tissue hydroxyproline and histopathological study. the study revealed that the rate and extent of healing post-alkali (trial group) injury is much higher compared to chemical injury induced by 2n-naoh (standard). lesions treated by applying alkali leave wounds and these wounds need not be treated by other healing medicine. the alkali itself has property which leads to healing of its own wounds. abstract keywords : alkali, wister albino rats, sodium hydroxide. bhardwaj ashanka dr. ashanka bhardwaj mds(oral pathologist),jammu kour sarabjeet dr. sarabjeet kour pg scholar, jammu institute of ayurveda and research nardini, jammu, india volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 68 x gjra global journal for research analysis rats of control group will receive topical normal saline application. standard group will receive topical sodium hydroxide application. trial group will receive topical strong alkali application. drugs used in the study: 1. achyranthus aspera (apamarg) alkali – prepared as per 11th chapter of sutra sthan. 2. sodium hydroxide – readily available in open market. instruments like disposable 1ml syringe, needle, blade, pen marker, cotton, glows, applicator, petty dish, sterile container, seizer. experiment animals wistar strain albino rats of either sex or albino rat were obtained from animal house attached to department of pharmacology, sdm centre for research in ayurveda and allied sciences udupi. the experimental protocol was approved by the institutional animal's ethics committee under the reference no. sdmcra/ iaec-2013-14 st 10. the animals were fed with normal rat diet and water ad libitum throughout the study. they were acclimatized in the laborator y condi t ion for two weeks pr ior to the experimentation. the housing provided has the following conditions: controlled lighting of 12:12h light and dark cycle, temperature of 25ºc and relative humidity of approximately 50%. inclusion criteria: a) healthy wistar albino rats of either sex with average weight of 180-220gm were selected randomly for the study. exclusion criteria: a) which does not fulll the above criteria b) infected. c) pregnant. d) those healthy wistar albino rats which are under other experiments will be excluded. exprimental procedure: 42 wister albino rats of either sex weighing 180 220g will be selected and grouped into 7 different groups, each with 6 rats. normal saline group (control) in the experimental set up, the normal saline groups were serving as a control group. there the application of normal saline done on the predetermined area for 1 day, 7 days and 14 days. after topical application rats were sacriced under deep ether anesthesia after 24 hours, 7th day and 14th day respectively. test groups (strong achyranthus aspera alkali) test group rats were anaesthetized under ketamine (50mg/kg) and xylazine (3mg/kg). the anaesthetized rats were shaved on dorsal region 5cm below the neck region. using permanent marker 2x2 cm circular mark was done. using ne needle nick (technical procedure used for achieving ne bleeding on prick) was given. the test drug achyranthus aspera alkali were applied on a marked area and allowed for 180 seconds. after 180 seconds the area were washed with lemon juice. in 1 day, 7 days and 14 days study after topical application of test drug achyranthus aspera alkali, rats were sacriced under deep ether anesthesia after 24 hours, 7th day and 14th day respectively. standard group (2n-naoh) in 1 day, 7 days and 14 days study, the standard drug 2n-naoh were applied on a predetermined area allowed for 180 seconds. after 180 seconds the area were washed with lemon juice and after topical application of standard drug 2n-naoh, rats were sacriced under deep ether anesthesia after 24 hours, 7th day and 14th day respectively. in all groups, on the day of sacrice, blood were drawn from rats retro orbital vein puncture and sent for biochemical investigation and the skin tissue carefully excised and sent for histopathological examination. histopathological studies – stored in a mixture of 30ml formalin& 270 ml distilled water in different sterile containers. hydroxyproline content estimation – stored in about 2-3 ml ns solution in petri dishes which were deep frozen to – 200c. the obtained results of the test groups were compared with that of the standard and control groups. statistical analysis of biochemical and hydroxyproline data will generated by one way anova followed by dunnets multiple comparison “t” test as post hoc test if p<0.05 using statistic software of graph pad prism 4.0 version. wound healing parameters a) biochemical parameter: total hematology, total protein and c-reactive protein. b) hydroxyproline estimation in skin tissue. c) histopathological examination of part of skin. result with respect to the primary objective of the study which was to assess healing patterns following alkali induced tissue injury compared to healing patterns following tissue injury by standard chemical (2n-naoh), this study showed the following: 1) tc:in 1st day, 7th day, trial group showed higher in total count compared to standard and control group. on 14th day study trial group showed lower total count compared standard group, which indicated that inammatory reaction subsided in trial group. 2) crp:higher levels on 1st day, 7th day and 14th day in trial group indicated stronger inammatory process compared to standard and control. 3) tp:on 7th day and 14th day study trial group showed higher level compared to standard and control group, this shows higher release of tp due to tissue destruction. 4) hydroxyproline:on 7th day and 14th day study hydroxyproline content was higher in trial group compared to standard and control, which indicated that collagen synthesis and wound healing were better in trial group. 5) histopathological study: histopathological study slides revealed, chronologically in 1 day study, after 24 hours shows crust formation, epithelial layer disruption in the epidermis, cell inltration, edema, loss of collagen bers, overall local tissue injury observed more and on 7th day, 14th day study shows almost a normal picture. dermis, epidermis and hypodermis presented normal prole. inammatory cells were almost absent in most of the sections. epidermal layer was continuous and well developed observed and overall more of tissue repair process in trial treatment group compared to standard group. in contrast to this epithelialization was impaired and there was tissue loss in standard treated group compared to trial group. overall among ve parameters, all ve parameters showed better healing patterns in alkali induced tissue injury when compared to standard chemical tissue injury. conclusion this controlled, standardized experimental study has shown that topical use of strong alkali,causes healthy tissue injury, induces excellent subsequent healing at the site of injury, a phenomenon not seen at same degree in standard chemical induced injury. the rate and extent of healing post alkali injury is much higher than chemical injury induced by 2n-naoh. the study demonstrates that strong alkali is a complex, comprehensive topical ayurvedic therapeutic tool and not a simple corrosive. though this study has been carried out by causing injury to healthy tissue (kshanana), the ndings can be extrapolated to lesions treated with topical alkali use also. it is, however, important to emphasize that the study should not be interpreted to use alkali as a healing agent in clean wound, which it is not. sushrutha has not made any such description. further studies can focus on destruction followed by healing effects of topical use of alkali on skin lesions, volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra effects when applied for different time durations and clinical studies. references 1. acharya sushruta, sushrutasamhita; dalhana, nibandasangraha commentary; edited by jadavjitrikamji acharya and naarayan ram acharya; chowkhambhasurabhaarati prakashan,varanasi,1st edition; reprint 2010; sootrasthana 11/3,pg no.45. 2. acharya sushruta, sushrutasamhita; dalhana, nibandasangraha commentary; edited by jadavjitrikamji acharya and naarayan ram acharya; chowkhambhasurabhaarati prakashan,varanasi,1st edition; reprint 2010; sootrasthana 11/6,pg no.46. 3. annexure iii,kshara ph. 4. annexure iv, sodium hydroxide ph. 5. acharya sushruta, sushrutasamhita; dalhana, nibandasangraha commentary; edited by jadavjitrikamji acharya and naarayan ram acharya; chowkhambhasurabhaarati prakashan,varanasi,1st edition; reprint 2010; sootrasthana 11/5,pn.45. 6. comprehensive study on twak shareera and histological changes on application of kshara by dr.pralhad.d.subbannavar in 2008 from rguhs bengaluru. (unpublished). 7. clinical study to evaluate local effects of pratisaaraniya kshara (apamarga) in dushta vrana by dr.vivek.n.patil in 2011-12 from rguhs bengaluru. (unpublished) x 69gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: rheumatoid arthritis (ra) is a chronic progressive autoim mune disorder characterized by symmetric erosive synovitis and some times shows multisystem involvement (1). while lowered concentrations of antioxidants in the blood considerably increase the probability of the occurrence of ra (2). many investigators have focussed on oxidative stress since last few years and suggest that ra patients are more prone to lipid peroxidation (3). the calcium role is not clear in ra, however, the relationship between calcium, vitamin d, and parathyroid hormone suggests the possible role of calcium in ra and there is a change in mineral within bone which are calcium, and phosphorus (3). changes in lipid prole have been observed in different inammatory disease such as ra (4). ra patients are in increased risks of atherosclerosis and cardiovascular diseases (cvd) than the overall population (5). bone contains both organic and inorganic material. the organic matter is mainly protein; the inorganic or mineral component is mainly crystalline hydroxyapatite {ca10(po4)6(oh)2}. approximately of body's 99% calcium and 85% phosphorus are present in bone. the exact reason behind bone erosion and joint deformities is not fully understood. this study was aimed to study mda level as a marker of oxidative stress in patients with ra as well as the changes in ca, and p level in recently diagnosed ra patients compared to healthy subjects and there is continuing interest in the metabolic changes occurring in ra and to estimate the serum calcium /phosphorus ratio in ra patients. material and methods: the sample was taken from a group of 100 patients with ra (50 male and 50 female), age (45-70 years). the control was diagnosed if they having any diseases such as diabetes, infectious diseases. ra was diagnosis based on clinical histories such as esr and rheumatoid factor. statistical analysis: statistical analysis was done by using student t-test to compare between the two groups and statistically signicance set at p<0.05. the data of this study were given as mean ± standard deviation. results were diagnosed with rheumatoid arthritis at slims hospital with 100 healthy people who represent controls. in this study patient with ra belonged to the age group of 45-70 years. among patients of ra 50 patients were males and 50 were females as shown in table 1. the mean±sd of age in males was 53.21±8.12 and the mean±sd of the female was 55±11.1. results: table. 1: serum levels of total lipid peroxide (mda), calcium, phosphorus and calcium/phosphorus in control subjects and rheumatoid arthritis patients. table. 2 : pairwise correlation analysis in ra patients our results shows comparison of mda, calcium and phosphorus levels in ra with control subjects. statistically signicant increase in levels of lipid peroxide (p<0.001) and phosphorus (p<0.001) whereas statistically signicant decrease in calcium (p<0.001) was found in patients of ra as compared to control subjects. whereas phosphorus level was increased signicantly (p<0.001) in ra patients as compared to control subjects. on the contrary, calcium/phosphorus ratio was decreased signicantly (p<0.001) in ra patients as compared to control subjects. on the contrary, mda was negatively correlated with calcium/phosphorus ratio (r = 0.74). discussions : serum calcium levels decreased signicantly, phosphorus levels increased signicantly and calcium / phosphorus ratio decreased signicantly in ra patients compared to the controls.rheumatoid arthritis (ra) is an inammatory polyarthritis, leading to joint destruction, deformity and loss of function. extra-articular features and systemic symptoms usually occur and may accompany the onset of joint symptoms..serum calcium levels decreased signicantly, phosphorus levels increased signicantly and calcium / phosphorus ratio decreased signicantly in ra patients compared to the controls. lower calcium level may be due to insufcient calcium intake and quicken osteoporosis, more sodium intake in our food may cause calcium depletion (6). free radical that produced by ros that case chronic inammatory cells nearby bone with subsequent bone destruction (7). ra is usually associated with localized or generalized osteoporosis, erosions and hand and generalized bone mineral density (bmd) loss resulting in functional disability and increased risk of clinical fractures. mda, calcium, phosphorus and its ratio in rheumatoid arthritis patients original research paper shivananda reddy. n department of orthopaedics, r.v.s. institute of medical sciences, chittoor, andhra pradesh,india x 19gjra global journal for research analysis orthopaedics rheumatoid arthritis (ra) is an inammatory polyarthritis, leading to joint destruction, deformity and loss of function. rheumatoid arthritis (ra) is an autoimmune disorder, occurs when there are attacks of the immune system on body's tissues especially the joint, causing a painful, swelling, that nally results in bone deformity, increased free radical level in defect joint and reduce the level of the antioxidant system can cause tissue damage. serum levels of lipid peroxides, calcium, phosphorus and ratio of calcium/phosphorus in ra patients were determined and compared with normal healthy controls. signicant increases in lipid peroxides (p<0.001) phosphorus (p<0.001) levels were found in patients presenting with ra as compared to controls. whereas signicant decrease in calcium (p<0.001) and calcium/phosphorus ratio (p<0.001) were found in rheumatoid arthritis patients as compared to controls. negative correlation was observed between mda and calcium/phosphorus ratio in patients with rheumatoid arthritis. abstract keywords : rheumatoid arthritis (ra),malondialdehyde, calcium,phosphorus volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra prabhakar reddy. e* department of biochemistry and central laboratory head, sri lakshmi narayana institute of medical sciences, pondicherry605 502, india *corresponding author 20 x gjra global journal for research analysis many drugs shave an affected-on calcium metabolism and cause a low level of calcium in ra. it was assuming that high level of phosphorous was related to tissue hypoxia with an elevated in atp breakdown resulting in the release of inorganic phosphorous from cells. however, hypoxia create by hypertrophy and hyperplasia within synovial joints [(8). it was observed that calcium in ra a low level in serum whereas phosphorous has shown a high level in contrast to control, that can be concluded to be a danger factor for ra cases. these results recommend to increase mg, ca, p in the dies with a supplement that might be helpful for a patient with ra. further studying is necessary to estimate various biochemical markers that inuences patient with ra. statistical analysis by unpaired t test shows that the levels of serum calcium were decreased and phosphorus levels were increased statistically, which were highly signicant (p<0.0001). low calcium may be due to prolonged inadequate calcium intake and accelerated osteoporosis. in ra patients as compared to healthy controls. these results are in accordance with several other studies (913). ra patients are vulnerable to steroid induced and disease associated osteoporosis. the high salt intake in our population may exacerbate calcium deciency. at the proximal tubule, were sodium and calcium absorbs option are linked. although not specically studied, many disabled people rely heavily on pre-packed food and meals, much of which is high in sodium (14). ra is associated with collection of chronic inammatory cells occurring adjacent to bone with subsequent bone destruction. it is possible that generated oxygen derived free radicals may be important in bone resorption (15). calcium/phosphorus levels were disturbed in ra patients and more disturbed in anemic ra patients. so, supplements of calcium, iron and vitamin d are needed for ra patients.in the formation of bones, calcium/phosphorus ratio is very important. it is possible that, generation of reactive oxygen species may be particularly important factor for bone resumption in inammatory process (16). hypoxic conditions also disrupt an intracellular ionic environment and alter calcium and phosphorus level (17). these results are also in accordance with a signicantly decreased calcium/phosphorus ratio in ra patients as compared to controls in our study clearly indicates that, there is an altered calcium and phosphorous metabolism in ra. as calcium and phosphorous are important constituent of bone, ultimately bone metabolism is altered in ra, the event observed by many workers (18-19). negative correlation between calcium/phosphorus ratio and lipid peroxide (r = -0.89) suggests that the generation of reactive oxygen species in excess may be particularly important in the bone resorption that occurs in association with inammatory diseases (20).the earlier studies (21). generation of reactive oxygen species is an important factor in the development and maintenance of rheumatoid arthritis (ra) in humans. mda, the product of lipid peroxidation reacts with lysine residues in protein to produce immunogenic molecules, which can exacerbate inammation. the longer chain polyunsaturated fatty acids are especially potent at increasing lipid peroxidation and causing cell damage by oxidative stress (22). ra is associated with collection of chronic inammatory cells occurring adjacent to bone with subsequent bone destruction. it is possible that generated oxygen derived free radicals may be important in bone resorption. there is a contradiction with present data on the calciumphosphorus ratio with another study of ra (rheumatoid arthritis) patients that a decreasing level of calciumphosphorus ratio [23-24] and researchers have documented alterations of calcium and phosphorous metabolism [23]. it is postulated that the elevation of phosphorous was related to tissue hypoxia with an increase in atp degradation resulting in the release of inorganic phosphorous from cells. in ra, hypoxic environment triggers oxygen free radicals generation and alters oxidative metabolism within the cell. it leads to disruption in intracellular ionic environment and altered calcium and phosphorus levels. some authors suggest that hypocalcemia results due to drugs used in ra, but decreased mean total body calcium levels in ra patients who did not received that corticosteroid drugs strongly suggest that, this is an integral feature of ra (25). conclusion: calcium and phosphorus level can be studied for the preferable therapeutic management of ra. the decrease in serum calcium / phosphorus ratio indicated that, calcium and phosphorus metabolism is altered in ra. in patients serum levels of calcium and calcium/phosphorus decreased and further studies on dietary management of calcium and phosphorus are needed. increased oxidative threat in rheumatoid arthritis is evidenced by raised lipid peroxides. with a better understanding of the pathophysiology of ra, new therapeutic approaches are emerging to provide precision medicine for individuals. table. 1: serum levels of malondialdehyde (mda), calcium, phosphorus and calcium/phosphorus in control subjects and rheumatoid arthritis patients. values are expressed as mean ± sd; *p < 0.001 table. 2 : pairwise correlation analysis in ra patients references: 1. taysi, s., polat, f., gul, m., sari, r. a. and bakan, v. (2002) lipid peroxidation, some extracellular antioxidants and antioxidant enzymes in serum of patients with rheumatoid arthritis. rheumatol. int. 21, 200-204. 2. sklodowska, m., gromadzinska, j., biernacka, m., wasowicz, w., wolkanin, p., marszalek, a., brozik, h. and pokuszynska, k. (1996) vitamin e, thiaobarbituric acid reactive substance concentrations and superoxide dismutase activity in the blood of children with juvenile rheumatoid arthritis. clinical and experimental rheumatology 14, 433-439. 3. serdar ozturk, h., burak cimen, m.y., bolgen limen, o., kacmaz, m. and durak, i. (1999) oxidant/antioxidant status of plasma samples from patients with rheumatoid arthritis. rheumatol. int. 19, 25-37. 4. steiner g, urowitz mb, editors. lipid proles in patients with rheumatoid arthritis: mechanisms and the impact of treatment. seminars in arthritis and rheumatism; 2009: elsevier. 5. kaplan mj. cardiovascular complications of rheumatoid arthritis: assessment, prevention, and treatment. rheumatic disease clinics. 2010;36(2):40526. 6. stone j, doube a, dudson d, wallace j, editors. inadequate calcium, folic acid, vitamin e, zinc, and selenium intake in rheumatoid arthritis patients: results of a dietary survey. seminars in arthritis and rheumatism; 1997: elsevier. 7. garrett ir, boyce bf, oreffo r, bonewald l, poser j, mundy gr. oxygenderived free radicals stimulate osteoclastic bone resorption in rodent bone in vitro and in vivo. the journal of clinical investigation. 1990;85(3):6329. 8. walwadkar s, suryakar a, katkam r, kumbar k, ankush r. oxidative stress and calcium-phosphorus levels in rheumatoid arthritis. indian journal of clinical biochemistry. 2006;21(2):134. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra sr. no parameters no. of subjects control subjects rheumatoid arthritis patients 1 serum malon di aldehyde (mda) μmol/l 100 1.98 ± 0.67 4.88 ± 1.52* 2 serum calcium (mg/dl) 100 10.65 ± 1.81 7.98 ± 1.48* 3 serum inorganic phosphorus (mg/dl) 100 2.95 ± 0.40 4.95 ± 0.92* 4 calcium/ phosphorus ratio 100 3.73 ± 0.63 41.96 ± 0.673* sr. no pairwise correlation of serum parameters 'r' value 1 negative correlation between mda and calcium/phosphorus ratio . 0.89 9. walwadkar sd, suryakar an, katkam rv, kumbar km, ankush rd. oxidative stress and calcium-phosphorus levels in rheumatoid arthritis. indian j clin biochem 2006;21(2):134-137. 10. 6. scott dl, farr m, howkins cf, wilkinson r, bold am. serum calcium levels in rheumatoid arthritis. ann rheum dis 1981;40:580-583. 11. ropes mw, rossmeisl ec, bauer w. calcium and phosphorus metabolism in rheumatoid arthritis and degenerative joint disease. research paper from harvard medical school, boston p.785-789. 12. bramble mg, blake dr, white t, sly j, kerr dn. ionised calcium in rheumatoid arthritis: effect of nonsteroidal anti-inammatory drugs. br med j 1980;281:840-841. 13. verstraeten a, dequeker j. mineral metabolism in postmenopausal women with active rheumatoid arthritis. j rheumatol 1986;13(1):43-46. 14. stone j, doube a, dudson d, wtallace j. inadequate calcium, folic acid, vitamin e, zinc and selenium intake in rheumatoid arthritis patients: results of a dietary survey. semin arthritis rheum 1997;27(3):180-185. 15. garrett ir, boyce bf, oreffo roc, bonewald l, poser j, mundy gr. oxygenderived free radicals stimulate osteoclastic bone resorption in rodent bone in vitro and invivo. j clin invest 1990;85:632-639. 16. johannes, w. h., bijlsma, m.d., johannes, w.g. and jacobs, m.d. (2000) hormonal preservation of bone in rheumatoid arthritis. neuroendocrine mechanisms in rheumatic disease 26, 897-910. 17. cheesman, k.h. and slater, t.f. (1993) an introduction to free radical biochemistry. br. med. bull. 49(3), 481-93. 18. verstraeten, a. and dequekar, j. (1986) mineral metabolism in postmenopausal women with active rheumatoid arthritis. the journal of rheumatology 13 (1), 43-46. 19. oelzner, p., muller, a., deschner, f., huller, m., ahendroth, k., hein, g. and stein, g. (1998) relationship between disease activity of serum levels of vitamin d metabolites and pth in rheumatoid arthritis. calcif. tissue int. 62(3), 193-198. 20. garrett, r., boyce, b.f., oretto, r.o.c., bonewald, l., poser, j. and mundy, g.r. (1990) oxygen derived free radicals stimulate ostoclastic bone resorption in rodent bone in vitro and in vivo. j. clin. invest. 85, 632 639. 21. bhogade, r.b., suryakar, a.n., katkam, r.v., sardeshmukh, a.s., rathi, d.b. (2002) oxidative stress in rheumatoid arthritis. indian medical gazatte 3842. 22. darlington, l.g. and stone, t.w. (2001) antioxidants and fatty acids in the amelioration of rheumatoid arthritis and related disorders. bri. journal of nutr. 85, 251-269. 23. s.d. walwadkar, a.n. suryakar, r.v. katkam, k.m. kumbar and r.d. ankush, oxidative stress and calcium-phosphorus levels in rheumatoid arthritis, indian j. clin. biochem., 21(2), 2006, 134-137. 24. d. de carvalho pereira, r.p.a. lima, r.t. de lima, m. da conceição rodrigues gonçalves, l.c.s.l. de morais, s. do carmo castro franceschini, r.g. filizola, r.m. de moraes, l.s.r. asciutti and m.j. de carvalho costa, association between obesity and calcium: phosphorus ratio in the habitual diets of adults in a city of northeastern brazil: an epidemiological study, nutrition j., 12, 2013, 90 (doi: 10.1186/1475-2891-12-90). 25. arieff, a.i. and defronzo, r.a. (1985) fluid electrolyte and acid base disorders (1); edited by allen i. arieff, ralph and a. defronzo. section 1, chapter 12, 625659, published by churchill livingstone. 27. reid, d.m., kennedy, n.s.j., smith, m.a., tothill, p. and nuki, g. (1982) total body calcium in rheumatoid arthritis effects of disease activity and corticosteroid treatment. bmj. 285, 330332. x 21gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction cardiovascular diseases (cvds) have now become the leading cause of mortality in india. a quarter of all mortality is attributable to cvd. ischemic heart disease and stroke are the predominant causes and are responsible for >80% of cvd deaths. the global burden of disease study estimate of agestandardized cvd death rate of 272 per 100� 000 population in india is higher than the global average of 235 per 100�000 population. some aspects of the cvd epidemic in india are particular causes of concern, including its accelerated buildup, the early age of disease onset in the population, and the high case fatality rate. in india, the epidemiological transition from predominantly infectious disease conditions to noncommunicable diseases has occurred over a rather brief period of time. cardiac arrhythmias routinely manifest during or following an acute coronary syndrome. although the incidence of arrhythmia is directly related to the type of acs the patient is experiencing, the clinician needs to be cautious with all patients in these categories for example, nearly 90% of patients who experience acute myocardial infarction (ami) develop some cardiac abnormality and 25% have a cardiac conduction 1disturbance within 24 hrs of infarct onset. arrhythmias often complicate ami, that it is debatable, whether to consider them under complications or under the clinical spectrum of ami. the nature, frequency, as well as timing of the arrhythmias are important factors in deciding the 2life expectancy and mortality of the patient. case study the study will be carried out in the emergency room, as well as the intensive coronary care unit (iccu) and the cardiology ward of d.y. patil hospital, navi mumbai, india. it will be a prospective observational study that will continue through the months of december 2017 to december 2018 (12 months) with a sample size of 100. inclusion criteria: patients within the ages of 18 who satisfy the who denition for the diagnosis of myocardial infarction will be included in this study: the diagnosis is made upon the presence of the following three criteria: ÿ a clinical history of ischemic type of chest discomfort. ÿ changes in serially obtained electrocardiographic tracings (new st – t changes, presence of pathologic q wave, new left bundle branch block [lllb]) ÿ a fall/ rise in serum cardiac markers. exclusion criteria: ÿ patients below the age of 18 ÿ gravid females. ÿ patients with recurrent myocardial infarction ÿ patients with valvular heart disease. ÿ patient with history of arrhythmia results table no. 1incidence of arrhythmias table 1: shows incidence of various types of arrhythmias in ami. many of the cases presented with more than one type of arrhythmia. ventricular arrhythmias were present in a total of 26 % of patients of which 10% had vt and 16% had vpbs. sinus tachycardia was present in 24% and sinus bradycardia in 19%. svt was present in 3%, af in 2% and atrial ectopic in 3%. bundle branch block was seen in 14 %, complete heart block in 5% and av blocks (i and ii) in 6% of patients a study of incidence of arrhythmias in myocardial infarction in a tertiary care hospital original research paper dr. siddharth chouhan junior resident dept. of medicine dr. d. y. patil hospital, navimumbai x 1gjra global journal for research analysis general medicine myocardial infarction is dened by the demonstration of myocardial cell necrosis due to signicant and sustained ischemia. cardiac arrhythmias routinely manifest during or following an acute coronary syndrome. although the incidence of arrhythmia is directly related to the type of acs the patient is experiencing, the clinician needs to be cautious with all patients in these categories for example, nearly 90% of patients who experience acute myocardial infarction (ami) develop some cardiac abnormality and 25% have a cardiac conduction disturbance within 24 hrs of infarct onset abstract keywords : myocardial infarction ,arrhythmia volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr santwana chandrakar* head of unit, dept of medicine, dr. d. y. patil hospital, navimumbai *corresponding author dr. varun shetty associate professor, dept of medicine, dr. d. y. patil hospital, navimumbai types no. of cases percentage sinus tachycardia 24 24 sinus bradycardia 19 19 atrial ectopics 3 3 atrial brillation 2 2 svt 3 3 vpb 16 16 ventricular tachycardia 10 10 av blocks i and ii 6 6 av block iii 5 5 bundle branch block 14 14 2 x gjra global journal for research analysis conclusions: cardiac arrhythmias routinely manifest during or following acs. early recognition and management of post myocardial infarction arrhythmias can signicantly modify the morbidity and mortality in myocardial infarction. as for incidence of various types of arrhythmias in ami, many of the cases presented with more than one type of arrhythmia. ventricular arrhythmias were present in a total of 26% of patients, out of which 10% had vt and 16% had vpbs. sinus tachycardia was present in 24% and sinus bradycardia in 19%. svt was present in 3%, af in 2% and atrial ectopic in 3,43%. bundle branch block was seen in 14%, complete heart block in 5% and av blocks (i and ii) in 6% of patients. references: 1. perron ad, sweeney t. arrhythmic complications of acute coronary syndromes. emerg med clin n am 2005;23:1065-1082 2. robin nm, bramah sn. arrhythmias in acute myocardial infarction. in: norris rm edt. myocardial unfarctionits presentation, pathogenesis and treatment. new york: churchill livingstone, 1st edn, part-1, 1982:p.55-63 3. swart g, brady wj, debehnke dj, ma oj. acute myocardial infarction complicated by hemodynamically unstable bradyarrhythmia: prehospital and ed treatment with atropine. am j med 1999 nov;17(7):647-652 4. crimm a, severance hw, coffey k, mckinnis r, wagner gs. prognostic signicance of isolated sinus tachycardia during rst three days of acute myocardial infarction. am j med 1984 jun;76(6):983-988 volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction in the global media-age, television has played crucial role in transforming the society. it has come forth as momentous medium of transformation of enlightenment and tidings. with the objectives to inform, to educate and to entertain its spread the knowledge prospects in the world. it has widely efcient to bring the change in the society. moreover, it brings the universe into the living room. as a result, it has a vivid impact on viewers and predominance in the their mind, thoughts, and beliefs especially on women. women always considered as “special audience categorically in soap opera's women are mainly 'focused audience'. initially, the target audience of soap opera's were 'the home makers'. television serials are prominent genre of the entertainment world. it highlights the women's perceptions, views towards the world through . in many research study, it reects that tv serials has great impact and effect on viewer's life, particularly female lifestyle. they follow the fashion and living style, etiquette which are shown by daily soap. soap operas are becoming the mentor of metro women too. their hypnotism has been converting their world. the imaginary world of soap operas is changing them into introverted personalities. the research reects the fact that the characters of soap operas are taking the place of members of their family. they also came to know the social problems of neighboring states, which is a healthy sign about their awareness. but the sad part is that they are now more unaware about the needs of their own society. tv serials woven the women image stereotype with glamorous ways. it does not portray the reality of the female's role in the society. consequently, a woman has been portrayed in stereotypical, fashionable way and never as a brilliant and condent as men. but now the scenario is changing day by day. some serials producing content for sporting woman's life, business tycoon and working women. moon jana(2016) storyline, screening, portrayal of women, in every sphere it matured a lot. it successfully overcomes the� k� genre, where “sans-bahu” where the main character, where one of them whether vamp or the holy cow. in those serial storylines or the treatment were more or less same and nonetheless the portrayal of women. quarrelsome sans, extra-marital affairs of husband, conspiracy in the family, loud make-up and dresses, etc. were becoming the sign of serials. shoma munshi book (2013)it analysis the ve prime-time soaps and argues that this particular genre of popular culture, social issues and practices focusing on the complex constructions of family, tradition, indian-ness, and gender, she also analyses narrative structures of soaps in the context of their fractured and never-ending time frames and plot outlines. review of literature many studies have been conducted globally and nationally for studying the impact of soap operas on different categories and age groups of audiences. but limited studies have been conducted on the 'depiction of women image in television serials beenish zaheen(2010) portrayal of women by star plus soap operas: a feministic perspective while focusing on the problems faced by women in our society and the role played by star plus soap operas in identifying social inequities faced by women and reecting the positive changes related to the status of the research of the study will mainly focus on the following aspect. it analyzed the kind of feminist ideology (liberal feminism, socialist feminism, and radical feminism) being focused by star plus soap operas in presenting their female characters. it analyzed the female characters portrayed by star plus soap operas, whether women are portrayed in the traditional role or as a sexual object. archana kumari & himani joshi(2015) gender stereotyped portrayal of women in the media: perception and impact on adolescent. it is without a doubt that media have a huge inuence on people and it can be a dominant medium for advocacy of gender equality and uplifting the present status of women in the society. but unfortunately media are reinforcing stereotyped images of women and their roles in society. the news regarding women is mostly about their hardships and atrocities imposed upon them. it shows the gender insensit ivi ty of the media. i t has become indispensable that the media should take responsibilities of acting as a powerful instrument for bringing social change for women in more favorable terms. objectives of the study 1. to analyze the gender insensitivity in tv serials. 2. to analyze the women characters depicted by star plus serials, whether female are portrayed as a stereotype or traditional. 3. to know the depiction of female characters in social role perspectives. hypothesis serials represent the women image as a stereotype and with gender inequality. methodology of the study the present study on 'depiction of women image in television serials. the content analysis is used to achieve the objectives of the present study. serials of star plus channel have been selected for the sample. serials are selected on the basis of trp;ye hai mahobatein, ye rishta kya kehlata hai, tu suraj depiction of the women image in soap opera: a evaluative study original research paper narinder kaur ph.d scholar, journalism and mass communication, chaudhary devi lal university, sirsa journalism television soap operas or sops are a prominent genre of entertainment and has a vivid impact on viewers' mind, thoughts, and beliefs especially on women. the study nds to the women characters depicted by star plus serials, whether female are portrayed as a stereotype or traditional. the study knows the depiction of female characters in social role perspectives. the imaginary world of soap operas is changing them into introverted personalities. media is considered to be an important tool for transformation in the society. women need to ensure that media reect images that develop positive and constructive role of women in society. the content analysis method is used to achieve the objectives. the study on 'depiction of women image in television serials. the content analysis method is used to achieve the objectives. star plus channels serials has selected as a sample. serials are selected on trp, ye hai mahobatein, ye rishta kya kehlata hai, tu suraj mein sanjh, namakaran.the study reveals that mostly female characters in soap operas were shown as stereotypical. on the other hand ,male character numbers more than female character when serials are based on women life struggle . abstract keywords : volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 76 x gjra global journal for research analysis mein sanjh…, namakaran. it describes the status of women, values, social perspectives of women, participation of women in social activities, decision making, self independent, economic aspects. samplestar plus soap operas are considered as the population of study where as a sample of 4 soap operas being th thshown from 5 march to 15 march 2018.during prime time 7am to 10am will be selected for study. the names of soap operas selected for analysis are; 1 ye hai mahobbetein 2. yeh rishta kya kehlata hai 3 tu suraj mein sanjh piya 4 namakaran signicance of the study media is considered to be an important tool for transformation in the society. women need to ensure that media reect images that develop positive and constructive role of women in society. moreover, to know which type of women image more show by soap opera. as per the aims of study the current study will analyze the patterns, values and social participation in social activities and the status of women in soap operas. it helps to know how female characters are represented in the society. to know how many characters are played by females. data and interpretation data collected by the content analysis from four soap operas th thbeing telecast during prime time 5 to 15 march 2018. researchers analyzed all the female characters. depiction of women image in soap opera by star plus. data analyzed in statics and presented in tables. which are followings1 table status of women table 1 data reveal that 62.08% female characters in star plus soap operas were portrayed as a stereotype character. women were bounded in limited roles like mother, house wives and so on. moreover, 17.24 % female characters were portrayed in as glamorous /sexual objects. these serials depicted that female characters were only for glorify the shows . vulgar scenes build negative image of women. it also reveals that 10.34% female depicted as antagonist and other hand, 10.34% women portrayed as the protagonist. it can be said soap operas give equal space to antagonist and protagonist. 2.table social role perspectives of women the data in table 2 chalk out that 25.71% female character in star plus soap operas were portrayed as fashionable characters. those were worn western dresses and modern attires. which become trend setters for audience as like indo werstern dresses popular in society due too serials characters. moreover, 74.29 % female characters were portrayed in as traditional characters. those were wearing the traditional dresses like sarees and suits and follow the customes ritauls. in other words we can say who are following rituals and wearing sarees and suits they are called sanskari characters in serials. it also tells that women depicted as fashion conscious who could not manage without heavy sarees etc. 3. table need of participation of women in social activities the data in table 3 reveal that 35.53% female characters in star plus soap operas were portrayed as need equal educational rights. they want to study as like male characters like tu suraj mein sanjh piya presented the educated women character sandhya who ght for justice and women rights too. it also reveals that 27.63% female characters in star plus soap operas were portrayed as demanding equal social rights like against domestic violence , eve teasing, legal rights etc. furthermore the data also show that 36.84% female characters in star plus soap operas were portrayed as demanding equal economic rights . they want to be independent. 4.table. decision making power comparison between men and women table no. 4 illustrates that 46.67% female characters in star plus soap operas were portrayed as decision making power, whereas 53.33% male characters were shown as having main decision making authority. it reveals that women have limited decision making power. not as much empowered and independent . it has shown men to have more decision making power rather than female. 5.table self independent and dependent on male characters volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra serials name stereotype character glamours/ sexual objects antagonist protagonist 1 ye hai mahobbetein 11 1 2 2 2 ye rishta kya kehlata hai 11 6 3 1 3 tu suraj mein sanjh piya 6 2 1 1 4 namakaran 8 1 0 2 total 36 10 6 6 total % 62.08% 17.24% 10.34% 10.34% serials name fashionable traditional 1 ye hai mahobbetein 2 9 2 ye rishta kya kehlata hai 1 11 3 tu suraj mein sanjh piya 1 3 4 namakaran 5 3 total 9 26 total % 25.71% 74.29% serials name need of social rights need of education al rights need of economic rights 1 ye hai mahobbetein 8 12 12 2 ye rishta kya kehlata hai 4 3 7 3 tu suraj mein sanjh piya 7 3 3 4 namakaran 8 3 6 total 27 21 28 total % 35.53% 27.63% 36.84% serials name women men 1 ye hai mahobbetein 2 3 2 ye rishta kya kehlata hai 1 3 3 tu suraj mein sanjh piya 2 1 4 namakaran 2 1 total 7 8 total % 46.67% 53.33% serials name working women business women home makers dependent on male characters 1 ye hai mahobbetein 1 3 3 5 2 ye rishta kya kehlata hai 1 0 7 7 3 tu suraj mein sanjh piya 1 2 3 2 4 namakaran 2 0 5 2 total 5 5 18 16 total % 11.36% 11.36% 40.92% 36.36% x 77gjra global journal for research analysis the data in table 5 reveal that 11.36% female characters in star plus soap operas were portrayed as working women, whereas 40.92 % female characters were portrayed as housewives. the study says that mostly women were homemakers in these serials expect tu suraj mein sanjh piya. it also tells that 11.36% female characters in star plus soap operas were portrayed as business women and 36.36% dependent on male characters for their economic aspects. 6 table gender inequality the data in table 6 reveal that 40.64% male characters in star plus soap operas. it also tells that 59.36% female characters in star plus soap operas were played by women. it also shows that these soap operas main lead character were women. the story revolves around that characters. results this research attempts to analyze the portrayal of women by star plus soap operas. in this 38 female characters of four star stplus soap operas being telecast during prime time 5 march to th15 2018 were analyzed. after collecting all the data, the researcher has presented it in the form of a table. the table representing the data gathered from content analysis of star plus soap opera. discussion and conclusion this research is conducted by the researcher to analyze depiction of women image in soap opera by star plus. take into account the objectives of the research, the researchers selected sample of 4 soap operas being telecast th thduring prime time 5 to 15 march 2018. researchers analyzed all the female characters. depiction of women image in soap opera by star plus. while the studying it analyzed that 46.67% female characters in star plus soap operas were portrayed as main decision making power, whereas 53.33% male characters were shown as having main decision making authority. it has shown men to have more decision making power rather than female. it analyzed those 59.36% female characters in star plus soap operas were played by women. it also shows that these soap operas main lead character were women. the story revolves around those characters. the study reveals that 11.36% female characters in star plus soap operas were portrayed as working women whereas 40.92 % female characters were portrayed as homemakers. it also says that the women, 36.36% dependent on male characters for their economic aspects. it chalks out that 25.71% female character in star plus soap operas were portrayed as fashionable characters. those were worn western dresses and modern attires. moreover, 74.29 % female characters were portrayed in as traditional characters. those were wearing the traditional dresses like sarees and suits and so on. it also tells that women depicted as fashion conscious who could not manage without heavy sarees etc. references 1. shoma munshi ( 2010). television soaps play a role in empowering women, routledge, new delhi 2. keval j. kumar (2013) -mass communication in india, jai publishing house, delhi. 3. johson james, (2015). stereotypical depiction of female characters in malayalam serials; a study of sathwardhanam and amala serials. 4. dr.aaliya ahmed , ms. malik zahra khalid, (2014).the construction of female characters in contemporary hindi serials post liberalization. 5. beenish zaheen, (2010) . portrayal of women by star plus soap operas; a feminist perspective. 6. archana kumari & himani joshi,(2015). gender stereotyped portrayal of women in the media perception and impact on adolescent. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra serials name men women 1 ye hai mahobbetein 10 11 2 ye rishta kya kehlata hai 7 12 3 tu suraj mein sanjh piya 4 7 4 namakaran 5 8 total 26 38 total % 40.64% 59.36% 78 x gjra global journal for research analysis 1. introduction this paper is basically worried about the upset outline process and assembling machine of programmed compact hammering machine. prototype which can be defeated the issue of off base hammering and strange effect of hammering in procedure of manufacturing. a conceivable arrangement of the issue of moderate hammering speed and anomalous hammering by a work is plan a programmed convenient hammering machine given mechanical advances in assembling process technique. the suitability of such an idea was explored as far as delivering reasonable and compacted plan for specialist which can be exchange anyplace of this machine by any laborers. production its principle function is to safely and preciously hammering work like to perform the punching operation, lleting operation, riveting operation and smithy operation i.e. upset forging etc for all designed operating conditions. this paper describes cad modeling, design and analysis of automatic portable hammering machine. a programmed hammering machine self-working machine going to assume an imperative part in the assembling procedure (hammering process). hammering machine utilized as a part of the generation of material extending from instruments, to pivots, car frame forming, molding of metal and so forth. the present development identied with metal squeezing machine and forming machine included certain outstanding challenges in regard of to drive nail, t parts, forge metal and break separated question. the innovation has for its question cure this downside and to empower, by including helper implies, to drive nail, t parts, manufacture metal and break separated protest the like. hammering is the most generally utilized in mechanical operation and also development action. hammering or screws 1.1 slider crank mechanism in this prototype model we used slider crank mechanism to convert rotary motion into linear motion. a crank is an arm attached at a right angle to a rotating shaft by which reciprocating motion is imparted to or received from the shaft. it is used to convert circular motion into reciprocating motion, or vice versa. the arm may be a bent portion of the shaft, or a separate arm or disk attached to it. attached to the end of the crank by a pivot is a rod, usually called a connecting rod (con rod). the end of the rod attached to the crank moves in a circular motion, while the other end is usually constrained to move in a linear sliding motion. the term often refers to a human-powered crank which is used to manually turn an axle, as in a bicycle crank set or a brace and bit drill. in this case a person's arm or leg serves as the connecting rod, applying reciprocating force to the crank. there is usually a bar perpendicular to the other end of the arm, often with a freely rotatable handle or pedalattached. fig 1: slider crank mechanism design, cad modeling & fabrication of automatic hammering machine original research paper dr. deo raj tiwari department of mechanical engineering, iimt college of engineering , greater noida x 127gjra global journal for research analysis mechanical engineering this paper discuss about cad modeling, design automatic portable hammering machine can be considered and analysis of automatic hammerin as the backbone of any hammering operation in mass our goal for this paper is to design and fabricate an automatic hammering machine. and for this, we have calculated the maximum torque, impact velocity for hammering, torque force and also shear failure in bolt joint. in our project we are using torque force to perform various manufacturing operation in industries like riveting, upset forging, punching etc. also time required for operation is less so it is useful in mass production. in this project we have prepared solid model of project assembly by using catia v5r20 software {computer aided three dimensional interactive application}. the snapshots of every component are attached in the le in design section. the model consists of motor, shaft, hammer, jigs and xtures. from this we fabricate conceptual model of automatic hammering machine. automatic portable hammering machine is one of the new techniques proposed in design in order to achieve instant hammering accurate repetition and impacting, fast hammering process. it should be user friendly without any risk and worker manual effort can be used easily automatically. in the past, a labor used hammer for to drive nail, t parts, break apart and more. it would be used manually with more effort and man power used in process. but now a day it is possible to make it process easy by invented automatic hammering. there are very clear benets that the industry sees while using automated systems. these advantages can be very benecial in the long run. we assure that our products are one of the best and they are long lasting. abstract keywords : catia v5r20 1, automatic2, cad modeling3, impact velocity4, torque force5, shear6, accurate7 fazle alam* department of mechanical engineering, iimt college of engineering , greater noida *corresponding author gurender pal department of mechanical engineering, iimt college of engineering , greater noida volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra faiz ali faiz department of mechanical engineering, iimt college of engineering , greater noida harvesh yadav department of mechanical engineering, iimt college of engineering , greater noida 128 x gjra global journal for research analysis many applications require a machine with reciprocating, linear sliding motion of a component. engines and com pressors require a piston to move through a precise dis tance, called the stroke, as a crank continuously rotates. other applications such as sewing machines and power hacksaws require a similar, linear, reciprocating motion. a form of the slider-crank mechanism is used in virtually all these applications. [1] 1.2 objectives of projects ÿ determination of impact velocity and torque force of hammer. ÿ to determine the time required for the various operations. ÿ prepare the modelling of project on catia v5r20. ÿ automation with minimum man power. ÿ low initial and operating cost. ÿ as time required in less useful in mass production. 1.3 analytical techniques. analytical methods can also be used to achieve precise results. advanced analytical techniques often involve intense mathematical calculation. in addition, the signicance of the calculations is often difcult to visualize. the analytical techniques incorporated in this text couple the theories of geometry, cad modeling and graphical mechanism analysis. this approach will achieve accurate solutions, yet the cad modeling of automatic hammering machine graphical theories allow the solutions to be visualized. a signicant of automatic hammering machine dedicated to these analytical techniques. [1] 1.4 features ÿ instant hammering. ÿ fast hammering process. ÿ no manual effort. ÿ portable system. ÿ low initial cost. ÿ low tooling cost. ÿ accurate repetition and impact. ÿ user friendly. ÿ easy maintenance. 2. project method & components this project has various different design paths to complete our products while matting the objectives. these means we will have to implement and compare our different design to insure the best product on our sat of objectives .this paths have changed as we progressed through our project, and there were few fore seen methods that we expand upon in the design section. the basic design for automatic hammering machine is to have motor xed on stand, and then motor shaft is inserted in center hole of the disc. disc is connected to the hammer rod with the link rod when we supply the dc current to the dc motor by using adopter then the motor shaft start rotating further transmit the spinning motion to the disc by using shaft the rst decision is to create an impact force for the respective operation this will help to determine product afford ability. a more efcient yet expensive design would be to have battery instead of adopter. there is bound to be various obstacles and design method to be implemented as projected progressives and will be observed and recorded as they occur. 2.2 component fig 2: prototype model automatic hammering machine 2.1.1 dc motor a dc motor is any of a class of rotational electrical machines that believers coordinate current electrical vitality. adc wiper gear motor is used which having 30 rpm speed and runs on 96 watt power and transmits 30.55 n-m maximum torque. 2.1.2 hammer in this project we have used hammer having weight 1.5kg for various operations such as punching, upset forging, riveting, e tc . these types of manufactur ing operat ions in manufacturing industries. 2.1.3 disc a disc is a wheel on a hub or shaft that is intended to help development and alter of course of a rigid link or belt. the disc having eccentric holes in which bolts are tted to connect linkages. 2.1.4motor drive shaft a drive shaft or cardin shaft is a mechanical part to transmit torque and revolution, typically used to associate different segments of a drive prepare that can't be associated straightforwardly as a result of separation or the need to take into account relative development between them. the shaft is connected to eccentric disc and is transfers rotational motion from motor to hammer rod. fig 3: prototype automatic hammering machine the most reliable design of automatic hammering machine are described below along with their specication in order to show the different existing approaches to the small and portable automatic hammering concept. these data could be useful when performing the initial sizing in the design stage of automatic hammering machine project. following are 13 designs for initial data collection: ÿ total weight =6 kg. ÿ hammer weight = 1.5 kg. ÿ hammer length =460mm. ÿ hammer stroke height = 186 mm. ÿ width = 355 mm. ÿ height = 450 mm. ÿ length = 580 mm. ÿ disc thickness = 1 mm. ÿ battery (supply voltage) =12v and 7 ampere. ÿ motor = denso india ltd (sr05950-4772), 30 rpm, 12v. dc motor. ÿ diameter of pulley =250 mm. ÿ length of link rod = 200mm. ÿ typical operation = common riveting for 2 mm rivet. 3. design of hammering machine 3.1. calculations a) to calculate maximum torque by motor motor rating, given data: n = 30 rpm volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra i = 8 a v = 12v power transmitted by motor, p = v × i = 12 × 8 then, p = 96 w p = 96 = t = 30.55 n-m distance of rod ba, fig 4: free body diagram to nd the distance of ba, by pythagoras theorem 2 2 2(ab) + (bc) = (ca) 2 2 2(ab) + (153) = (420) (ab) = 391.14 mm b) to nd torque force transmitted we have two cases case 1: when hammer moves downward. given: (bc) = h = 153 mm = 0.153 mm maximum torque = 30.55 n-m 3 = 30.55 × 10 n-mm length of hammer rod = 420 mm = 0.42 m torque force =tmax × length of hammer rod tf = tf = 83.86 n-m. case 2:when hammer goes upward, torque force will be decreased c) to find impact velocity of hammer, given: h =153 mm = 0.153 m t (time required for one re revolution of disc) = 2 sec. so, v = h × t v = 0.15 × 2 v = 0.306 m /sec so the impact velocity of hammer is 0.306 m /sec. result thus for riveting of 2mm rivet calculated the impact velocity is 0.306 m/sec with a torque force of 83.86 n-m is sufcient and it is calculated successfully. [4] d) to calculate shear stress in bolted joint we have bolted joints so there is torsional shear stress in joints, we have, t = 30.55 n-m. d = diameter of bolt 10 mm. j = polar moment of inertia. result as the standard permissible value of shear stress for m10 bolt is 3396.8 × 10 n/mm2 and the calculated value of shear stresses is 2311.73 × 103 n/m so therefore the value of shear stress is less than permissible shear stress the design is safe. [4] 4) computer aided modelling 4.1 introduction cad modelling is used by many designers to create elaborate computerized model of objects. cad is computer-aided design. engineers, architects, and even stands artists utilize computers to assist their design projects. computers allow them to in visualize their designs and confront problems before they have expended any of the resources necessary to put them into physical form cad modelling takes many different forms depending on the type of project. some models are simple two dimensional representations of various views of an object. others are elaborate threedimensional crosssections that show every detail in great depth. it is an important industrial art involved in automotive, aerospace, prosthetic, and artistic designs. the use of cad modelling is massively widespread; anything from chairs to rockets can be designed with the aid of computer programs. cad modelling has had a profound effect on the process's development. first, a general idea must be made to solve a specic problem. next, cad modelling is used to work out the specics of the model's design. 4.2 type of cad modeling 4.2.1 wireframe models wireframe systems were developed in the early 1960s to automate design drafting of the early 3 cad systems used wireframe models. the very rst systems were only 2d and the user had to construct a model point by point and line by line. a wireframe model is represented by tables dening edges and points. the start point and the end point of each edge are stored in the edge table. an edge may be a line or a curve. the coordinates of each point are stored in the point table. this representation is natural for a designer who is familiar with mechanical drawing" since is the lines and curves in a x 129gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 2 πnt 60 2π30×t 60 30.55 × 0.42 0.153 h volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra drawing which dene 3d shape a wireframe it simply in a computer as a data structure. the storage space is del stored very is l and the access time very short. 4.2.2 surface models surface models a surface model is represented by tables of edges and points, as is a wireframe model, but additional to wireframe. a surface model is represented by tables of faces. the face table stores information on which edges are attached to each face, in most conventional cad systems for free-form surfaces, surface models have been used as internal representations. however, a surface model is a set of faces, and as such can be ambiguous when determining the volume of an object. surface models play an important role in industry, because they give an accurate description of the surface of an object. an example of a very simple surface models shown in figure. 4.2.3 solid models because there is no ambiguity in using a solid s 3d object, the importance of using solid modelling has been widely recognized. solid models can support a wide range of activities, like interference check computation of volume and surface area, nite element analysis etc. in general, most solid modelling systems have adopted either constructive solid geometry csg) or boundary representation (b-rep) as representations of solid solids. solid models may be divided in three basic classes as follows: l. decomposition models represent a solid as a collection of simple object from a xed collection of primitive object types, combined with a single gluing operation; 2. constructive models represent a solid as a combination of primitive solids each of the primitives is represented as an instance of a primitive solid type. different types of constructive modelling representations are half pace representation and csg; 3. boundary models represent a solid in terms of its boundary. the boundary of a solid is a surface that is usually represented as a collection of faces. faces again, are often represented as a bounded region of the surfaces. b-rep represents a solid boundary as a "skin" around the object. following showing the 3d solid models of various components of project by using modelling software catia v5r20 4.3 cad drawings of hammering machine fig 5: 3d view of automatic hammering machine fig 6: side view of automatic hammering machine 5.1 advantages ÿ available in wide variety of sizes. ÿ maintain good control and required force. ÿ low cost. ÿ save man power. ÿ saves time. ÿ time delay can be achieved easily. ÿ mass production. 5.2 disadvantages ÿ this mechanism is only suitable for few operations. ÿ as torque force required is more there is difcult to nd the motor to achieve the required torque. ÿ having little wear. 5.3 application ÿ in manufacturing industries to perform different operations as follows. ÿ to perform smithy operation i.e. upset forging. ÿ to perform the punching operation. ÿ to perform lleting operation as torque force produce is sufcient for the operation. ÿ to perform riveting operation etc. 6. conclusions we have successfully calculated the torque force of the motor. for the design the impact velocity and torque force for riveting of 2 mm rivet is calculated accurately. the entire modelling of the project is done with the help of catia v5r20. in this addition to this. the project work has provided us an excellent opportunity and experience, to use our limited knowledge. we gained a lot of practical knowledge regarding. planning, perching, assembling and machining while doing this feel that the project work is good solution to bridge the gates project work. we between institutions and industries. we are proud that we have completed the work with limited time successfully automatic hammering machine is working with satisfactory condition. we have done to our ability and skill making ma work. 7. future scope the concept of an automatic hammering machine in this paper has been shown to have a place in the actual market and to ll a need demanded by potential customer. in this paper, the concept of automatic hammering machine prototype will have to fulll the basic design requirement, let us add the proposed concept will a few more lines about our impression project work. help in production line where many workers are used for the material handling purpose it also reduce the cost and threshing time requirement of more number of worker will completely eliminated as only two workers can carried out the be complete operation. the project objective originally is to reduce human efforts in manufacturing industries. the in future the complete stress analysis of the project model could be done. this analysis could be done by us. moreover, for the automatic hammering machine to achieve fully success in the future, many collateral improvement must be done in terms of systems (autopilot technology, for instant) and time delay management (pedal operated control will be required) and some modication can will be done in this project 9. references [1] david h. myaszk, mechanisms and machine analysis – 4th edition. [2] www.hotelkishanpalaceheritage.com. [3] www.nevoprojects.com/automated-portablehammering-machine. [4] machine design book rs khurmi& jk gupta for calculation. 130 x gjra global journal for research analysis background lung cancer is a major cause of cancer related mortality. 1about 85% of cases are related to cigarette smoking . biological markers known as tumour markers are used as predictors of response to treatment in several types of malignant tumours including lung cancer. serial estimation helps in estimating the response to treatment, monitoring the course of the disease, predicting survival rate, surveillance for 2recurrences . cea was one of the rst tumour markers evaluated in lung cancer, elevated levels are seen in 40–80% of patients with lung cancer. cea expression and secretion by tumour cel ls promote metastat ic spread thereby, inammatory environment supporting tumour formation 3helping in estimating the prognosis of the disease . aims & objectives ÿ to determine level of cea in patients with biopsy proven cases of lung cancer. ÿ to evaluate serum cea levels as a tumour marker for lung cancer. materials and methods this study was conducted from january 2018 to october 2019 at geetanjali hospital, udaipur. study consisted of 74 patients with proven biopsy of carcinoma lung and demographic data such as age, sex & addiction history were noted. inclusion criteria comprised of all male and female patients of 18 years and above, histo-pathologically conrmed cases of carcinoma lung and patients giving informed consent. exclusion criteria included all other malignancies, pancreatitis, inammatory bowel disease, pancreatitis, cirrhosis of liver. the selected patient underwent serum cea level at geetanjali medical college and hospital laboratory with the normal reference values as per gmch laboratory protocols being serum cea: up to 4ng/ml. results in the present study, maximum number of patients were of the age group between 51 to 60 years (41.89%) .68 (91.89%) males and 6 (8.11%) female patients were affected. maximum number of patients were in stage iv accounting for 42 (56.76%) patients. 38 (51.35%) patients were of adenocarcinoma followed by 26 (35.14%) with squamous cell carcinoma and 10 (13.51%) with small cell carcinoma. 27 (71.05%) out of 38 patients with adenocarcinoma, 10 (38.48%) out of 26 patients with squamous cell carcinoma and 6 (60%) out of 10 patients with small cell carcinoma showed cea values more than normal. on applying chi square test, the difference was found statistically signicant with p value of (.034). 30 (71.43%) patients out of 42 of stage iv, all 5 patients of stage iiib,4(57.14%) out of 7 cases of iiia and 2 (28.57%) out of 7 cases of both stages iia & iib showed higher cea level than normal. on applying chi square test, the difference was found statistically signicant with p value of (.005). 42 out of 74 patients developed metastasis wherein highest number of cases were seen with adenocarcinoma being 24 patients and highest frequency of metastasis was seen to adrenals in 10 patients. higher than normal level of cea was seen in all 3 (100%) patients of pleural metastasis followed by brain metastasis was seen in 5 (83.33%) patients out of 6 patients, liver metastasis was seen in 5 (71.43%) patients out of 7 patients, adrenal metastasis was seen in 6 (60%) patients out of 10 patients, bone metastasis was seen in 4 (57.14%) patients out of 7 ,7 (77.78%) patients out of 9 patients of multiple metastasis showed higher than normal level of cea. on applying chi square test, the difference was found statistically non-signicant with p value of (0.679). table 1 types of distribution a study of carcino embryonic antigen (cea) levels in lung cancer original research paper dave manan resident, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india x 59gjra global journal for research analysis general medicine background lung cancer is a major cause of cancer-related mortality. about 85% of cases are related to cigarette smoking. cea was one of the tumour markers use to evaluate lung cancer, also elevated levels are seen in 40–80% of patients with lung cancer, showing a high sensitivity for adenocarcinoma and for advanced stage studies show that cea level in serum is signicantly increasing in patients with lung cancer. serum cea level can be used as a sensitive and specic screening test for various cancers including lung cancer. method 74 patients were studied at geetanjali hospital, udaipur. only biopsy proven cases of carcinoma lung were interviewed and demographic data such as age, sex & addiction history were noted. results among 74 patients diagnosed with lung cancer highest cases were seen in patients with adenocarcinoma 38 (51.35%) followed by squamous cell carcinoma with 26 (35.14%) followed by small cell carcinoma 10 (13.51%). 27 (71.05%) out of 38 patients of adenocarcinoma, 10 (38.48%) out of 26 patients of squamous cell carcinoma and 6 (60%) out of 10 patients of small cell carcinoma showed cea values more than normal. 30 (71.43%) patients out of 42 of stage iv, all 5 patients of stage iiib 4 (57.14%) out of 7 of iiia patients 2 (28.57%) out of 7 patients of both stages iia & iib showed higher cea level than normal. higher than normal level of cea was seen in all 3 (100%) patients of pleural metastasis followed by brain metastasis was seen in 5 (83.33%) out of 6 patients, liver metastasis was seen in 5 (71.43%) out of 7 patients, adrenal metastasis was seen in 6 (60%) out of 10 patients, bone metastasis was seen in 4 (57.14%) out of 7 patients showed higher than normal level of cea. conclusion this observation highlights the importance of tumour markers in relation to histological type and tumour staging. routine serum cea testing in patients with nonsmall cell lung carcinoma than small cell lung carcinoma, allows the identication of a signicant proportion of patients at high risk of developing a tumour relapse being cost effective. abstract keywords : lung cancer, carcinoembryonic antigen levels volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra shrimali lalit* professor, department of general medicine geetanjali medical college and hospital udaipur (rajasthan) india *corresponding author agarwal ankit assistant professor, department of oncology, geetanjali medical college and hospital udaipur (rajasthan) india type no. % adenocarcinoma 38 51.35 60 x gjra global journal for research analysis table 2 comparison between various types of lung cancer & cea table 3 cea level in correlation with metastasis table 4 comparison between various stages of lung cancer & cea discussion serum tumour markers are of signicance to the clinician in treating patients with cancer. in oncology set up serum tumour markers aid in the diagnosis, pathologic classications, and evaluation of the stage of disease and prognosis .lung cancer being the leading cause of cancer death in both men and women needs to be evaluated based on indices used for 4diagnosis, prognosis, choice of therapy the general trend of male patients is due to various reasons including tobacco smoking and most commonly seen in the age group of 3060yrs and due to lack of awareness of the ill effects of tobacco 5smoking in our study observed age group among patients with lung cancer is in between 51-60 years (41.89%)range 6with male preponderance (91.89%). oscar arrieta et al study in the year 2013 documented the male preponderance (54.4%) and age group being in between 47-60years (59.4%) to be affected more than other age groups, which is similar to the present study. our study conducted on 74 patients showed 69 patients (93.24%) to be associated with smoking while remaining 5 (6.75%) were found to be non-smokers by history 7and examination. in konstantinos charalabopoulos et al study, 46 patients were smokers (92%) among 50 patients suffering from lung cancer, remaining 4 patients (8%) were non-smokers. adenocarcinoma is the most common histolo gical group in men and women worldwide. studies conducted 8 9 10by jae jun kim et al , chen et al zaleska et al all showed that adenocarcinoma is the commonest type of lung cancer with 51.8%, 72.9% and 48.10%respectively which is similar to the present study where 51.35% were adenocarcinoma. in our study, 30 (71.43%) cases out of 42 of stage iv showed 10higher cea level than normal. zaleska et al . in the year 2010 showed that 33 (41.77%) cases out of 79 of stage iv showed higher cea level than normal with p value (< 0.024). study by 6arrieta et al also showed similar observation where stage iv showed higher cea levels than normal with a p value (< 0.03) all 5 cases of stage iiib showed higher cea level than normal. out of 7 cases of iiia 4 (57.14%) showed higher cea level than normal. a study conducted by 11aoyagi k in the year 1999 observed that cea levels estimation in stage i-iii lung cancer patients to be statistically signicant with p value of (0.041) some studies have reported that serum cea levels were signicantly higher in patients with metastatic disease as compared to patients with non-metastatic disease. (91) (92) 12(93) study by ahmet et al did not show signicant difference in serum cea levels between stage iii and stage iv, which is similar to our study. in the present study 24 out of 42 patients were adenocarcinoma type with distant metastasis which is similar to the study conducted by arrieta et al (73). higher than normal level of cea was seen in all 3 (100%) patients of pleural metastasis followed by brain metastasis were 5 (83.33%) out of 6 patients, liver metastasis were 5 (71.43%) out of 7 patients, adrenal metastasis were 6 (60%) out of 10 patients, bone metastasis were 4 (57.14%) out of 7 patients showed higher than normal level of cea, 7 (77.78%) in the present study. 13a study by arrieta et al -studying metastasis to brain showed that brain metastasis in patients with adenocarcinoma subtype and higher than normal level of cea at diagnosis. 12study by ahmet et al concluded that higher than normal level of serum cea were signicant for predicting distant metastases, which is similar to the present study where it was found that distant metastasis was seen in higher than normal level of cea levels in 30 (71.43%) patients out of 42 patients of metastasis. high serum cea levels suggest micro metastatic disease, also prognostic values of high cea serum levels can 13,14be accounted for by tumour change 15a study conducted by jiasi wang et al observed that 128 out of 213 patients showed metastasis in which 49 (38.3%) patients were adenocarcinoma, 47 (36.7%) patients were squamous cell carcinoma and 24 (18.8%) patients were small cell carcinoma and corresponds with our study. this study suggested that serum cea as a valuable marker in the assessment of tumour metastasis in lung cancer patients. early identication and location of metastasis with the help of such tumour markers such as serum cea levels can be useful for clinical selection of treatment and can therefore create 16better prognosis conclusion tumour markers are related to histological type and tumour staging. routine serum cea testing in patient with non-small cell lung carcinoma than small cell lung carcinoma, allowing the identication of a signicant proportion of patients at high risk of developing a tumour relapse being cost effective. cea level estimation can be used as a biomarker and as a combination with other tumour markers to suggest the histological diagnosis and metastasis risk. in cases of sclc, serum cea estimation can get affected by various factors and is not being used as an ideal marker. differentiation and staging of the different types of lung cancer based on serum cea levels varies greatly as serum cea levels get affected by various factors such as smoking volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra squamous cell carcinoma 26 35.14 small cell lung carcinoma 10 13.51 74 100.00 type cea level total % of patients with cea level higher than normal no. of cases with cea <4 ng/ml no. of cases with cea >4 ng/ml adenocarcinoma 11 27 38 71.05 small cell lung cancer 4 6 10 60 squamous cell carcinoma 16 10 26 38.46 cea level metastasis total adrenal bone brain liver pleural multiple cea level <4 ng/ml 4 3 1 2 0 2 12 cea level >4 ng/ml 6 4 5 5 3 7 30 % of patients with cea level higher than normal 60 57.14 83.33 71.43 100 77.78 71.43 stage cea level total % of cases with cea level higher than normal no. of cases with cea <4 ng/ml no. of cases with cea >4 ng/ml ia 2 0 2 0 ib 3 0 3 0 iia 5 2 7 28.57 iib 5 2 7 28.57 iiia 3 4 7 57.14 iiib 0 5 5 100 iv 12 30 42 71.43 etc. hence serum cea level estimation can be considered as a tool for prognosis and grading than as a marker for predicting the nature of the disease. references 1. beasley mb, brambilla e, travis wd. the 2004 world health organization classication of lung tumors. seminroentgenol 2005;40:90-7. 2. pamies, r.j. and crawford, d.r. (1996). tumour markers: an update med. clin. north am. 80,185-199. 3. gold p, freedman so. demonstration of tumour-specic antigens in human colonic carcinomata by immunological tolerance and absorption techniques. j exp med 1965 mar 1;121:439–462 4. buccheri and ferrigno et al, identifying patients at risk of early postoperativerecurrence of lung cancer: a new use of the old ceatest annthoracsurg 2003;75:973–80 5. stevens dp, mackay ir. increased carcinoembryonic antigen in heavy cigarette smokers. lancet 1973;2:1238–9. 6. oscar arrieta, cynthia villarreal garza et al,usefulness of serum carcinoembryonic antigen(cea) in evaluating response to chemotherapy in patients with advanced non small-cell lung cancer: a prospective cohort study, bmc cancer 2013, 13:254 7. konstantinos charalabopoulos,1 agathikarakosta et al cea levels in serum and bal in patients suffering from lung cancer correlation with individuals presenting benign lung lesions and healthy volunteers, medical oncology,vol. 24, no. 2, 219–225, 2007 8. jae jun kim, m.d.1, kwanyonghyun,the signicance of serum carcinoembryonic antigen in lung adenocarcinoma, korean j thorac cardiovasc surg 2015;48:335-344 9. feng chen, jia li, diagnostic value of cyfra 21-1 and carcinoembryonic antigen in diagnosis of operable lung cancer from benign lung disease, journal of cancer research and therapeutics – vol.14 (2);2018 10. zaleska m, szturmowicz m, zych j, sliz b, demkow u, langfort r, et al. elevatedserum nse in inoperable non-small-cell lung carcinoma (nsclc) is associated with a better response but worse prognosis. pneumonolalergol pol2010;78(1):14–20 11. aoyagi k, miyake y, urakami k, kashiwakuma t, hasegawa a, kodoma t,et al: enzyme immunoassay of immunoreactive progastrinreleasing peptide(31–98) as tumor marker for small cell lung carcinoma: development and evaluation. clinchem 1995;41: 537–543 12. ahmet ursavas, mehmet karadag et al serum carcinoembryonicantigen level as a predictive marker for distant metastasis in non-small cell lung cancer,eur j gen med 2007;4(3):107-114 13. arrieta o, saavedra-perez d, kuri r, aviles-salas a, martinez l, mendozaposada d, castillo p, astorga a, guzman e, de la garza j. brain metastasis development and poor survival associated with carcinoembryonic antigen (cea) level in advanced non-small cell lung cancer: a prospective analysis. bmc cancer. 2009 dec;9(1):119 14. concannon jp, dalbow mh, hodgson se, et al. prognostic value of preoperative carcinoembryonic antigen (cea) in patients with bronchogenic carcinoma. cancer 1978;42:1477-83 15. yuan gao,pingping song et al, elevated serum cea levels are associated with the explosive progression of lung adenocarcinoma harboring egfr mutations,gao et al bmc cancer,2017,17:484 16. jiasi wang,yanpeng chu et al,the clinical value of carcinoembryonic antigen for tumor metastasis assessment in lung cancer,2019,peerj 7:e7433 17. reck m,popat s et al, metastatic non-small cell lung cancer(ns clc) :esmoclinical practice guidelines for diagnosis, treatment and follow up. annals of oncology 25(suppl 3):iii27-iii39 x 61gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction the dengue virus is a avivirus having four distinct serotypes; den-1, den-2, den-3 and den-4. the incidence of disease and its severity varies between primary and secondary infections and possibly also across different dengue virus serotypes [1]. the clinical presentation of dengue fever varies from simple febrile illness to dengue hemorrhagic fever and dengue shock syndrome which may sometime lead to death. pleural effusion is one of the respiratory complications. determination of the nature and clinical course of pleural effusion is important. severe dengue with massive pleural effusion and hypoxemia constitute important causes of death in those infected with the dengue virus. the mortality rate with severe forms of dengue infection may approach 47% [2]. the world health organization (who) guidelines [3] and national guidelines by government of india [4] offer a useful approach to immediate uid resuscitation in various stages of the disease. kabra, et al. [5] and soni, et al. [6] have described difculties in uid management in children in the indian context. diagnosis is largely clinical and is supported by serology and identication of viral material in blood. no specic methods are available to predict outcome and progression. careful uid management and supportive therapy is the mainstay of management. pleural effusion is one of the complications of dengue fever resulting from the plasma leakage into the pleural cavity. in dengue fever it is one of the severity markers and is of exudative type. it can be detected clinically and can be conrmed radiologically through ultrasound the objective of the present study is to study the role of furosemide infusion and outcome in the management of hypoxemia in children due to pleural effusion and ascites with dengue fever 48 hours after the onset of critical phase. methods this comparative study was conducted in paramitha children hospital, a tertiary care pediatric referral centre at hyderabad with a 20 bedded pediatric intensive care unit (picu). ethical clearance from the institution's ethical committee was obtained to conduct this study. participants included children of either gender between the ages of 1 month to 18 years, who are positive for ns1antigen assay by elisa, admitted between june 2019 to september 2019 and having signs and symptoms of hypoxemia after 48 hours of critical phase were evaluated and included in the study ultrasonography was used for quantifying the pleural effusion and ascites for all of them then they are randomly assigned into either of the two groups after shifting into picu as group a (receiving diuretic therapy along with oxygen) compared to a group b (treated with only oxygen). abg analysis was done and started on oxygen therapy with titrating iv uids with continuous bp, spo2 and urine output monitoring. furosemide infusion was administered for those in group a at 0.05-0.1 mg/kg/hour for 24 to 48 hours titrating to maintain a urine output of 3-5 ml/kg/hour. those requiring inotropic support and complicating as hlh (haemophagocytic syndrome) were excluded from the study. duration of requirement of oxygen therapy and total duration of stay in hospital were compared among both the groups. chisquare test was used to compare and p value less than 0.05 was considered signicant. results of the 2550 children admitted with dengue fever, 320 developed signs and symptoms of hypoxia and conrmed by abg analysis, accounting for an incidence of 12.5%. all the children were even positive for dengue igm. each group consist of 150 children with 20 of them excluded from the study (table1 and 2). the mean time of onset of hypoxemia from the rst symptom was 7 days. females were most commonly affected gender group developing severe symptoms. the mean age of children developing hypoxemia due to massive pleural effusions was 8 years but there is a biphasic mode of involvement with peak age groups of 1 to 5 years and 10 to 15 years. the mean duration of oxygen requirement was for 2 days in group a and 4 days in group b. the duration of stay in hospital was for 6 days in group a while it is 10 days for group b. chisquare test analysis was applied for the results. the role of outcome with usage of furosemide is signicantly benecial with a p value of 0.03. discussion the present study demonstrated the advantage of usage of furosemide infusion in children with severe dengue infection complicating as massive pleural effusion and developing hypoxemia. a signicant decrease in duration of supplemental oxygen requirement and total duration of stay in hospital was noted following furosemide infusion, thus demonstrating an improvement in overall clinical outcome. dey et al [7] suggests for usage of furosemide only for those children with uid overload but in this study furosemide was a comparative study of usage of furosemide infusion in children with dengue fever with hypoxemia at a tertiary care centre at hyderabad, india original research paper dr. parvath reddy* dch department of pediatric intensive care unit, paramitha childrens hospital, hyderabad, telangana, india. *corresponding author paediatrics objectives: to study the role of furosemide infusion and outcome in the management of hypoxemia in children with dengue fever 48 hours after the onset of critical phase. methods: children between the ages of 1 month to 18 years, who are positive for ns1antigen assay by elisa and developed signs and symptoms of hypoxemia were evaluated and included in the study. patients were studied as group a (receiving diuretic therapy) compared to a group b (treated with only oxygen). furosemide infusion was administered at 0.05-0.1 mg/kg/hour for 48 hours, maintaining a urine output of 3-5 ml/kg/hour. results: signicant difference was noted for duration of requirement of oxygen therapy and the number of days of hospitalization among the two groups (p=0.03). conclusion: diuretic infusion improves outcome with fast recovery and less duration of hospital stay in children with dengue with hypoxemia. abstract keywords : hypoxemia, dengue, diuretics, outcome volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. krishna chaitanya dnb department of pediatric intensive care unit, paramitha childrens hospital, hyderabad, telangana, india. 100 x gjra global journal for research analysis used for group a with signs and symptoms of hypoxemia and ultrasound quantied pleural effusion and ascites. our results are similar to the report by ranjit, et al. [8] who demonstrated the efcacy of uid removal using diuretics or dialysis in children with dengue fever. reddy, et al. [9] reported in their study about the benet of using furosemide for children developing ards and getting ventilated. in a study performed by balasubramanian et al., ultrasonography was found to be superior to radiography in detecting pleural effusion [10]. ultrasonography monitoring was used in this study also. the efcacy of furosemide infusion with respect to changes in the arterial blood gas demonstrates its role in respiratory function. it is known that in the recovery phase of dengue fever, there is reabsorption of uid from the extra vascular compartment. in these patients, diuretics should be tried, which could improve oxygenation and avoid the need for mechanical ventilation. early intervention can help improve case management and optimise the use of resources such as hospital staff, beds, and intensive care equipment. conclusion furosemide infusion improves survival in the management of severe dengue fever with hypoxemia, with signicant improvement in oxygenation and decrease in need for ventilation and duration of hospitalization. limitations: this study was limited due to the insufcient data as we did not consider factors regarding associated confounding factors such as different caregivers and a different support structure. funding: none. conicts of interests: none stated. what this study adds: furosemide infusion improves survival in the management of severe dengue fever with hypoxemia, with signicant improvement in oxygenation and decrease in need for venti lation and duration of hospitalization. tables table 1. baseline characteristics of study population. table 2. comparative observations in the study references 1. khan e, hasan r. dengue infection in asia; a regional concern. j postgrad med inst. 2011;26(1):1-6. 2. agarwal r, kapoor s, nagar r. a clinical study of patients with dengue haemorrhagic fever during the epidemic of 1996 at lucknow, india. southeast asian j trop med public health. 1999;30:735-40. 3. dengue: guidelines for diagnosis, treatment, prevention and control new edition. geneva, who, 2009. 4. national guidelines for clinical management of dengue fever. india. 2015. 5. kabra sk, jain y, singhal t, ratageri vh. dengue hemorrhagic fever: clinical manifestations and management. indian j pediatr. 1999;66:93-101. 6. soni a, chugh k, sachdev a, gupta d. management of dengue fever in icu. indian j pediatr. 2001;68:1051-55. 7. dey a, dhabe h, shah i. fluid replacement in children with dengue and factors associated with pulmonary edema. pediatr oncall j. 2017;14: 3134.03–305. 8. ranjit s, kissoon n, jayakumar i. aggressive management of dengue shock syndrome may decrease mortality rate: a suggested protocol. pediatr crit care med. 2005;4:412-9. 9. reddy kr, basavaraja gv, shivananda furosemide infusion in children with dengue fever and hypoxemia. indian pediatr 2014; 51:3 10. balasubramanian s, janakiraman l, kumar ss, muralinath s, shivbalan s. a reappraisal of the criteria to diagnose plasma leakage in dengue hemorrhagic fever. indian pediatr. 2006;43:334–9. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra total children admitted with dengue in hospital 2550 total children shifted to picu 320 total study population 300 mean age group 8 most severe affected gender female peak age goups affected (1 to 5 and 10 to 15) oxygen total stay group a 2 days 6 days p =0.03 group b 4 days 10 days x 101gjra global journal for research analysis introduction ischemic heart disease (ihd) is the generic designation for a group of pathophysiologically related syndromes resulting from myocardial ischemiaan imbalance between the supply (perfusion) and demand of the heart for oxygenated blood. in more than 90% cases, the cause of myocardial ischemia is obstructive atherosclerosis lesion in the coronary arteries. thus ihd is often termed as coronary artery disease (cad) or coronary heart disease (chd). the most common cause of 1 myocardial ischemia is atherosclerotic disease of coronary artery (or arteries) that is sufcient to cause a regional reduction in myocardial blood ow and inadequate perfusion of the myocardium supplied by the involved coronary artery. obesity, insulin resistance, and type 2 diabetes mellitus are increasing and are strong risk factors for ihd. cardiovascular diseases have been gaining importance in developing countries like india recently because of increased incidence of the disease. normal serum uric acid in male 4.0-7.0 mg/dl and in female 3.0-6.0 mg/dl . the role of uric acid as a risk factor for 3 cardiovascular disease or a prognostic factor is controversial. uric acid is produced by the enzymatic activity of xanthine oxidase and is the nal product of purine metabolism . 4 xanthine oxidase produces oxidants in this process that may have role in cardio-vascular diseases. some study suggested that uric acid can cause intracellular stress and inammation leading to endothelial injury and enhancement of vasoconstrictor effect . uric acid(2,6,8trioxypurine) is the nal 5 excretory product of purine metabolism in humans .uric acid . can serve as important antioxidant by getting itself converted (non-enzymatically) to allantoin. it is believed that the antioxidant role of ascorbic acid in primates is replaced by uric acid ,since these animals have lost the ability to synthesize ascorbic acid. most animals (other than primates) however, oxidize uric acid by the enzyme uricase to allantoin, where the purine ring is cleaved. allantoin is then converted to allantoic acid and excreted in some shes. further degradation of allantoic acid may occur to produce urea (in amphibans, most shes and some molluscs) and, later, to ammonia (in marine invertebrates) there are several studies 2 which are conducted overtime to address this issue but there is no any consistent data which suggest the relation of serum uric acid with acute myocardial infarction. therefore this study is designed to evaluate the relation of serum uric acid in acute mi. aim and objectives to study the relationship between serum uric acid level and prognosis in indoor patients with acute myocardial infarction. objective: 1 . to determine the relationship between serum uric acid level and major cardiovascular events in patients with acute myocardial infarction. 2. to give specic recommendations on the basis of ndings of the study. material and method ÿ study design the present prospective study was conducted in the department of medicine in rohilkhand medical college and hospital from period of november 2019 to january 2020 ÿ study group a total number of 100 patients of acute myocardial infarction admitted in department of medicine of rohilkhand medical college and hospital during the study period were taken ÿ inclusion criteria 1. age ≥18 years 2. all the patients of acute myocardial infarction admitted within 7 days of presentation during the study period in rohilkhand medical college and hospital. 3. both st segment elevation myocardial infarction (stemi) and non-st segment elevation myocardial infarction (nst emi) will be included in the study. the prognostic role of serum uric acid level in indoor patients with acute myocardial infarction original research paper dr. sarda mukund shyam junior resident, general medicine department, rohilkhand medical college and hospital, bareilly room number 17, pg and interns hostel, rohilkhand medical college and hospital, bareilly, uttar pradesh 243001 medicine ischemic heart disease (ihd) is the generic designation for a group of pathophysiologically related syndromes resulting from myocardial ischemiaan imbalance between the supply (perfusion) and demand of the heart for oxygenated blood. in more than 90% cases, the cause of myocardial ischemia is obstructive atherosclerosis lesion in the coronary arteries. some study suggested that uric acid can cause intracellular stress and inammation leading to endothelial injury and enhancement of vasoconstrictor effect5. there are several studies which are conducted overtime to address this issue but there is no any consistent data which suggest the relation of serum uric acid with acute myocardial infarction. serum uric acid (sua) levels can be measured in almost all hospitals, especially in developing countries, which have no facilities to measure other more expensive prognostic markers such as high sensitive c reactive protein, brain-type natriuretic peptide, interleukin-6 and many others. this simple, easily available, inexpensive laboratory parameter (estimation of serum uric acid) may help in settings where facilities are lacking, can be a useful biomarker to prognosticate patients of acute myocardial infarction abstract keywords : volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. dhanakar thakur* associate professor, general medicine, rohilkhand medical college and hospital, bareilly *corresponding author dr. anubhav gupta junior resident, general medicine department, rohilkhand medical college and hospital, bareilly 22 x gjra global journal for research analysis ÿ exclusion criteria 1 any patient with the history of medical illness known to elevate uric acid level, viz a. gout b. chronic renal failure c. systemic or local infection d. malignancy e. repeated blood transfusion f. hematological disorder g. chronic alcoholism 2. patient with history of intake ofa. hyperuricemic drug (thiazide, salicylate, ethambutol, pyrazinamide, allopurinol). b. impaired renal function (serum creatinine >2mg/dl). c. had an episode of mi within 3 months. d. had severe valvular heart disease. methods of study the patients admitted in department of medicine in rohilk hand medical college and hospital with symptoms of acute myocardial infarction were screened with 12 lead ecg & tropt and those fullling the inclusion and exclusion criteria of our study will be taken as the study subject. the study group selected will be subjected to routine blood investigation, blood sugar fasting & post prandial , fasting lipid prole, serum uric acid, chest x-ray, usg abdomen and echocardiography. the demographic information, cardiovascular history and risk factors(smoking, hypertension and diabetes mellitus) of patients were obtained from medical records results out of 100 patients, 83 (83%) were males and 17 (17%) were females accounting a ratio of m male to female 4.8:1. patient's age ranged from 2680years more than half of patients were between 40-60 years (54%) followed by >60 (32%) and <40 (14%) years.all 100 patients in the study were subjected to 2d echo and we observed that 65 patients (65%) had normal left ventricle function and remaining 35 patients (35%) had lv dysfunction ranging from mild to severe. mild lvd was found among 17% patients and moderate lvd was in 13%. severe lvd was in 5% patients. when we compared 2d echo ndings with serum uric acid levels on day 1, we found clinical correlation. abnormal uric acid was higher among whom abnormal lvf (42.9%) than normal lvf (33.8%). however, the association was statistically insignicant (p>0.05). also on comparing 2d echo in the form of lvef with outcome of patients mortality was higher among moderate and severe lvd. the association was statistically signicant (p=0.02).study by chen et al and shetty et al found similar 6 7 observation when they evaluated lv dysfunction by 2d echo and compared with uric acid. patients with moderate to severe lv dysfunction had high uric acid levels. when we see the distribution of uric acid, we found that abnormal uric acid was in 37% and 34% at day 1 and day 4 respectively. the change in the pattern of uric acid from day 1 to day 4 was statistically insignicant (p>0.05). fig. 1: correlation of lvef with uric acid day 1 table-1: correlation of outcome with lvef chi-square test, *signicant table-1 & fig.1 shows the correlation of lvef with outcome. mortality was higher among moderate and severe lvd. the association was statistically signicant (p=0.02) fig. 2: correlation of outcome with uric acid conclusion in the present study of 100 patients with acute myocardial infarction we observed signicant correlation with various factors. based on the ndings the conclusion drawn is: 1. in patient's with acute myocardial infarction, patients with hyperuricemia had higher mortality. 2. there was a positive correlation of outcomes with 2d echo .. 3there was a clinical correlation between hyperuricemia and left ventricle dysfunction which was statistically insignicant. 4hyperuricemia is an indicator of poor prognosis in acute myocardial infarction. recommondation: sua serum uric acid levels can be measured in almost all hospitals, especially in developing countries, which have no facilities to measure other more expensive prognostic markers such as high sensitive c reactive protein, brain-type natriuretic peptide, interleukin-6 and many others. this simple, easily available, inexpensive laboratory parameter (estimation of serum uric acid) may help in settings where facilities are lacking, can be a useful biomarker to prognosticate patients of acute myocardial infarction. besides this, controlling hyperuricemia might also be a promising strategy for the prevention of ami. we strongly recommend that patients with higher levels of these markers on admission should be closely monitored for ami associated complications. to address this issue whether efcacy of serum uric acid level in these patients is signicant or not, a detailed study with large sample size may be required. although of few limitations, we consider that our study make an important contribution, since similar studies especially inconsistent in their result. limitation of the study: 1major limitations of our study may be the small number of patients. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra lvef no. of patients outcome p-value expired discharged no. % no. % normal 65 9 13.8 56 86.2 0.02* mild lvd 17 1 5.9 16 94.1 moderate lvd 13 6 46.2 7 53.8 severe lvd 5 1 20.0 4 80.0 x 23gjra global journal for research analysis 2most of our patients in study were male. a large study, especially with more female patients could be more informative. 3another limitation of the study is that we could not follow up our discharged patients. references 1. kumar v, abbas ak, fausto n, mitchell rn. robbins basic patho logy. 8thedition. saunders and elsevier publishers.2007;379-420. 2. u. satyanarayna, u. chakrapani. biochemistry 3rd edi. kolkata: 2008 chapter17, metabolism of nucleotides; 394. 3. victor w. rodwell. harper’s illustrsted biochemistry. 30th edi. new york: mcgraw hill education; 2015. chapter 33, metabolism of purine & pyrimidine nucleotides; 354. 4. john j. cush .harrison’s principles of internal medicine. 19th edi. new york; 2015 chapter 393, approach to articular and musculoskeletal disorders; 2222. 5. wasserman a, shnell m, boursi b, guzner-gur h. prognostic signicance of serum uric acid in patients admitted to the department of medicine. the american journal of the medical sciences. 2010 jan 31;339(1):15-21 6. chen l, li xl, qiao w, ying z, qin yl, wang y, zeng yj, ke yn. serum uric acid in patients with acute st-elevation myocardial infarction. world journal of emergency medicine. 2012;3(1):35-9 7. shetty s, rao a, k. s, s r. serum uric acid as a prognostic biomarker & its correlation with killip class in acute myocardial infarction. international journal of biomedical research. 2013;4(7):312 volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 24 x gjra global journal for research analysis background the three-delays model provides a suitable framework for identifying and assessing the barriers faced by pregnant women before they access appropriate care. three categories of factors are identied as key contributors to the delays fueling maternal mortality: delay in making decisions in seeking care (first delay), delay in reaching the health facility (second delay), and delay in receiving appropriate care at the health facility (third delay). this model has also been applied to understand factors related to perinatal and neonatal mortality (mbaruku g et al, 2009; waiswa p et al, 2010). this review mainly focuses on the effect on the second delay: reaching the health facility. the reasons why transportation delays occur have been well documented and include difcult geographical terrain, cost of transport, lack of phones and vehicles, suboptimal distribution and location of health facilities (thaddeus and maine 1994, jahn and de brouwere 2001). many communities in karamoja, uganda are extremely remote and rely on seasonal roads, which are impassable especially during the rainy season. there are no maternity waiting homes. the second delay is also a direct consequence of a combination of poor, non-existent, or unaffordable transportation either from the community to the rst-line health care facility or from the latter to a referral facility. the 'second delay' thus contributes disproportionately to poor maternal health outcomes where the above-mentioned conditions exist like in karamoja. transport voucher scheme programs have been widely used throughout uganda. in the past 15 years, there have been ve programs established to bring a variety of voucher options for women throughout uganda. a voucher feasibility study conducted in 2004 led to the kfw-nanced rst uganda voucher program – the “healthy life voucher” in 2006 – that provided access to sexually transmitted infections (sti) diagnosis and treatment in south western uganda. this scheme was available to everyone and redeemed through selected pharmacies and drug shops situated in poorer socioeconomic areas. several other schemes lead by baylor university, makerere university, usaid, dfid, the world bank and the government of uganda, have focused on vouchers to help pregnant women and families. lacking in the current knowledge the impact of transport vouchers on the second and third delay have not been well evaluated in uganda. most studies have documented the outcomes of the transport voucher as part of a wider reproductive health voucher scheme. this assessment thus contributes new knowledge by providing empirical evidence on whether, how and in what circumstances the transport voucher inuences the second and third delay in using maternal and child health services. as a component of the wider unicef support for the “maternal and newborn health (mnh) program” in karamoja, unicef implemented a four-year mnh project (2015-2018) which included increasing utilization and quality of intra-partum, emergency obstetric and newborn services. the transport voucher scheme aimed at (1) ensuring transportation of pregnant mothers to deliver at health facilities (2) improving emergency transportation for referred complicated deliveries from lower to higher-level health facilities, (3) reducing neonatal mortality in the rst 7 days after delivery and (4) reducing home deliveries due to lack of transport. objectives this report serves to provide lessons from experience based on interpretation of karamoja transport voucher scheme successes and failures so as to improve future programming of such transport voucher schemes on “second and third delay”. in addition, it deepens knowledge, assumptions and limitations of the facility-issued transport voucher on facility delivery and emergency transportation to inform development cooperation. the specic objectives are: a. to assess women's experiences with and perceptions about accessing delivery services prior to and after introduction of the transport voucher scheme; b. to assess the effectiveness of the voucher scheme in increasing facility deliveries and completing emergency referrals; c. to assess relevance, efciency and scalability of the voucher scheme to inform unicef's phase-out strategy; d. to explore factors explaining the differences in uptake of the transport voucher scheme between districts. methods the uganda national household survey (unhs 2017) shows that karamoja has remained the poorest region in the country with poverty incidence above 60%, which is far higher than the national average of 27%. karamoja also has the highest illiteracy rate with 51% of people aged 6-24 years old never attending school, and only 26% considered literate. high assessment and documentation of maternal and newborn transportation voucher scheme in karamoja, uganda original research paper andrew balyeku unicef uganda x 1gjra global journal for research analysis health science keywords : jesca nsungwa sabiiti* ministry of health uganda *corresponding author h. jung unicef uganda volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra g. latigi unicef uganda p. pirio unicef uganda m. ahmadzai unicef uganda v. berdaga unicef uganda chioma unicef uganda 2 x gjra global journal for research analysis levels of poverty and illiteracy may thus contribute to why most mothers face major barriers in utilizing the facility-based maternal health facility services improved by the project. discussions with district staff conrmed that the region has a scarcity of ambulance services and no established means of maternal transport for delivery at health facilities nor emergency referral transportation from health centre (hc) iiis that offer normal delivery services to higher level facilities (hc ivs and hospitals) that offer comprehensive emergency obstetric and newborn care services. preliminary discussion also revealed that even though the local boda boda were increasingly available in the rural areas, they had not been considered as suitable modes of transport for women in early labour by both the community and health workers. the rural boda boda cyclists indicated that they are community members who have social ties to the beneciary communities, thus are naturally willing to assist mothers when they are in need of transportation to health facilities. improved security was also mentioned as a contributor to more boda boda penetrating in the deeper areas of karamoja. the boda boda cyclists further submitted that though boda bodas had expanded their reach to the rural areas, transportation costs were unaffordable for rural people, the vast majority of whom lacked any cash income. placing the transport voucher scheme within the wider maternal and newborn health program in karamoja ensured that mothers received quality services at the facilities. study design the study was designed to have three parts. first facilitybased data on health unit deliveries in all the seven districts of karamoja region was analyzed to assess effectiveness of the transport voucher. the data showed the number and rate of institutional deliveries increased after the introduction of the voucher. next a cross sectional survey was conducted on december 2017 by interviewing both voucher-users and nonusers in the selected three districts, namely kaabong, abim and amudat district which showed a low, middle and high utilization of the voucher, respectively. this survey compared outcomes between users and non-users in terms of a rate of home delivery, normal delivery and emergency delivery and factors that made them deliver in health facilities. lastly a qualitative study was carried out by interviewing communities and district health teams in the three districts. qualitative methods included in-depth interviews with voucher scheme managers from cuamm and district health ofcers, as well as focus group discussions with voucher scheme transporters and women beneciaries. the in-depth interviews were conducted in english, while the household and focus group discussions in ngakaramajong. the qualitative data was recorded verbatim and fgd information translated into english by the research assistants and arranged in assessment themes. table 1: data sources used population (patients, doctors, hospitals, etc.) the inclusion criteria for the survey were: (1) women who delivered babies in the last 9 months preceding the survey, irrespective of whether the delivery was preterm or term and of the birth outcome (whether the baby was alive or dead); (2) next of kin of women who died during childbirth in the last 9 months preceding the survey; (3) residents in the study area, and; (4) women capable of providing informed consent, including emancipated minors. women who were not resident in the study area at the time of the birth of their baby or women with a severe mental disorder were excluded. the voucher scheme started without any geographic and household wealth targeting which was appropriate for karamoja region where the majority target beneciaries were deemed very poor. discussions showed that over time, the resources available were insufcient for such a universal coverage approach and more geographical targeting was thus employed to focus on mothers in sub-counties located more than 10 km from hc iiis and emergency maternal and sick newborn referral. sampling strategy of the household survey we selected three districts out of total seven districts in karamoja region. the three districts such as kaabong, abim and amudat district represented a low, middle and high performing one, respectively in terms of utilization rate of the voucher. to detect a difference in outcomes between voucher users and non-users, the below formula was utilized and yield 235 women in each group. the study thus targeted a minimum of 240 households of each group and eventually surveyed a total of 248 voucher beneciaries and 247 non-beneciaries in the three study districts. 2 2sample size or n = (zα +z ) * (p (1-p )+p (1-p )) / (p -p ) ,/2 β 1 1 2 2 1 2 where zα is the critical value of the normal distribution at α/2 /2 (for a condence level of 95%, is 0.05 and the critical value is α 1.96); zβ is the critical value of the normal distribution at β (e.g. for a power of 80%,β is 0.2 and the critical value is 0.84), and p 1 and p are the expected sample proportions of the two groups.2 within each district, sub-counties were purposefully selected by excluding those close to health facilities where the voucher scheme is not implemented any more due to the gradual phase-out strategy. within each selected sub-county, 5 villages were blindly selected from a list of villages provided by the district staff. each selected village was then visited, and the rst household chosen by randomly selecting directions from the central point of the village by spinning a pencil. when the pencil stopped, the direction indicated by the nib was selected. subsequent households were selected following the “nearest household from the last household to the right” criteria until the required sample size of 10 beneciaries and 10 non-beneciaries was obtained. interviewers then moved to the next selected village and repeated the selection process. quantitative data was entered and analyzed by means of the statistical package for social services (spss) and microsoft excel. comparison was made on knowledge, attitudes and outcomes between voucher beneciaries and nonbeneciaries. reasons for participation/non-participation volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra data source tools sampling num ber 1. program implementers in-depth guide none 3 2. district health ofce in-depth guide purposive (highest-, midand lowestperforming) 3 3. transporters fgd guide purposive (1 group per district) 3 4. mothers who used vouchers in last pregnancy household questionnaire quota sampling (about 80 per district) 248 5. mothers who did not use vouchers in last pregnancy household questionnair e quota sampling (about 80 per district) 247 6. secondary project data tabulation matrix of project data jan 2016dec 2017 project data na were captured. in a separate hierarchical model, the predictors of nonparticipation were studied. the background characteristics of beneciaries and nonbeneciaries of the transport vouchers were found almost identical and comparable and this could be attributed to the sampling approach of selecting respective respondents from the same village clusters. in general, equal numbers of voucher beneciaries and non-beneciaries were sampled and they shared similar background characteristics. about one half of the mothers in both groups are below 24 years, and it is noteworthy that about 5% were young adolescents below 15 years. more than three quarters of women respondents had no education or had not completed primary school, implying that the community is generally illiterate. almost 90% of both voucher beneciaries and non-beneciary respondents were married. results trends of institutional deliveries during the voucher scheme implementation data from project reports shows that for the two years from january 2016 to december 2017, the scheme provided transport vouchers for 15,151 deliveries or 42% of the 36,078 reported deliveries at health facilities for the same period. the scheme scaled down as shown by a reduction of the proportion of mothers transported by voucher from 55% in 2016 to 31% in 2017. in spite of the transport voucher reduction, the number of facility deliveries registered rose from 17,008 to over 19,070 in the same period. this indicates that the cessation of the transport voucher in some subcounties did not substantially affect increases in facility delivery rates. x 3gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra nonbeneciaries (n=247) beneciaries (n=248) by district abim 84 80 amudat 83 85 kaabong 80 83 age below 15 years 6% 4% 15-24 years 40% 44% above 24 years 54% 52% education attainment none 54% 54% did not complete primary 27% 19% primary school completed 11% 15% secondary 9% 10% tertiary and above 0% 0% marital status married 88% 90% single 10% 9% widowed/separated/divorced 2% 2% gravidae 1 23% 21% 2 19% 23% 3 19% 23% 4 17% 14% 5 and above 22% 18% table 3: transport voucher use and outcomes indicator jan-dec 2016 jan-dec 2017 total (2016-2017) number of deliveries at hu 17,008 19,070 36,078 total number of deliveries supported by voucher (a=b+c) 9,420 5,731 15,151 % of deliveries transported by voucher 55% 31% 42% number of mothers transported to deliver at hc iii using voucher (b) 8,290 4,087 12,377 number of mothers referred (complications) using voucher (c) 1,130 1,644 2,774 mode of delivery for referred mother caesarean section 435 779 1214 vaginal delivery 382 496 878 maternal referral outcome maternal death 30 14 44 fsb 46 38 84 neonatal referral outcome alive 77 123 200 death 20 14 34 source: unicef-cuamm voucher scheme report 2016-2017 and hmis data note: the health unit delivery data comes from only health facilities operating the transport voucher schemes in the 7 districts of karamoja region. data also shows that the scheme is shifting towards supporting emergency referral transportation and less of community to facility transportation. the number of mothers transported to deliver at health facilities using a transport voucher reduced by one half, and that of mothers with complications referred using transport voucher increased by over 500 between 2016 and 2017. it is also observed that the number of caesarean sections among the referred cases rose by 79%, while vaginal delivery among referred cases increased by 30% over the period. neonatal outcomes also noticeably improved for the referred babies from 20% of referred babies dying in 2016 compared to 9.5% in 2017. though all this cannot solely be attributed to the transport voucher scheme, it is clear that the voucher helped in improving early and quick referrals necessary for the survival of mothers and babies. the voucher costs were limited to boda bodas (motorcycle taxis), because this is the main mode of commercial transport readily available in the karamoja rural areas. traditional birth attendants (tbas) who escort mothers late at night were given ugx 5,000 ($1.4) motivation honorarium. the role of tbas has thus been reinvented from delivery to provision of support to mothers for facility-based deliveries. tbas now positively collaborate with the health facility workers to support facility delivery. the transport voucher has contributed to strengthening community health systems, especially in mobilizing demand for health facilities. the initiative has also established possibilities for public-private partnerships in the emergency referral system. discussions with boda boda riders revealed that they seek to form an association with leadership that interfaces with the health facility. they propose having a coordinator at the facility to interface on their behalf with the facility management. the transporter usually selected the facility to take the mothers to and through experience, and transporters have learned to navigate the mothers through the facility or seek out midwives from their homes late at night. the districts together with cuamm developed simple protocols and guidelines for the transport voucher scheme, which are available for improvement as well as for reference in scaling up other reproductive health voucher programs in uganda. though the voucher protocols were developed with the district staff, the responsibilities and roles of the district staff were not claried, and key informant interviews with district health ofcers showed that they were not full part ic ipants. the performance r isk and thus the accountability for results remained with cuamm as the voucher management agency. there was also a worry from the key informant discussions that facility staff did not benet much from the voucher and the increased facility utilization increased the work burden without addressing necessary inputs such as additional human resource. there was also concern from the district health managers that the transport voucher undermined the district's referral system, as the mothers preferred going straight to “bigger” facilities. in addition, husbands not moving with wives to delivery curtailed promotion of more meaningful male involvement in delivery support to their wives. thus, delivery expenses were placed outside the family and this could cause unsustainable dependence. different outcomes between the voucher beneciaries and non-beneciaries almost all mothers gave birth to a live child and there was no signicant difference in the outcome of pregnancy between the beneciaries and non-beneciaries of the voucher in regard to giving birth to a live child or child still surviving at least 9 months after delivery (see table 5). table 5: pregnancy outcome of previous delivery source: household interviews data shows a signicant difference in source of information about the transport voucher. the study was done at the time when the scheme was scaling down and thus mothers in subcounties near facilities were not offered the transportation at the time of the study. table 6 below shows that about 42% of the non-beneciaries were informed about the voucher scheme during their anc visits. table 6: informed about transport voucher to facility at anc source: household interviews there is no difference between the place of deliveries among beneciaries and non-beneciaries for delivery at health centers, with the majority (76%) delivering at these levels. this is because most non-beneciaries also delivered in hc iiis even prior to 2016. however, signicantly more non-voucher beneciaries delivered at home. in addition, we found a statistically signicant difference in emergency referrals between voucher user and non-user, proving the voucher scheme improved emergency referrals for complicated delivery cases. table 7: place of delivery *indicates (p<0.005) source: household interviews the result shows that the voucher contributed to the women's decision to deliver in health facilities and access health facilities (p<0.005). we found statistically signicant differences between the two groups in delivering in their preferred places (p<0.005). a higher proportion of beneciaries (90%) delivered in their preferred place such as health facilities compared to non-beneciaries (78%) as shown in figure 2. table 8: preferred place for delivery source: household interviews figure 2: proportion who delivered at place of choice as shown in table 9, the transport voucher was effective in motivating beneciaries to deliver in health facilities. 37.2% of the beneciaries and 4.5% of non-beneciaries selected the transport voucher as the reason why they delivered in the hfs. the result shows a statistically signicant difference between the two groups' response and proves that the voucher contributed to their decision to deliver in health facilities (p<0.005). signicantly more non-beneciaries relied on the decision of the husband/family-preferred proximal facilities for delivery and expected better pregnancy outcomes. in general, both groups felt that these facilities had the adequate health workers and could get quick referrals in case of emergency, but that less than half believed that facilities had the required medicines. presence of doctors and nurses was the primary reason for health facility delivery in both beneciary (76.9%) and nonbeneciary group (75.7%). availability of quick referral in case of emergency was the secondary reason in both groups: 58.3% of beneciaries and 59.7% of non-beneciaries. better pregnancy outcomes and adequate resources (medicine) came as the third and fourth reasons to choose the hf delivery. for these factors, both groups showed similar responses. furthermore, it is seen from the results that availability and use of transport voucher beneciary non-beneciary gave birth to live child in most recent delivery 99.60% (244/245) 98.40%(242/246) child from last pregnancy still living 99.60% (244/245) 98.40%(242/246) use of transport voucher beneciary non-beneciary informed about transport voucher to facility at anc 91.5% (227/248) 42.4% (104/245) use of transport voucher beneciary non-beneciary home* n 1 17 % 0.40% 6.90% hospital* n 52 34 % 21.00% 13.80% health centre n 188 187 % 75.80% 75.70% on the way n 7 9 % 2.80% 3.60% total n (%) 248 (100%) 247(100%) non-beneciary beneciary n % n % not sure 3 2.48% 2 0.00% at home/at relative's home 1 0.00% 0.00% government hospital 66 36.36% 58 29.87% health centre 176 60.33% 187 68.83% house of the tba 1 0.83% 1 1.30% total 247 100.00% 248 100.00% volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 4 x gjra global journal for research analysis quality of services inuence women's selection of the institutional delivery more than the transport voucher. as the voucher was already proven effective to increase the hf delivery in the region, the other interventions of improving services at hf level seem to complement success of transport vouchers. table 9: reasons for delivering in facility (multiple choices allowed up to 3) * indicates p<0.005 source: household interviews the effectiveness was also affected by availability of transport. the report on “assessment of availability of transport options in karamoja” done by cuamm in june 2013 showed that, in most districts, the more urban sub-counties had more options available compared to those distant from the town councils, as expected. it also noted that many subcounties in kaabong and abim districts did not have any transport option available. it was also found that about 25% of mothers required transportation from the community to a facility at night, which meant that special arrangements had to be made, especially in remote districts like kaabong, because of low availability of boda boda cyclists at night. one of the special arrangements that evolved in response to this was the use of tbas to escort mothers to health facilities late at night. the tbas were provided ugx 5000 (usd 1.4) through the project as a motivation to do this. this is a positive development, since the role of tbas has thus been redened from promoting home deliveries to providing support to mothers for institutional deliveries. tbas now positively collaborate with the health facility workers to ensure that mothers attend anc and deliver in health facilities. client satisfaction with transportation on type of transport in the region, household interviews showed that a signicant proportion of both beneciaries and non-beneciaries used boda boda. this is in line with ndings from the initial “assessment of availability of transport options in karamoja”, which indicated that motorcycles are the commonest available local transportation means. analysis of household data showed that a statistically signicant proportion of non-beneciaries walked to the health facility for delivery as compared to beneciaries as shown in table 12. the higher use of vehicles may be attributed to the emergency transportation among the voucher users. table 10: type of transport used to delivery location and level of satisfaction * indicates p<0.005 source: household interviews users were satised with their transportation means and time spent while travelling. there was no difference among the beneciaries and non-beneciaries in time taken to arrange transport or reach the facility with almost 90% taking less than two hours to reach the facility. it is also signicant that voucher beneciaries were more satised with duration of transport to the facility and the mode of transport they used than the nonbeneciaries. on how beneciaries contacted the transporters, about 60% of the beneciaries contacted the cyclists using mobile phones and 23% directly contacted the rider at their homes. though the voucher was free of cost, about 58% of beneciaries indicated that they were willing to top up the voucher costs if necessary. on who should be paying transportation of pregnant women to health facilities for delivery, 22% of the beneciaries felt that households should be paying for transportation of pregnant women to health facilities for delivery. discussion the assessment shows that the transport voucher is highly relevant given that unsafe deliveries at home and poor a poor referral system were major causes of maternal morbidity and mortality in karamoja. it addressed a key obstacle to utilization of institutional delivery within the wider mnh program and was necessary in facilitating utilization of the improved availability and quality of health facility services in karamoja. placing the transport voucher within the wider program ensured that expectant mothers and very sick babies accessed a comprehensive package. the study showed a need to support transport vouchers in hard-to-reach areas to turn a health unit delivery pattern. especially, the transport voucher was proven more effective for emergency referrals than normal deliveries. if a nancial resource is limited, the voucher scheme should focus supporting the referrals at rst. additionally, quality of care (presence of midwives/medical doctors and medicine) was shown as the most motivating factor for institutional delivery along with the voucher. when the voucher scheme is introduced in other regions, transportation incentive as well as other interventions to improve rmncah cares should be planned together. the transport voucher was especially relevant in mobilizing locally available transportation. by ensuring the availability of free transportation from the community to the facility, coupled with community mobilization, most mothers came to appreciate the importance of facility delivery. given the karamoja situation where the ambulance services are grossly insufcient, the voucher facilitated emergency referrals through mobilizing private transporters and fueling the ambulances that otherwise did not have adequate government budgets. karamoja communities now have an explicit system to provide emergency transport for pregnant use of transport voucher beneciaries (n=247) non-beneciaries (n=243) better pregnancy outcome* n 116 148 % 47.00% 60.90% quick referral in case of emergency n 144 145 % 58.30% 59.70% presence of doctors and nurses n 190 184 % 76.90% 75.70% adequate resources (medicine) n 115 119 % 46.60% 49.00% husband/family decision n 65 77 % 26.30% 31.70% transport voucher* n 92 11 % 37.20% 4.50% near home* n 32 60 % 13.00% 24.70% use of transport voucher beneciaries nonbeneciaries type of transport used for hf deliveries ÿ car (private)* n 9 2 % 3.60% 0.80% ÿ car (public) n 3 3 % 1.20% 1.20% ÿ motor cycle* n 190 127 % 76.60% 51.40% ÿ truck n 1 4 % 0.40% 1.60% ÿ walked or other* n 45 111 % 18.10% 45.00% satised with travel time spent to arrive in delivery site* n 197/248 137/240 % 79.40% 57.10% satised with mode of transport* n 211/247 144/247 % 85.4% 58.3% volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 5gjra global journal for research analysis women who require care at basic and comprehensive emergency obstetric care facilities. almost all the respondents mentioned that the transport voucher scheme could last only as long as the donor project. however, the effects will remain in that now the karamoja community recognizes the importance and benet of the hf delivery. all district managers concurred that the scheme should be scaled down because the hf deliveries had increased, and the community has seen the benets. they however recommend that emergency transportation should remain, because capacity for ambulance services is still low. the role of peer mothers and tbas is also deemed substantial in mobilizing mothers to attend anc as well as facility deliveries and this should be maintained. this scheme has shown that high rates of facility delivery are possible in communities with very low institutional delivery rates like karamoja. additionally, both voucher users and non-users selected a presence of skilled health workers, possible referrals in case of emergency and available medicines as major reasons why they chose institutional deliveries. this nding suggests that the availability and quality of care are also important motivating factors along with the transport voucher. the success of the voucher scheme can be attributed to the unicef mnh program being comprehensive and complementing. thus, when the voucher scheme is introduced in other regions, it should be planned together with other interventions to improve mnh care. the voucher scheme has been implemented from 2014 through to 2018 to increase institutional deliveries in karamoja region. to be prepared against ending donors' support and ensure sustainability, unicef has employed a gradual phase-out strategy by focusing sub-counties beyond 10km radius away from health facilities since 2017. before the exit of the scheme, unicef needs to sensitize both the community and facility before the transition in order to ensure that the community recognizes their role in birth preparedness and takes up the responsibility for transportation. the use of transport vouchers could be coupled with mobilization of “covert” traditional birth attendants in the rural communities, especially towards shifting their roles from facilitators of unsafe home deliveries to promoters of institutional deliveries. they can be effective in mobilizing mothers to go for anc and facility delivery. health facility workers can potentially work as voucher distributors to achieve efciencies in scheme management. this is because when facility workers are deployed as voucher distributors, there would be less need to create entirely new voucher management mechanisms in the existing health system, avoiding an increase of administrative cost for voucher management. as the government plans results based financing (rbf) in the health sector, there will be needed to consider how voucher distribution can be included within the regular government facility operations, especially in regard to emergency maternal and newborn transportation. the transport voucher scheme makes a difference in emergency referral transportation. in many cases, facilitybased ambulances are lacking, not fueled when needed or even difcult to maintain. yet, emergency obstetric referral is needed as 15% of deliveries are anticipated as emergency cases for c-section. the voucher distribution by facility workers provides a basis and opportunity for health facilities and districts to budget operational costs for hiring private transporters for emergency referrals. another option would be to establish a community-based health insurance (cbhi) scheme. opportunity exists to introduce appropriate cbhi schemes now that demand for facility deliveries has gone up in the region. as the transport voucher exits, the cbhi scheme could be initiated to cover transportation, since the quality of services in the facilities has been improved through wider mnh program for karamoja. annex annex 1: districts, sub-counties and villages visited annex 2: vouchers used yellow = ugx 5,000/ yellow = ugx 10,000/ 1. abim lokokor lomaran alerek lomeripus lopeeru loyoroit central lomerpus morunyang olem central lorempus namatengew lotuke loroo nangolechwa adagkolo naborokocha naseperwa adagkolo north namosing nawoyagum adakolo 3. kaabong nayolopak obokoloth central kalapata kawalokol obolokot lochoto lopeeru obolokot central lomonnollo loreepu odolokot lomorangae namatengen lotukei lomoryangae lokartwoxi adakolo moruedikae kathile magamaba moruedikae east sangar bedata moruedikae west golopak magamaga napechokei lokiaal bedata napeichokei lokial bedata east napeichukei lowakus bedata south kamion nagara koya bedata kamion central nakwayelel olimlim lochoto naporukolong morulem lokiyoto narouchom odolo east moruatap sokodokan rachkoko nachakunet sangara rachkoko central nawaudo lokiaal rackoko central kathile lokial nyakwae kathile nagara adagkolo north kathile east nakwayel agule kathile north nakwayelel athedar north kathile west naporukolong nyikinyiki lemugete nyikinyiki north lokariwon nyikinyiki south lopelpel okolot lopepel teramoth nakosowan 2. amudat narionomoru amudat narube alakas nasuguru karita kathile west cheptapoyo kathile kaichom kawalakol morunyang kabokorio namodo kakochi namodoo kamadorio volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 6 x gjra global journal for research analysis red = ugx 25,000/= blue = ugx 50,000/= annex 3: assessments of ownership of transport means in districts june 2013 district vehicle owners abim amudat kaabong kotido moroto nakapiripirit napak grand total church/mission 1 1 2 4 government health unit ambulance 3 2 3 1 3 12 government health unit other vehicle 1 6 8 15 ngo 2 1 3 ngo health unit ambulance 1 1 1 1 1 5 ngo health unit other vehicle 1 1 other government institution (e.g. sub-county, town council, farm, etc.) 1 1 2 12 16 other private organization 3 1 4 private company/business organization 5 5 private individual business person 7 4 17 2 30 private individual non-business 1 1 3 3 9 17 unknown 1 5 1 7 grand total 8 14 8 20 11 52 6 119 source: cuamm assessment of availability of transport options in karamoja annex 4: transport voucher facility register distribution list district hsd subcounties hc ii names hc ii hc iii names hc iii hc iv names hc iv hospital names hospitals total hu (no. of registers) abim 1 6 14 kiru, kanu, amita, atunga, koya, wiilela, gangming, awach, katabok, adea, obolokome, oreta, pupu kamuya, opopongo 4 alerek, orwamuge, morulem, nyakwae 0 1 abim 19 kaabong 2 14 17 lokerui, lomeris, lotim, kamion, lokwakaromoe, kaimese, lomodoch, lokanayona, narengepak, lochom, kakamar, pire, lokori, lobalangit, kocholo, st. jude kapedo, kalimon 8 lokolia, kaabong mission, kalapata, loyoro, kathile, kopoth (sidok), kidepo, kapedo 1 kareng a 1 kaabong 27 napak 1 7 5 amedek, nabwal, apeitolim, morulinga, ngoleriet 6 iriir, lorengechora, lokopo, lopei, kangole, lotome 0 1 matany 12 nakapirip irit 2 8 8 karinga, moruita, nabulenger, nakaale, lomorunyangae, nabilatuk mission, nayonae angikalio, natirae, 8 lemsui, moruita updf, nakapiripirit, namalu, namalu prison, amaler, lolachat, lorengedwat 2 tokora, nabilat uk 0 18 amudat 1 4 2 alakas, cheptapoyo 2 karita, loroo 0 1 amudat 5 kotido 1 6 11 lokiding, losakucha, losilang, lookorok, napumpum, kamoru, rikitae, nakwakwa, lopuyo, (mobile: apalopus (kanangorok), apa lopama (lobanya) 7 kacheri, kanawat, lokitelaebu, karamoja diocese (kdds?), kddo, nakapelimoru, panyangara, rengen 1 kotido 0 19 volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 7gjra global journal for research analysis references 1. ahmed s, khan mm. a maternal health voucher scheme: what have we learned from the demand-side nancing scheme in bangladesh? health policy plan. 2011;26(1):25–32. doi: 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[pubmed] [cross ref] 2. alfonso yn, bishai d, bua j, mutebi a, mayora c, and ekirapa-kirach e (2015). cost effectiveness analysis of a voucher scheme combined with obstetrical quality improvements: quasi experimental results from uganda. health policy and planning 30(1):88-99. 3. bellows nm, bellows bw, warren c. the use of vouchers for reproductive health services in developing countries: systematic review. tropical med int health. 2011;16:84–96. 4. bohren ma, hunter ec, munthe-kaas hm et al. 2014. facilitators and bar riers to facility-based delivery in lowand middle-income countries: a quali tative evidence synthesis. reproductive health 11: 71. 5. brody cm, bellows n, campbell m, potts m. the impact of vouchers on the use and quality of health care in developing countries: a systematic review. glob public health. 2013;8:363–88. 6. chalo, r. n., salihu, h. m., nabukera, s., & zirabamuzaale, c. (2005). referral of high-risk pregnant mothers by trained traditional birth attendants in buikwe county, mokono district, uganda. journal of obstetrics and gynaecology, 25(6), 554–557. 7. cham m, sundby j, vangen s. maternal mortality in the rural gambia, a qualitative study on access to emergency obstetric care. reproductive health. 2005;2(1). 8. corinne grainger, anna gorter, jerry okal, and ben bellows: lessons from sexual and reproductive health voucher program design and function: a comprehensive review; int j equity health. 2015 february 17; 14: 20. 9. demand-side nancing for maternal and newborn health: what do we know about factors that affect implementation of cash transfers and voucher programmes? available from: https://www.researchgate.net/ publication/ 319403835 [accessed oct 11 2017]. 10. east africa community. (2014). situational analysis and feasibility study of options for harmonization of social health protection systems towards universal health coverage in the east african community partner states.technical report. east african community, arusha. http:// ihi.eprints.org/2795/ 11. ekirapa-kiracho e, waiswa p, rahman mh, makumbi f, kiwanuka n, okui o, rutebemberwa e, bua j, mutebi a, nalwadda g, serwadda d, pariyo gw, peters d. increasing access to institutional deliveries using demand and supply side incentives: early results from a quasi-experimental study. bmc int health hum rights. 2011;11(s1):9–10. [pmc free article] [pubmed] 12. ensor t. consumer-led demand side nancing in health and education and its relevance for low and middle income countnries. int j health plann manage. 2004;19(3):267–285. doi: 10.1002/hpm.762. [pubmed] [cross ref] 13. gabrysch, s., & campbell, o. m. r. (2009). still too far to walk: literature review of the determinants of delivery service use. bmc pregnancy & childbirth, 9, 34. 14. glaser em, abelson hh, garrison kn. putting knowledge to use. san francisco: jossey-bass publishers; 1983. 15. glassman a, duran d, fleisher l, singer d, sturke r, angeles g, charles j, emrey b, gleason j, mwebsa w, saldana k, yarrow k, koblinsky m. impact of conditional cash transfers on maternal and newborn health. j health popul nutr. 2013;31:48–66. 16. gopalan ss, mutasa r, friedman j, das a. health sector demand-side nancial incentives in lowand middle-income countnries: a systematic review on demandand supply-side effects. soc sci med. 2014;100:72–83. 17. hunter bm, portela a, bick d. the effects of cash transfers and vouchers on the use and quality of maternity care services: a systematic review. plos one. 2017;12(3):e0173068. 18. john bua, ligia paina, elizabeth ekirapa kiracho: lessons learnt during the process of setup and implementation of the voucher scheme in eastern uganda: a mixed methods study. implement sci. 2015; 10: 108. published online 2015 aug 6. doi: 10.1186/s13012-015-0292-3 19. kakaire, o., kaye, d. k., & osinde, m. o. (2011). male involvement in birth preparedness and complication readiness for emergency obstetric referrals in rural uganda. reproductive health, 8, 12. 20. kaye, d. k., kakaire, o., & osinde, m. o. (2011). maternal morbidity and nearmiss mortality among women referred for emergency obstetric care in rural uganda. international journal of gynaecology and obstetrics, 114(1) 84–85. 21. kweku m, webster j, taylor i, burns s, dedzo m. public-private delivery of insecticide-treated nets: a voucher scheme in volta region, ghana. malaria journal. 2007;6:14. doi: 10.1186/1475-2875-6-14. [pmc free article] [pubmed] [cross ref] 22. lagarde m, haines a, palmer n. conditional cash transfers for improving uptake of health interventions in lowand middle-income countries: a systematic review. jama. 2007;298:1900–10. 23. louise ackers, elena ioannou, and james ackers-johnson: the impact of delays on maternal and neonatal outcomes in ugandan public health facilities: the role of absenteeism: health policy plan. 2016 nov; 31(9): 1152–1161. published online 2016 may 3. 24. maine d. (1991). safe motherhood programs: options and issues. new york: centre for population and family health, columbia university. 25. mbaruku g, van roosmalen j, kimondo i, bilango f, bergstrom s. perinatal audit using the 3-delays model in western tanzania. int j gynaecol obstet. 2009;106(1):85–8. doi: 10.1016/j.ijgo.2009.04.008. [pubmed] [cross ref] 26. meyer c, bellows n, campbell m, potts m: the impact of vouchers on the use and quality of health goods and services in developing countries: a systematic review 2011; 2011. 27. moyer ca, mustafa a. 2013. drivers and deterrents of facility delivery in sub saharan africa: a systematic review. reproductive health 10: 40. 28. murray sf, hunter bm, bisht r, ensor t, bick d. effects of demand-side nancing on utilisation, experiences and outcomes of maternity care in low and middle-income countries: a systematic review. bmc pregnancy childbirth. 2014;14:30. 29. mutyaba, s. t., & mmiro, f. a. (2001). maternal morbidity during labor in mulago hospital. international journal of gynaecology and obstetrics, 75(1), 79–80. 30. pariyo, g. w., mayora, c., okui, o., ssengooba, f., peters, d. h., serwadda, d., . . . ekirapa-kiracha, e. (2011). exploring new health markets: experiences from informal providers of transport for maternal health services in eastern uganda. bmc international health and human rights 11(suppl. 1), s10. 31. paxton a, maine d, freedman l, fry d, lobis s: the evidence for emergency obstetric care. int j gynaecol obstet. 2005, 88: 181-193. 10.1016/j.ijgo. 2004.11.026. 32. rob u, rahman m, bellows b. 2009. using vouchers to increase access to ma ternal healthcare in bangladesh. international quality of community health education 30: 293–309. 33. rodolfo c pacagnella, josé g cecatti, mary a parpinelli, maria h sousa, samira m haddad, maria l costa, joão p souza, robert c pattinson: delays in receiving obstetric care and poor maternal outcomes: results from a national multicentre cross-sectional study. bmc pregnancy and childbirth 201414:159 34. ronsmans c, graham wj. maternal mortality: who, when, where, and why. lancet. 2006;368(9542):1189-200. 35. sochas l, grainger c, gorter a, grifth d, boddam-whetham l. (2013). what can vouchers do for universal health coverage? brieng note from options consultancy services ltd, london, uk 36. souza j.p., tuncalp o., vogel j.p., bohren m., widmer m., oladapo o.t., say l., gulmezoglu a.m., temmerman m. (2014). obstetric transition: the pathway towards ending preventable maternal deaths. bjog 2014; 121 (suppl. 1): 1–4. 37. tami a, mbati j, nathan r, mponda h, lengeler c, schellenberg ja. use and misuse of a discount voucher scheme as a subsidy for insecticide-treated nets for malaria control in southern tanzania. health policy plan. 2006;21(1):1–9. doi: 10.1093/heapol/czj005. [pubmed] [cross ref] 38. thaddeus s, maine d (1994) too far to walk: maternal mortality in context. social science and medicine 38 1091-1110 39. the unfpa emergency obstetric care checklist for planners. unfpa, new york, usa. 2002. 40. tooth l.r., mishra g.d. (2015). mother’s education and adverse birth outcomes, journal of epidemiology and community health, 69, 9. 41. van de poel e, flores g, ir p et al. 2014. can vouchers deliver? an evaluation of subsidies for maternal health care in cambodia. bulletin of the world health organization 92: 331–9. 42. waiswa p, kallander k, peterson s, tomson g, pariyo gw. using the three delays model to understand why newborn babies die in eastern uganda. trop med int health. 2010;15(8):964–72. doi: 10.1111/j.1365-3156.2010.02557.x. [pubmed] [cross ref] 43. weeks, a., lavender, t., nazziwa, e., & mirembe, f. (2005). personal accounts of ‘near-miss’ maternal mortalities in kampala, uganda. bjog: an international journal of obstetrics and gynecology, 112(9), 1302–1307. 44. who, unfpa, unicef, the world bank. pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. integrated management of pregnancy and childbirth. 2006. wq 175 2003wo-1. moroto 2 6 6 kakingol, lopelipel, kosiroi, rupa, dmos clinic, nakapelimen 5 tapac, loputuk, nadunget, army baracks, kidepo st pius 0 1 moroto rrh, rdmoroto 3 div filed hosp? 12 karamoja 10 51 63 40 4 5 112 unicef transit voucher publication (final)source: cuamm assessment of availability of transport options in karamoja volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 8 x gjra global journal for research analysis 1.0 introduction “durability of hydraulic cement concrete is dened as its ability to resist weathering action, chemical attack, abrasion or any other process of deterioration. durable concrete will retain its original form, quality and serviceability when 1exposed to environment.” (aci 201.2r-01 ). deterioration of reinforced concrete structures results from external factors or internal causes within the concrete itself. the reduction in strength or damage to the surface of the concrete can result from physical and chemical aggression, or from mechanical damage caused by impact, abrasion, erosion or cavitation. corrosion of steel bars is a main factor affecting both the concrete durability and strength. the research, designs & standards organization (rdso) indian railway report rdso bs-14 has concluded that most thof the structures built during the rst half of the 20 century have performed well. however, quite a number of structures built during the last 30 years have suffered durability problems resulting in premature deterioration. the rdso study concluded that structural damage due to reinforcement corrosion is the major factor, which adversely affected the 2.strength, durability and stability of the structure (rdso 1999) in the united states, according to the federal highway association and based on 1995 prices, the infrastructure deciencies due to corrosion has jumped from $300 billion in 31995 to $1.3 trillion in 2000 [roberge, p.r., (1999] . in canada, some studies found that rehabilitation cost for corrosion of reinforcing steel is estimated to be about $3.0 billion per year 4[elsener b., (2001)] . the experimental studies, especially on the structures those located at seafront in egypt (hassan h. et 5al) revealed that the salt-laden weather has a severe negative effect on reinforced concrete buildings. 2.0 present study: under this study some residential buildings which were built approximately 40 years back were selected to assess the structural condition of the buildings. the buildings are located at sriharikota island, india which is a land mass sandwiched between bay of bengal in the east and pulicat lake in the west. 0sriharikota island is geographically located at 80.2 e and 013.7 n. the average elevation is about 4m and maximum elevation is about 10m above msl. it is prone to severe weather phenomena like tropical cyclones, thunderstorms, and squally weather. shar being a coastal area, it experiences sea breeze and land breeze also. as per the report of central electrochemical research institute, 6, karaikudi (natesan et al. 2004) the places sriharikota, chennai naval base, mormugao port, port blair, and mettupalayam are extremely corrosive in india. 2.1 structures description: the buildings are residential buildings which were built during the year approximately during 1975-76 were selected to assess the structural condition of the buildings. the building units are ground + 2 units with load bearing structure with rcc roof slab and other rcc elements like staircase, chajjas etc. the grade of concrete adopted during construction is m15. 2.2 preliminary studies conducted to assess the condition of buildings using ndt methods, and evaluating electrochemical parameters of concrete the following procedure has been adopted. this different studies conducted are as follows: i. visual observations / extent of distress. ii. non-destructive (nd) tests, such as, ÿ profometer survey (to determine concrete cover thickness) ÿ rebound hammer test (to determine de-lamination zones) ÿ ultrasonic pulse velocity test. (to assess integrity of concrete) ÿ iii. partially destructive tests like ÿ core sampling, extraction of cores and testing in the laboratory. ÿ evaluation of electrochemical parameters of concrete (ph, s, cl-). ÿ half-cell potential survey to determine extent of corrosion activity in the rc members, where corrosion symptoms are observed. ÿ carbonation test at random locations on the r.c.c member, and in the extracted core samples. 2.3 important findings: 2.3.1 visual inspection: the upkeep of the campus and buildings is observed to be good. however, due to marine environment the concrete and steel have undergone changes, and the reinforced concrete members in particular, have indicated changes in their properties, as a result of which distress is also exhibited in certain blocks/quarters. the distress is observed in the form of cracking along the reinforcement, spalling of cover concrete, and exposure of reinforcement in many reinforced concrete members. figure 1 :: spalled beam element diagnosis and analysis of old concrete structures in coastal environment: field investigations, analysis & recommendations original research paper v l satish research scholar jntu college of engg kakinada engineering deterioration of reinforced concrete structures results from external factors or internal causes within the concrete itself. recently the aspects of concrete durability and performance have become a major subject of discussion especially when the concrete is subjected to severe environment. the ndings of various studies earlier carried out on durability with respect to coastal structures are discussed in this paper. the ndt studies conducted on some old buildings at sriharikota island are analyzed and the major factor contributing to the deterioration of structures is presented. chloride induced corrosion is found to be main factor affecting both the concrete durability and strength. recommendations for delaying the onset of corrosion in rcc structures in coastal structures are suggested. corrosion inhibitors admixed in concrete are found to be possible solution for new structures. abstract keywords : durability, coastal environment, ndt studies, corrosion, chloride proles, chloride induced corrosion, corrosion inhibitors dr v ravindra* professor of civil engineering jntu college of engg kakinada. *corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 32 x gjra global journal for research analysis figure 2 :: crack in the tension zone of a beam 2.4 important findings from nd studies ÿ rebound hammer test values (rhv) on the surface at grid points and on the surface (at random locations) in the slab portions, wherever taken are uniform. however higher compressive strength in some rcc members reects carbonated cover concrete. ÿ half – cell potential (hcp) survey using copper-copper sulphate half-cell was conducted on rcc members, where corrosion symptoms were observed. the hcp values observed showed more positive. most results show probability of 50% corrosion activity present in the reinforcement. ÿ it is observed from the ultrasonic pulse velocity test results that the slabs, columns & beams tested, have concrete integrity range from doubtful to good. some of the up values indicate that the concrete possess voids (honey combed in the interior portions). ÿ the mean compressive strength of cubes obtained is about 16 n/ sqmm which is satisfactory with respect to the design strength of 15 n/ sqmm. the condition is to be assessed by considering all the parameters and not only the strengths. ÿ the in-situ carbonation tests on slabs, beam, column indicate that reinforcements are corroded due to carbonated layer reaching up to concrete cover thickness after the carbonation test. in the quarters, out of 14 tests, about 9 samples have shown signs of carbonation. ÿ as per is : 456:2000, the maximum total acid soluble 3chloride content expressed as kg/m of concrete should be 0.6 for reinforced concrete. therefore for reinforced concrete with 2400 kg / cum density, max chloride content works out to (0.6/2400)x 100= 0.025%. the average chloride content of the test samples is 0.17% which is very high compared to the permissible value. 3.0 conclusions & recommendations: the chloride content in rcc structures is alarmingly high. studies revealed that chloride induced reinforcement corrosion is the predominant reason for the failure of rcc elements. the structures located here at study area were surrounded by chloride laden environment, which resulted in electrochemical corrosion of steel reinforcements. the ingress of chloride ions into the concrete affected the reinforcement steel and thereby corroding the reinforcement. the corroded reinforcement caused cracking and spalling of concrete. for localized repairs, polymer modied cement mortar is suggested for the structures. high performance repair mortars are available as protective coatings can be applied. also, application of anticarbonation coatings, migratory corrosion inhibitors etc can be used as an effective measure for improving the durability of reinforced concrete structures. for new structures, the addition of corrosion inhibitors in fresh concrete emerges to be a principal corrosion prevention method. corrosion inhibitors, which come in powder, gel and liquid form can be introduced into the concrete mix at the time of construction for new structures to retard the rate of corrosion. 3.1 corrosion inhibitors: corrosion inhibitor is dened as “a chemical substance that decreases the corrosion rate when present in the corrosion system at suitable concentration, without signicantly changing the concentration of any other corrosion agent.” (iso 80441989). generally the mechanism of the inhibitor is one or more of three that are cited below: ÿ the inhibitor is chemically adsorbed (chemisorption) on the surface of the metal and forms a protective thin lm with inhibitor effect or by combination between inhibitor ions and metallic surface; ÿ the inhibitor leads a formation of a lm by oxide protection of the base metal; ÿ the inhibitor reacts with a potential corrosive component present in aqueous media and the product is a complex. fig 3: mechanism of a conventional corrosion inhibitor 3.2 classification: the corrosion inhibitors can be classied in different ways. 3.2.1. based on the physical mode of application: those compounds which are added to the fresh concrete at the time of mixing for new structures are known as admixed inhibitors. those compounds which are applied on the hardened concrete surface and are able to diffuse through concrete to the underlying rebar to form a monolayer lm at the steel-concrete interface. 3.2.2 based on their mechanism of protection. ÿ anodic inhibitor : anodic inhibitors act on the dissolution of the steel and they reduce the corrosion rate by an increase in the corrosion potential of the steel. passivating inhibitors like nitrites represent special types of anodic inhibitors and they are generally very effective inhibitors if present in sufcient concentrations. the most commonly used anodic inhibitor is calcium nitrite. sodium nitrite, sodium benzoate and sodium chromate have also been used. ÿ cathodic inhibitor :cathodic inhibitors act on the oxygen reaction on the steel surface and they reduce the corrosion rate by a decrease in corrosion potential. the most commonly used cathodic inhibitors are sodium hydroxide and sodium carbonate, which are supposed to increase the ph near the steel, and reduce the oxygen transport by covering the steel surface, phosphates, silicate and polyphosphates are also used. ÿ mixed inhibitor: mixed inhibitor act on both anodic and cathodic sites and they reduce the corrosion rate without a signicant change in the corrosion potential, generally by surface adsorption over the surface of the steel in contact with the inhibitor and consequently forming a thin protective layer. in mixed type inhibitors, material with the hydrophobic group that have polar groups such as n, s, oh is effective. organic polymer compounds such as amines and amino alcohols are also used. 3.3 results of studies conducted on corrosion inhibitors: two commercially available corrosion inhibitors, anodic inhibitor (calcium nitrite based) and bipolar inhibitor mixed in concrete made from portland pozzolana cement (ppc) and ordinary portland cement (opc) are studied in terms of modication of the workability and mechanical properties volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 33gjra global journal for research analysis and durability parameters. ÿ there is no improvement in the workability of opc concrete mixes or ppc concrete mixes by addition of both the corrosion inhibitors compared to the control mix. ÿ the 3 days and 7 days compressive strength result yielded less values compared to the control mix for calcium nitrite inhibitor in opc mixes. however the 28 days result is marginally more compared to the control mix. ÿ addition of bipolar inhibitor at dosage of 5% resulted in the considerable reduction of compressive strength by about 33% to 36% in opc mixes. ÿ the rapid chloride permeability tests revealed that the resistance of concrete for the ingress of chloride ions is improved by addition of corrosion inhibitors. references 1. american concrete institute (2001), “guide to durable concrete”, aci committee report. 2. rdso 1999, “durability of concrete structures” (report no. rdso bs-14 of march, 1999) 3. roberge, p.r., (1999), "handbook of corrosion engineering," mcgraw-hill. 4. elsener b., (2001), "corrosion for steel in concrete: state of the art report" european federation of corrosion publications, great britain. 5. hassan h. a, sanad a. m. and moussa m. a (2013). “environment impact on seafront reinforced concrete structures in egypt”, theisis, arab academy for science, technology 6. natesan, venkatachari and n palaniswamy ; (2005) “corrosivity and durability maps of india” 2004, cecri, karaikudi, lndia.,elibrary krc.cecri.res.in/ro_2005/013-2005 7. astm c 805, standard test method for rebound number of hardened concrete, annual book of astm standard, astm c805-85, detroit, 1994 8. astm c597-16, standard test method for pulse velocity through concrete, astm international, 2016 9. bis 13311part-1,2. “non-destructive testing of concretemethods of test” (1992) 10. bolzoni et al. “experiences on corrosion inhibitors for reinforced concrete” int. j. corros. scale inhib., 2014, 3, no. 4, 254–278. 11. han-seung lee et al.(2018) “corrosion inhibitors for reinforced concrete: a review” http://dx.doi.org/10.5772/intechopen.72572 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 34 x gjra global journal for research analysis introduction chronic obstructive pulmonary disease is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airow limitation that is due to airway and / or alveolar abnormalities usually caused 1by signicant exposure to noxious particles or gases . the term chronic systemic inammatory syndrome is proposed to take account of inammatory nature of copd and its co morbid conditions such as mets metabolic syndrome has . multiple risk factors that arise from insulin resistance accompanying abnormal adipose deposition and function. it is a risk factor for coronary heart disease, diabetes, fatty liver, and several cancers. obesity is seen in approximately 18% of patients with copd and is far more common in early stages 2(stage-i and ii) . 3,4several studies from north america have shown a prevalence of metabolic syndrome in copd patients in a 5range 29-58%. tanni et al reported mets in 36% of copd patients. indian data on the prevalence of mets or its 6components in copd are sparse. dave et al reported mets in 42% copd cases. the aim of this study was to investigate the prevalence mets in stable copd patients. methods this prospective study was conducted in 67 copd patients attending the department of tuberculosis and respiratory diseases, g.s.v.m. medical college, kanpur from april2017 to march -2018. inclusion criteria: ÿ stable copd patients. exclusion criteria: ÿ other respiratory diseases such as pulmonary tuberc ulosis, bronchial asthma, interstitial lung diseases, obstructive sleep apnea and lung cancer. ÿ known case of ischemic heart disease and chronic renal failure. ÿ unstable copd patients with acute exacerbation. patients attending hospital with cough and breathlessness were evaluated for copd as per gold-2017. all routine blood investigations including complete lipid prole and plasma glucose estimation (fbs & ogtt) were done. spirometry with reversibility was performed. metabolic syndrome is dened as per new international 7diabetes federation idf denition (idf) : ÿ central obesity (dened as waist circumference >90 cm for men and >80 cm for women, with ethnicity specic values for other groups) ÿ plus any two of the following four factors: ÿ raised tg level: >150 mg/dl (1.7 mmol/l), or specic treatment for this lipid abnormality. ÿ reduced hdl cholesterol: <40 mg/dl in males and < 50 mg/dl in females, or specic treatment for this lipid abnormality. ÿ raised blood pressure: systolic bp ≥130 or diastolic bp 85 mm hg, or treatment of previously diagnosed hypertension. ÿ raised fasting plasma glucose (fpg) ≥100 mg/dl (5.6 mmol/l), or previously diagnosed type 2 diabetes. ÿ if above 5.6 mmol/l or 100 mg/dl, oral glucose tolerance test is strongly recommended but is not necessary to dene presence of the syndrome. statistical analysis statistical analyses were performed using spss 22.0 software package and instat graphpad software. variables were analyzed using student's t test and p value less than 0.05 was considered signicant. results total 67 patients were included for nal analysis after exclu sion criteria. mean age of male was 58.67 ± 9.87 years while mean age of female was 57.23 ± 10.40 years. overall percentage of obese, overweight, normal weight and underweight were 31.3%, 23.9%, 29.8% and 14.9% respectively. 50% female and 22.2% male were obese. mean 2bmi of male was 24.33±6.64 kg/m and mean bmi of study 2population was 26.22±7.22 kg/m . the mean waist circumference of male was 86.91±13.31 cm while in female it was 87.18±14.51 cm. most parameters of lipid prole were deranged in study population. among all parameters of lipid prole, raised triglyceride was found in majority of patients (69.4%) followed a study to investigate the prevalence of metabolic syndrome in stable chronic obstructive pulmonary disease patients original research paper dr sachin kumar gupta (senior resident) dept of respiratory medicine, ird, sms medical college, jaipur x 3gjra global journal for research analysis respiratory medicine background: chronic obstructive pulmonary disease (copd) is associated with several extrapulmonary systemic manifestations including metabolic syndrome. metabolic syndrome is an aggregate of inter-related cardio-metabolic risk factors, comprising glucose intolerance, abdominal obesity, dyslipidemia and hypertension, which are associated with an increased risk of cardiovascular disease and type-2 diabetes. the objective of study was to assess prevalence of metabolic syndrome among copd patients. methods: this cross-sectional study was conducted from april 2017 to march 2018. total 67 copd patients were classied according to gold guideline. international diabetes federation (idf) guideline was used for metabolic syndrome(mets). results: prevalence of mets was 29.85%, highest (47.06%) in gold stage-ii, followed by stage-i (40%). conclusions: the presence of metabolic syndrome is common in patients with copd and all copd patients should be considered for its screening. abstract keywords : chronic obstructive pulmonary disease, metabolic syndrome volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr aashish kumar singh* (assoc prof) dept of respiratory medicine, ird, sms medical college, jaipur *corresponding author 4 x gjra global journal for research analysis prevalence of metabolic syndrome in our study was 29.85%. metabolic syndrome was most common in gold stage-ii (47.06%). (table-2) table-2 discussion prevalence of metabolic syndrome in our study was 29.85% (40.91%in female and 24.44% in male). metabolic syndrome was most common in gold stage-ii (47.06%) followed by stage-i (40%) followed by stage-iii (25.71%) and it was only 810% in stageiv. henrik watz et al reported metabolic syndrome in 47.5% patients with highest (53%) in stageii, 50% in stage-i, 44% in stage-iv and 37% in stage-iii. jesús 9díez-manglano et al found the overall prevalence of metabolic syndrome in copd patients was 42.9%, being more 10frequent in female (59.5%). marquis et al found frequency of metabolic syndrome in patients with copd was 21% and the frequency decreases to about 10% at gold stages iii and iv. there was no evidence that the relation between airow obstruction and metabolic syndrome varied with smoking. maximum patients of metabolic syndrome (45.5%) were in stage-i & ii combined and only 22.2% of patients were in stageiii & iv combined in our study. however, no signicant variation was found in triglyceride levels, hdl levels, raised bp and raised fbs among various stages of copd. it means that all parameters except central obesity were present in population and they were not affected by different gold stages. 2mean bmi of males in our study was 24.33 ± 6.64 kg/m while 2in case of females it was 30.07 ± 6.95 kg/m . overall mean bmi 2of study population was 26.22 ± 7.22 kg/m ,similar to emel 11 12bulcun et al and z.yasar et al . conclusion metabolic syndrome is more common in copd patients leading to signicant morbidity and mortality. thus, it is essential to focus on a comprehensive way of management of copd and its comorbidities rather than primarily treating the pulmonary symptoms. references : 1. global initiative for chronic obstructive lung disease (gold). gold 2017 global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, 2017 report. 2. steuten lm, creutzberg ec, vrijhoef hj, wouters ef. copd as a multico mponent disease: inventory of dyspnoea, underweight, obesity and fat free mass depletion in primary care. pri care resp j. 2006 apr 1;15(2):84-91. 3. park sk, larson jl. metabolic syndrome and associated factors in people with chronic obstructive pulmonary disease. west j nursing res. 2014 may;36(5):620-42. 4. poulain m, doucet m, drapeau v, fournier g, tremblay a, poirier p, et al. metabolic and inammatory prole in obese patients with chronic obstructive pulmonary disease. chronic resp dis. 2008 feb;5(1):35-41. 5. tanni se, zamuner at, coelho ls, vale sa, godoy i, paiva sa. are metabolic syndrome and its components associated with 5-year mortality in chronic obstructive pupmonary disease patients?. metab syndrome related disord. 2015 feb 1;13(1):52-4. 6. lopez ad, shibuya k, rao c, mathers cd, hansell al, held ls, et al. chronic obstructive pulmonary disease: current burden and future projections. euro res j. 2006 feb 1;27(2):397-412. 7. zimmet p, magliano d, matsuzawa y, alberti g, shaw j. the metabolic syndrome: a global public health problem and a new denition. j atheroscler thrombosis. 2005;12(6):295-300. 8. henrik watz, benjamin waschki, anne kirsten, kai-christian mu¨ller; gunther kretschmar, thorsten meyer, olaf holz, helgomagnussen. the metabolic syndrome in patients with chronic bronchitis and copd. 2009 chest; 136 (4):1039 9. jesús díez manglano, josé barquero-romero, pedro almagro, f. javier cabrera , francisco lópez garcía, lorena montero, joan b. soriano. copd patients with and without metabolic syndrome: clinical and functional differences. internal and emergncy medicine. 2013;1-27 10. karine marquis, françois maltais, véronique duguay, anne-marie bezeau, picrre le blanc, jcan jobin, paul poirier. the metabolic syndrome in patients with chronic obstructive pulmonary disease. journal of cardiopulmonary rehabilitation. 2005;25:226-232 11. emel bulcun, aydanur ekici, mehmet ekici. metabolic syndrome and chronic diseases in patients with chronic obstructive pulmonary disease. i̇zmir göğüs hospital journal.2015; 29:1-10 12. z.yasar, m. buyuksirin, f.d. ucsular, a.kargi, f.erdem, f. talay, o.k. kurt. is an elevated neutrophil-to-lymphocyte ratio a predictor of metabolic syndrome in patientswith chronic obstructive pulmonary disease? european review for medical and pharmacological sciences. 2015;19:956-962 volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table-1 : comparision of various parameters between mets and non-mets copd patients. parameter copd with metabolic syndrome (n=20) copd without metabolic syndrome (n=47) name of test (student t test) p value signicant/ non-signicant waist circumference 101 ± 11.17 81.30 ± 10.86 2.0047 0.329 not signicant tg 202.26 ± 97.72 140.86 ± 94.81 2.0287 0.41 not signicant hdl 50.26 ± 12.12 54.77 ± 12.76 2.0094 0.592 not signicant fasting blood sugar 133.22 ± 21.06 99.39 ± 20.06 2.0223 0.381 not signicant systolic bp 148.09 ± 29.31 126.41 ± 15.34 2.0527 0.0001 signicant by ldl (63.2%) and total cholesterol (63.2%). in female hdl was decreased in majority (58.3%) followed by ldl (36.8%) and total cholesterol (36.8%). raised fasting blood sugar (fbs) was more in female (54.5%) than males (31.1%). overall 38.8% patients had raised fbs or on antidiabetic drugs previously. (table-1) gold stage total patients metabolic syndrome total i 5 male 3 1 2(40%) female 2 1 ii 17 male 14 6 8(47.06%) female 3 2 iii 35 male 22 4 9(25.71%) 1(10%) female 13 5 iv 10 male 6 0 female 4 1 total 67(100%) 20(29.85%) background: dengue fever is the most prevalent mosquito-borne arboviral disease, which is a major international public concern worldwide which has emerged as a global public health issue in recent decades. it is present in about 128 countries and 1 around 4 billion individuals are at risk. in the recent years, dengue virus has crossed the geographic borders and has spread to many new countries affecting the urban as well as rural areas. at present, the southeast asia and western pacic 2regions are the most endemic regions. it caused by four dengue virus strains (denv-1, denv-2, denv-3 and denv-4) of the family flaviviridae; genus flavivirus and transmitted by 3the aedes aegypti mosquito. the disease is characterized by increased capillary permeability causing the leakage of uid from the bloodstream through the wall of small blood vessels into body cavities and abnormal bleeding occurs, sometimes from the teeth gums, nose and underneath the skin, causing petechial rashes. as a result, the volume of blood circulating in the blood vessels is reduced leading to hypovolemia and the blood pressure also becomes so low that it cannot supply sufcient blood to vital organs, leading to a critical conduction known as dengue shock syndrome. furthermore multi organ damage sets in. abdominal pain or tenderness, persistent vomiting, clinical uid accumulation, mucosal bleeding, lethargy and restlessness, hepatomegaly (liver enlargement > 2 cms), and laboratory increase in haematocrit concurrently with rapid drop in platelet count are all listed as warning signs in severe 4dengue fever. dysfunction of the bone marrow leads to deterioration in the number of platelets, which are required for effective blood clotting, thereby the risk of bleeding is increased and other major complication of dengue fever. pregnant women, infants, young children and thoseexposed to the virus multiple 5, 6 times are at increased risk of severe dengue disease. with this background, this study was undertaken with an objective of describing the demographic factors and various bleeding manifestations as noted in our cohort of dengue infected patients. methodology: a record based observational case series study is conducted among the dengue serology positive patients, admitted in the department of general medicine, hanagal shri kumareshwar hospital and research centre, s.nijalingappa medical college, bagalkot. study period: during 2015-2017 in the months of june to september. study population: a total of 210 patients were obtained from the case records. inclusion criteria: ÿ conrmed cases of dengue serology positive for ns1ag or igm or both. ÿ age more than 18 years. exclusion criteria: ÿ those patients who were negative for dengue serology ÿ cases of mixed infections were excluded from the study. study tools: we collected all the patient information sheet, clinical data and reports of hematological investigations of the dengue patients admitted in our teaching hospital. data analysis: data was entered in ms excel and and analysis was done using spss statistical package student version 23. the data is tabulated in the form of tables and graphs. percentages and proportions were used to represent the data. z test was applied to proportions. results: out of the 210 cases obtained from the case records of patients admitted from 2015-2017 in the months of june to september, most of them were found to be young. more than half of them spectrum of bleeding manifestations in dengue fever patients in a tertiary care hospital – three years record based study. original research paper dr veena munavalli assistant professor, department of general medicine, s n medical college & hsk hospital, bagalkot general medicine background: dengue is a major public health concern present in almost all parts of india. it presents with myriad of clinical ndings. many of the dengue fever cases are self-limiting, but the severity ranges from mild fever to life threatening complications, such as hemorrhage and shock. the current study is undertaken with an objective of describing the demographic prole and various bleeding manifestations as noted in the admitted dengue infected patients during the study period. methods: this is a three year case series study from 2015 to 2017 among 210 dengue serology positive patients aged >18 years, admitted in the department of general medicine, hanagal shri kumareshwar hospital and research centre, s. nijalingappa medical college, bagalkot during the months of june to september. data was entered in ms excel and analysed using spss statistical package student version 23. results: out of the 210 patients, maximum number of cases belonged to the age group of 18-40 years. young population were the ones who are commonly affected with dengue illness. there were 58.57% males and 41.42% females. thrombocytopenia is seen in 109 patients while bleeding manifestations occurred only in 18 patients with less than 20,000/cumm. regarding the presentation of warning signs in the patients, abdominal pain was the most common sign, followed by malena. conclusions: patients admitted with dengue fever were mostly young and males were predominantly seen. thrombocytopenia was reected as a major laboratory investigating nding observed in almost half of the patients, but bleeding manifestations were minimal. considering the spread of the disease and its complications, it is recommended that special preventive measures should be undertaken prior to the monsoon period. abstract keywords : dengue, bleeding manifestations, thrombocytopenia, bagalkot volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr ramu g* postgraduate, department of general medicine, s n medical college & hsk hospital, bagalkot *correspondiong author 40 x gjra global journal for research analysis (59%) were in the age group of 18-40 years, while 30% of the study patients were 41-60 years and only 11% of the patients were above 60 years. regarding gender distribution, males formed a majority overall (58.57%) as shown in table 1. table 1: distribution of the study population according to age and gender thrombocytopenia is seen in 109 patients (51.9%) i.e. platelet counts of less than 10,000/cu.mm was found in 24 patients (11.45%), while 10,000 to 1, 50,000/cu.mm was noted in 85 patients (40.47%). 101 patients (48.08%) had more than 1, 50,000/cu.mm platelet count. bleeding manifestations occurred only in 18 patients (8.57%), among whom 13 patients had platelet count of less than 10,000/cu.mm, and 5 patients had platelet count of 10,000 to 1, 50,000/cu.mm. males had more bleeding manifestations (55.5%) when compared to females (44.4%). table 2: distribution of the study population according to platelet count and bleeding manifestations table 3: distribution of the study population showing the bleeding manifestations with respect to gender regarding the presentation of warning signs in the patients, abdominal pain was the most common sign, seen in 26 patients, followed by malena noted in 10 patients. other warning signs included petechiae, bleeding gums, subconjunctival haemorrhage and haematuria as shown in table 4. table 4: distribution of the study population according to warning signs discussion: dengue illness in humans causes a spectrum of illnesses ranging from in apparent febrile illness to severe and fatal haemorrhagic disease. it is considered one of the most important arthropod borne viral diseases in humans in terms of morbidity and mortality. the present study was carried out from 2015 to 2017 among 210 dengue serology positive patients aged >18 years, admitted in in the department of general medicine, s nijalingappa medical college, hanagal shree kumareshwar hospital, bagalkot, and karnataka during the months of june to september to describe the clinical manifestations of the dengue fever. this study showed that the majority of dengue cases were young adults with the largest proportion in the age group of 18-40 years (59%). this is in accordance to the ndings of chajhlana sps et al and mehta 7, 8sr et al. this shows that young population are the ones who are commonly affected with dengue illness. there was a male preponderance in our study (58.57%), as compared to the study ndings of pawar a et al in north maharashtra (58.9%) 9, 7and chajhlana sps et al in hyderabad, telangana (56.3%). even studies conducted in countries outside india, showed that incidence of dengue was high in males in a study at sri lanka conducted by pdnn sirisena and others, who stated 10 that there were 186 males and 86 females in their study. this could be due to the fact that males are more frequently exposed to the risk of acquiring dengue than females because of the outdoor life they lead. further, females are usually better clothed than males. thrombocytopenia is seen in almost half of the patients i.e. platelet counts of less than 10000/cu.mm was found in 11.45% patients, while 10,000 to 1, 50,000/cu.mm was noted in 40.47% patients. this is in contrast to the ndings of chajhlana sps et al, where thrombocytopenia is found in 784.0 % patients. while the study ndings of mehta sr et al showed that 79% had thrombocytopenia with 3.01% having platelet count of < 10, 000/cu.mm, and 33.44% of less than 50,000/cu.mm, 32.77% had < 1 lakh/cu.mm and 30.76% had more than 1 lakh/ cu.mm platelet count on laboratory 8investigations. pdnn sirisena and others of sri lanka stated that the platelet 1 0 count of < 100,000 was seen in 65.3% cases. thrombocytopenia observed in dengue fever could be due to reduced production of platelets because of suppression of the bone marrow by the dengue virus and also due to the binding of dengue antigens to platelets and increased antibody mediated immunological destruction of platelets. in the current study, bleeding manifestations were noted only in 8.57% patients having less than 20,000/cu.mm, rest all were free from bleeding manifestations. this is very less compared to the ndings of chajhlana sps et al, where bleeding 7manifestations were found in 58.8% patients and 20% mainly in the form of gastrointestinal bleed as reported by mehta sr 8 et al. regarding the presentation of warning signs in the patients, abdominal pain was the most common sign, seen in 26 patients, followed by malena noted in 10 patients. other warning signs included petechiae, bleeding gums, subconjunctival haemorrhage and haematuria. this ndings were quite different when compared with the ndings of mehta sr et al, where abdominal pain was found in 42% patients, nausea/vomiting's in 56%, rash in 23%, malena in 8 20% patients and hepatosplenomegaly in 65% patients. another study at north maharashtra showed the presence of complications like skin rash and bleeding tendency were present in 32.1% and 17.8% respectively while abdominal pain is seen in 10.7% patients, pleural effusion is seen in 910.7% and hepatomegaly in 10.7% cases. limitations: in the present study, elisa test, which is more appropriate has not been used for the diagnosis of dengue fever patients due to high cost burden, instead the antibody card test is used. and also the stool occult blood test is not done for conrmation of malena. conclusion and recommendations: patients admitted with dengue fever were mostly young and males were predominantly seen. thrombocytopenia was reected as a common laboratory nding observed in almost half of the patients, but bleeding manifestations were volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra variable 2015 2016 2017 total age 18-40 years 46 38 40 124 (59.05%) 41-60 years 23 25 15 63 (30%) > 60 years 14 5 4 23 (10.95%) gender males 45 43 35 123 (58.57%) females 38 25 24 87 (41.42%) variable 2015 2016 2017 total platelet count < 10,000 4 6 14 24 (11.45%) 10,000 to 1.5 lakh 51 17 17 85 (40.47%) > 1.5 lakh 28 45 28 101 (48.08%) bleeding manifestations yes 6 8 4 18 (8.57%) no 77 60 55 192 (91.42%) bleeding manifestations males females total yes 10 (55.5%) 8 (44.4%) 18 (8.57%) no 113 (58.85%) 79 (41.14%) 192 (91.42%) warning signs 2015 2016 2017 total petechiae 2 1 2 5 abdominal pain 12 11 3 26 subconjunctival haemorrhage 1 1 1 3 malena 5 3 2 10 bleeding gums 1 2 2 5 haematuria 1 0 0 1 x 41gjra global journal for research analysis minimal. more attention should be given to patients with very less platelet counts, as they are the ones who land up in bleeding manifestations. considering the spread of the disease and its complications, it is recommended that special preventive measures should be undertaken prior to the monsoon period. providing health education campaigns about the fever, their warning signs and early referral may help prevent complications and deaths. references: 1. brady oj, gething pw, bhatt s (2012) rening the global spatial limits of dengue virus transmission by evidence-based consensus. plos negl trop dis 6: e1760 2. world health organization. comprehensive guidelines for prevention and control of dengue and dengue hemorrhagic fever. new delhi: who, searo; 2011. 3. rodenhuis-zybert ia, wilschut j, smit jm. "dengue virus life cycle: viral and host factors modulating infectivity". cellular and molecular life sciences. 2010; 67 (16): 2773–86 4. world health organization (2009) dengue guidelines for diagnosis, treatment, prevention and control new edition. geneva: world health organization; 2009. 5. martina be, koraka p, osterhaus ad. "dengue virus pathogenesis: an integrated view". clinical microbiology reviews.2009; 22 (4): 564–81. 6. whitehorn j, farrar j. "dengue". british medical bulletin. 2010; 95: 161–73. 7. chajhlana sps, mahabhasyam rn, varaprasada msm, anukolu rsr. socio demographic and clinical prole of dengue fever cases at a tertiary care hospital, hyderabad, telangana. int j community med public health 2017; 4: 2027-30. 8. mehta sr, bafna ta, pokale ab. demographic and clinical spectrum of dengue patients admitted in a tertiary care hospital. med j dy patil vidyapeeth 2018; 11:128-31. 9. pawar a, chafekar n. clinical study of diagnosed cases of dengue fever in tertiary care hospital in north maharashtra. mvp journal of medical sciences 2018; 5(1):58-63. 10. pdnn sirisena, f noordeen, l fernando. a preliminary study on clinical proles of dengue and dengue haemorrhagic fever suspected patients from two hospitals in the western province of sri lanka. sri lankan journal of infectious diseases 2014 vol.4 (2):99-107 volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 42 x gjra global journal for research analysis introducti̇on recurrent pregnancy loss (rpl) �s defined as at least 2 consecut�ve spontaneous abort�ons before the 20th week of pregnancy w�th the same partner [1, 2]. the amer�can soc�ety of reproduct�ve med�c�ne (asrm) has defined rpl as 2 or more consecut�ve pregnancy losses [3], whereas �n the most recent gu�del�nes of the reproduct�ve health and infert�l�ty assoc�at�on, rpl �s defined as 3 or more consecut�ve pregnancy losses [4]. in a study by w�lcox et al, a strong relat�onsh�p was shown between early pregnancy loss �n part�cular and endometr�al recept�v�ty [5]. these receptors play a role �n the control mechan�sm dur�ng embryo �mplantat�on and th�s recept�v�ty �s thought to be �map�red �n pat�ents w�th rpl [6]. implantat�on of the blastocyst to the endometr�um may only be poss�ble for a very short per�od and th�s �s known as the �mplantat�on w�ndow. as th�s �s a very compl�cated event, both the embryo and the endometr�al receptors must be well-synchron�sed [7]. of these receptors exam�ned �n the current study, muc�n-1 (muc-1) has been prev�ously �nvest�gated �n pat�ents w�th recurrent �mplantat�on d�sorder appl�ed w�th �nv�tro fert�l�sat�on and both the t�ssue and blood levels were found to be lower compared to the control group [8]. in the same study, glycodel�n-a (gda) levels were also found to be s�gn�ficantly lower both �n t�ssues and blood �n compar�son w�th the control group. in a study of endometr�al b�ops�es of rpl pat�ents, leukem�a inh�b�tory factor (lif) was shown to be lower �n the endometr�um compared to a control group, but the d�fference was not reported to be stat�st�cally s�gn�ficant [9]. in another study that exam�ned lif and interleuk�n-15 (il-15) �n the endometr�al b�ops�es of pat�ents w�th recurrent �mplantat�on d�sorder, lower levels were observed �n the pat�ents than �n the control group [10]. granulocyte colony st�mulat�ng factor (g-csf) �s a hematopo�et�c cytok�ne wh�ch st�mulates granulocyte prol�ferat�on and d�fferent�at�on, produces the maternofetal �nterface dur�ng embryo �mplantat�on and �s thought to have a role �n dec�dual and placental funct�ons [11, 12]. some stud�es have shown that the appl�cat�on of g-csf to pat�ents w�th recurrent �mplantat�on d�sorder and rpl pat�ents could be useful �n respect of pregnancy outcomes [13-15]. from the start�ng po�nt of the above-ment�oned stud�es, the a�m of th�s study was to compare the serum levels of muc-1, gda, lif, il-15 and g-csf �n rpl pat�ents and �n pat�ents who had not exper�enced any pregnancy loss and had at least one l�ve b�rth, and to be able to establ�sh an alternat�ve treatment approach based on the factors w�th the greatest effect. materi̇als and methods pat�ent select�on the study was conducted �n the obstetr�cs and gynaecology cl�n�c of evl�ya çeleb� tra�n�ng and research hosp�tal of dumlup�nar un�vers�ty, kutahya, turkey. a total of 87 pat�ents were �ncluded �n the study as 42 rpl pat�ents and 45 healthy pat�ents. approval for the study was granted by the eth�cs comm�ttee of ayd�n adnan menderes un�vers�ty med�cal faculty non-intervent�onal eth�cs comm�ttee (dec�s�on no: 11/11/2016-11). pat�ents present�ng at the obstetr�cs and gynaecology cl�n�c of dumlup�nar un�vers�ty med�cal faculty w�th a h�story of recurrent pregnancy loss were �nformed about the study, and those who w�shed to part�c�pate and met the �nclus�on cr�ter�a were �ncluded as the study group. the �nclus�on and exclus�on cr�ter�a are presented below �n sect�on 2-2. the control group was formed of pat�ents selected from those who presented at the polycl�n�c, met the study �nclus�on cr�ter�a and w�shed to part�c�pate. demograph�c data of age, abortus, par�ty and grav�da were recorded. med�cal h�stor�es were taken �nclud�ng med�cat�on use and chron�c d�seases. inclus�on and exclus�on cr�ter�a inclus�on cr�ter�a for the rpl group: 1. at least 2 consecut�ve abortus, the effect of muci̇n-1, glycodeli̇n-a, leukemi̇a inhi̇bi̇tory factor, interleuki̇n-15 and granulocyte colony sti̇mulati̇on factor in the unexplained recurrent pregnancy loss a case control study original research paper murat polat department of obstetrics and gynecology faculty of medicine, dumlupınar university, kütahya, turkey. gynaecology purpose: to exam�ne the effect on recurrent pregnancy loss of mucın-1, glycodel�n-a, leukem�a inh�b�tory factor, interleuk�n-15 and granulocyte colony st�mulat�on factor blood serum levels and for those w�th the greatest effect to be able to contr�bute to alternat�ve treatment approaches. mater�als and methods: the study was conducted between november 2016 and december 2016 �n the obstetr�cs and gynaecology cl�n�c of evl�ya celeb� tra�n�ng and research hosp�tal, dumlup�nar un�vers�ty med�cal faculty. a total of 87 pat�ents were �ncluded, compr�s�ng 42 pat�ents who had exper�enced at least 2 consecut�ve pregnancy losses before the 12th week, and a control group of 45 pat�ents w�th at least 1 l�ve b�rth and no pregnancy loss. exam�nat�on was made of the blood plasma levels of mucın-1, glycodel�n-a, leukem�a inh�b�tory factor, interleuk�n-15 and granulocyte colony st�mulat�on factor. results: in the pat�ent and control groups the muc�n-1 plasma levels were determ�ned as 0.88±0.45 ng/ml and 1.17±0.57 ng/ml (p=0.008) respect�vely, glycodel�n-a as 23.73 ng/ml and 25,92 ng/ml (p=0.006). leukem�a inh�b�tory factor as 64.59 pg/ml, and 72.14 pg/ml (p=0,011), interleuk�n-15 as 38.57 ng/ml and 31.44 ng/ml (p=0.013), and granulocyte colony st�mulat�on factor as 13.07 pg/ml and 14.11 pg/ml (p=0.056). conclus�on: accord�ng to the results of th�s study, mucın-1, glycodel�n-a, leukem�a inh�b�tory factor, and interleuk�n-15 play an �mprtant role �n the pathology of rpl. further stud�es conducted on these factors could be successful �n the treatment of rpl. abstract keywords : recurrent pregnancy loss, muc�n-1, glycodel�n-a, leukem�a inh�b�tory factor, interleuk�n-15, granulocyte colony st�mulat�on factor nadi keskin department of obstetrics and gynecology faculty of medicine, dumlupınar university, kütahya, turkey. ghanim khatib* department of obstetrics and gynecology faculty of medicine, çukurova university, adana, turkey. *corresponding author 56 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 2. aged at least 18 years, 3. max�mum age of 35 years to d�scount reduced ovar�an reserve, 4. no prev�ous l�ve b�rth. inclus�on cr�ter�a for the control group 1. no h�story of pregnancy loss, 2. age 18 years – 35 years, 3. at least one l�ve b�rth. exclus�on cr�ter�a for both the study group and the control group: 1. uter�ne anomaly (septate, b�cornate, un�corn uterus etc.), 2. myoma uter�s 3. endometr�al polyps 4. endocr�nolog�cal d�sorders (d�abetes, polycyst�c ovary syndrome, thyro�d funct�on d�sorder) 5. known chromosome anomaly that could cause rpl 6. c�garette smok�ng and alcohol consumpt�on 7. act�ve �nfect�on (as �t could affect the molecule levels �n the study) 8. ol�gomenorrhea -amenorrhea w�th a h�story of abnormal uter�ne bleed�ng wh�ch could affect endometr�al recept�v�ty, or use of �ntra-uter�ne dev�ce or oral contracept�ves 9. at least one d�agnos�s of thromboph�l�a blood sample collect�on as the molecules to be stud�ed are at the h�ghest amount �n the �mplantat�on w�ndow, blood samples were taken from all the part�c�pants �n th�s per�od. the blood samples were taken one week before the expected menstruat�on as lh �s at a peak 7-10 days later. after collect�on, the samples were centr�fuged at 10,000 rpm/m�n for 10 m�ns and serums were obta�ned and placed �n 2ml, ster�le, clear eppendorf cryo tubes. the samples were stored at -20˚c out of d�rect l�ght unt�l assay. pat�ents w�th hemorrhag�c, �cter�c or l�pem�c serums were excluded from the study. b�ochem�cal analys�s the samples were exam�ned us�ng the enz yme -l �nked immunosorbent assay (elisa) method �n a pr�vate b�ochem�stry laboratory by a med�cal b�ochem�stry spec�al�st. muc-1 was exam�ned w�th the elisa k�t of elabsc�ence b�otechnology co. ltd., wh�ch uses the sandw�ch-elisa method. in th�s k�t, the m�cro elisa plate �s first covered w�th ant�body spec�fic to human muc-1. standards or samples are added to the appropr�ate m�cro elisa plate wells and comb�ned w�th spec�fic ant�body. then a determ�nant ant�body w�th b�ot�n, spec�fic to human muc-1 and av�d�n-horserad�sh perox�dase (hrp) conjugate �s added to each m�cro-plate and �ncubated. free elements are washed and substrate solut�on �s added to each well. wells conta�n�ng only human muc-1, determ�nant ant�body w�th b�ot�n and av�d�n-hrp conjugate are seen w�th a blue colour. the enzymesubstrate react�on �s term�nated by add�ng sulphur�c ac�d solut�on and the colour becomes yellow. opt�c dens�ty (od) �s measured spectrophotometr�cally at a wavelength of 450 nm± 2nm. the od value �s proport�onal to the human muc-1 concentrat�on. the colour formed �s measured spectrophotometr�cally. then the concentrat�ons of the samples exam�ned are calculated from the drawn cal�brat�on curve. gda was exam�ned w�th the elisa k�t of elabsc�ence b�otechnology co.ltd, wh�ch uses the sandw�ch-elisa method. in th�s k�t, the m�cro elisa plate �s first covered w�th ant�body spec�fic to gda. standards or samples are added to the appropr�ate m�cro elisa plate wells and comb�ned w�th spec�fic ant�body. then a determ�nant ant�body w�th b�ot�n, spec�fic to gda and av�d�n-horserad�sh perox�dase (hrp) conjugate �s added to each m�cro-plate and �ncubated. free elements are washed and substrate solut�on �s added to each well. wells conta�n�ng only gda, determ�nant ant�body w�th b�ot�n and av�d�n-hrp conjugate are seen w�th a blue colour. the enzymesubstrate react�on �s term�nated by add�ng sulphur�c ac�d solut�on and the colour becomes yellow. opt�c dens�ty (od) �s measured spectrophotometr�cally at a wavelength of 450 nm± 2nm. the od value �s proport�onal to gda concentrat�on. the colour formed �s measured spectrophotometr�cally. then the concentrat�ons of the samples exam�ned are calculated from the drawn cal�brat�on curve. lif was exam�ned w�th the elisa k�t of elabsc�ence b�otechnology co.ltd, wh�ch uses the sandw�ch-elisa method. in th�s k�t, the m�cro elisa plate �s first covered w�th ant�body spec�fic to lif. standards or samples are added to the appropr�ate m�cro elisa plate wells and comb�ned w�th spec�fic ant�body. then a determ�nant ant�body w�th b�ot�n, spec�fic to gda and av�d�n-horserad�sh perox�dase (hrp) conjugate �s added to each m�cro-plate and �ncubated. free elements are washed and substrate solut�on �s added to each well. wells conta�n�ng only lif, determ�nant ant�body w�th b�ot�n and av�d�n-hrp conjugate are seen w�th a blue colour. the enzymesubstrate react�on �s term�nated by add�ng sulphur�c ac�d solut�on and the colour becomes yellow. opt�c dens�ty (od) �s measured spectrophotometr�cally at a wavelength of 450 nm± 2nm. the od value �s proport�onal to lif concentrat�on. the colour formed �s measured spectrophotometr�cally. then the concentrat�ons of the samples exam�ned are calculated from the drawn cal�brat�on curve. il-15 was exam�ned w�th the elisa k�t of elabsc�ence b�otechnology co.ltd, wh�ch uses the sandw�ch-elisa method. in th�s k�t, the m�cro elisa plate �s first covered w�th ant�body spec�fic to il-15. standards or samples are added to the appropr�ate m�cro elisa plate wells and comb�ned w�th spec�fic ant�body. then a determ�nant ant�body w�th b�ot�n, spec�fic to il-15 and av�d�n-horserad�sh perox�dase (hrp) conjugate �s added to each m�cro-plate and �ncubated. free elements are washed and substrate solut�on �s added to each well. wells conta�n�ng only il-15, determ�nant ant�body w�th b�ot�n and av�d�n-hrp conjugate are seen w�th a blue colour. the enzymesubstrate react�on �s term�nated by add�ng sulphur�c ac�d solut�on and the colour becomes yellow. opt�c dens�ty (od) �s measured spectrophotometr�cally at a wavelength of 450 nm± 2nm. the od value �s proport�onal to il-15 concentrat�on. the colour formed �s measured spectrophotometr�cally. then the concentrat�ons of the samples exam�ned are calculated from the drawn cal�brat�on curve. g-csf was exam�ned w�th the elisa k�t of elabsc�ence b�otechnology co.ltd, wh�ch uses the sandw�ch-elisa method. in th�s k�t, the m�cro elisa plate �s first covered w�th ant�body spec�fic to human g-csf. standards or samples are added to the appropr�ate m�cro elisa plate wells and comb�ned w�th spec�fic ant�body. then a determ�nant ant�body w�th b�ot�n, spec�fic to human g-csf and av�d�n-horserad�sh perox�dase (hrp) conjugate �s added to each m�cro-plate and �ncubated. free elements are washed and substrate solut�on �s added to each well. wells conta�n�ng only g-csf, determ�nant ant�body w�th b�ot�n and av�d�n-hrp conjugate are seen w�th a blue colour. the enzyme-substrate react�on �s term�nated by add�ng sulphur�c ac�d solut�on and the colour b e c o m e s y e l l o w . o p t � c d e n s � t y ( o d ) � s m e a s u r e d spectrophotometr�cally at a wavelength of 450 nm± 2nm. the od value �s proport�onal to g-csf concentrat�on. the colour formed �s measured spectrophotometr�cally. then the concentrat�ons of the samples exam�ned are calculated from the drawn cal�brat�on curve. stat�st�cal analys�s all analyses of the study data were performed us�ng spss vn 21 software. cont�nuous quant�tat�ve var�ables were stated as number, mean and standard dev�at�on and qual�tat�ve var�ables as number, med�an, 25th and 75th percent�les. for cont�nuous var�ables from �ndependent measurements that d�d not show normal d�str�but�on, the mann wh�tney rank sum test was appl�ed. a value of p<0.05 was accepted as stat�st�cally s�gn�ficant. results as a result of the analys�s of the demograph�c data of the study pat�ents, the mean age was determ�ned as 30.41±3.76 years �n the whole group and 30.44±3.91 �n the rpl pat�ent group and 30.40±3.68 years �n the control group (p=0,972). x 57gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 mean grav�da was determ�ned as 3.83±1.61 �n the rpl group and 1.80±0.73 �n the control group. mean par�ty was 0 �n the rpl group and 1.80±0.73 �n the control group. the number of abortus was 3.86±1.20 �n the rpl group and 0 �n the control group. these results were summar�zed �n table 1. table 1: compar�son of the pregnancy results between the groups. the muc-1, gda, lif, il-15 and g-csf plasma levels of the pat�ents were determ�ned and compared between the groups. the muc-1 level of the rpl group was found to be stat�st�cally s�gn�ficantly lower than that of the control group (0.88±0.45 ng/ml vs. 1.17±0.57 ng/ml, p=0.008). the gda level of the rpl group was found to be stat�st�cally s�gn�ficantly lower than that of the control group (23.73±3.72ng/ml vs. 25.92±4.20 ng/ml, p=0.006). the lif level of the rpl group was found to be stat�st�cally s�gn�ficantly lower than that of the control group (64.59±21.13 pg/ml vs. 72.14±20.89 pg/ml, p=0.011). the il-15 level of the rpl group was found to be stat�st�cally s�gn�ficantly h�gher than that of the control group (38.57±55.70 ng/ml vs. 31.44±43.65 ng/ml, p=0.013). no stat�st�cally s�gn�ficant d�fference was determ�ned between the rpl group and the control group �n respect of the g-csf levels (13.07±3.84 pg/ml vs 14.11±3.62 pg/ml, p=0.056). all these find�ngs were summar�zed �n table 2. table 2: compar�son between the groups accord�ng to muc-1, gda, lif, il-15 and g-csf values. di̇scussi̇on recurrent pregnancy loss (rpl) �s 2 or more consecut�ve losses before the 20th week of pregnancy. however, there are d�fferent defin�t�ons of th�s d�sease [16]. for example, �n the 2016 gu�del�nes of the reproduct�ve health and infert�l�ty assoc�at�on, rpl �s defined as 3 or more consecut�ve pregnancy losses before the 20th week of pregnancy [4]. the amer�can soc�ety of reproduct�ve med�c�ne (asrm) has defined rpl as 2 or more pregnancy losses, but these do not need to be consecut�ve [3]. although no clear consensus has been reached on the defin�t�on of rpl, several causes have been held respons�ble �n the et�ology. however, �n approx�mately half of pat�ents, the et�ology cannot be fully clar�fied. desp�te great efforts made by phys�c�ans �n the d�agnos�s and treatment of pat�ents where the et�ology cannot be fully establ�shed, no correspond�ng reasons can be found �n most cases. thus, there �s no chance of treat�ng approx�mately half of pat�ents when the et�ology cannot be determ�ned. the only current method for rpl of unknown causes �s close follow-up and mon�tor�ng. when �t �s cons�dered that 0.5%-2% of women are affected by th�s d�sease [16], there can be seen to be a great burden �n respect of the healthcare costs of d�agnos�s and treatment. moreover, these pat�ents may develop psycholog�cal problems and the marr�age may even be at r�sk [17]. pregnanc�es wh�ch cont�nue �n women w�th a h�story of rpl are generally seen to be del�vered by caesarean sect�on. when the �nd�cat�ons for caesarean del�very are exam�ned, the most common reason has been found to be that �t �s a valuable pregnancy [18, 19]. as there are d�fferent defin�t�ons of rpl made by prest�g�ous soc�et�es �n the field of obstetr�cs and gynaecology and et�olog�cal causes have not been clar�fied �n approx�mately half of cases, th�s suggests that there are several sc�ent�fic po�nts that are unknown and requ�re clar�ficat�on. in th�s context, the a�m of th�s study was to �nvest�gate poss�ble endometr�al �mplantat�on d�sorders among the as yet unexpla�ned et�olog�cal causes of rpl and to evaluate the plasma levels of a ser�es of cytok�nes wh�ch are effect�ve �n �mplantat�on. successful embryo �mplantat�on requ�res both a healthy embryo and a healthy endometr�um. there has to be correct and healthy commun�cat�on between the embryo and the endometr�um for the �mplantat�on to be successful. in ivf pat�ents w�th recurrent fa�lure of �mplantat�on, one of these two elements �s usually seen to be �mpa�red. several stud�es have shown �mpa�red endometr�al recept�v�ty �n ivf pat�ents w�th recurrent �mplantat�on fa�lure [8, 10, 20]. consequently, there may be a s�gn�ficant d�fference between pat�ent and control groups �n plasma concentrat�ons that re�ect the endometr�al express�on levels of a ser�es of markers that are requ�red for �mplantat�on. w�th th�s hypothes�s, the a�m of the current study was to compare rpl pa�tents and a control group �n respect of blood plasma levels of muc-1, gda, lif, il-15 and g-csf, wh�ch play a role �n endometr�al recept�v�ty and �mplantat�on and have been prev�ously stud�ed �n ivf pat�ents w�th recurrent �mplantat�on fa�lure. the results of the study demonstrated that the muc-1, gda and lif mean plasma values were stat�st�cally s�gn�ficantly lower �n the pat�ent group than �n the control group. the blood plasma il-15 level was determ�ned to be stat�st�cally s�gn�ficantly h�gher �n the pat�ent group than �n the control group. although the g-csf blood plasma values were lower �n the pat�ent group than �n the control group, th�s d�fference was not stat�st�cally s�gn�ficant (p=0.56). as prev�ously ment�oned, muc-1 �s both an ant�-adhes�on molecule and a molecule that has �mmunomodulator effects on tlymphocytes [21, 22]. the �mplanted embryo �s protected aga�nst fore�gn agents w�th the �mmunomodulator effect. although �t has been suggested �n prev�ous stud�es that a relat�vely low level of muc-1 �n the �mplantat�on w�ndow, �s �mportant for �mplantat�on, pat�ents w�th a h�story of rpl have been shown to have a s�gn�ficantly lower muc-1 level than the normal populat�on [8, 2324]. cons�stent w�th the find�ngs of prev�ous stud�es, the muc-1 level of the rpl pat�ents �n the current study was found to be lower than that of the control group. th�s paradox�cal s�tuat�on can be attr�buted to the fact that although a reduct�on �n muc-1 levels dur�ng the �mplantat�on w�ndow �s �mportant �n respect of �mplantat�on of the blastocyst to the endometr�um, the excess�ve reduct�on �n muc-1 levels �n rpl pat�ents cannot funct�on to protect the embryo and therefore leaves the embryo defenceless aga�nst external factors [(22, 25]. it has been proposed that by st�mulat�ng apoptos�s �n pro�n�ammatory monocytes, gda could have a role �n ma�nta�n�ng the ant�-�n�ammatory env�ronment that �s necessary for pregnancy [26]. in a study by tulppala et al, the gda serum levels �n the �mplantat�on w�ndow were compared between pat�ents w�th a h�story of rpl and a healthy control group, and the gda level was found to be lower �n the rpl group [27]. dalton et al also compared pat�ents w�th a h�story of rpl and a control group, through the exam�nat�on of the gda level �n �u�d adm�nstered to the uter�ne cav�ty as 10 ml ster�le sal�ne and then re-asp�rated dur�ng the �mplantat�on w�ndow. the gda level was determ�ned to be lower �n the rpl group than �n the control group [28]. in another study conducted on pat�ents w�th �mplantat�on fa�lure, gda levels both �n the serum and �n endometr�al t�ssue samples were found to be lower when compared to a healthy control group [8]. in the current study, the blood plasma gda levels were found to be lower �n the rpl pat�ents than �n the control group, wh�ch was cons�stent w�th find�ngs �n l�terature. var�able pat�ent group (n=42) mean±sd control group (n=45) mean±sd p grav�da 3,83±1,61 1,80±0,73 <0,001 par�ta 0±0 1,80±0,73 <0,001 abortus 2,86±1,20 0±0 <0,001 parameter total (n=87) mean±sd pat�ent group (n=42) mean±sd control group (n=45) mean±sd p muc-1 (ng/l) 0,88±0,45 1,17±0,57 0,008 gda (µg/l) 24,86±4,09 23,73±3,72 25,92±4,20 0,006 lif(pg/l) 68,49±21,22 64,59±21,13 72,14±20,89 0,011 il-15 (ng/l) 34,88±49,67 38,57±55,70 31,44±43,65 0,013 g-csf (pg/l) 13,60±3,73 13,07±3,84 14,11±3,62 0,056 58 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 several prev�ous stud�es have exam�ned the relat�onsh�p between lif and embryo �mplantat�on. it �s known that �mmed�ately before �mplantat�on, lif synthes�s �n the glandular ep�thel�um of the endometr�um reaches a max�mum level [29-30]. in the per��mplantat�on stage, the effects of lif reach�ng peak levels has been shown w�th trophoblast funct�on and placental vascular format�on [30, 31]. in a study by la�rd sm et al, the lif concentrat�on �n the uter�ne �rr�gat�on �u�d of pat�ents w�th �mplantat�on fa�lure was found to be lower than that of the normal populat�on [32]. in contrast, xu b et al found no d�fference between pat�ents w�th a h�story of rpl and a control group �n respect of endometr�al express�on of lif [9]. however, �n another study, lif levels were found to be s�gn�ficantly lower �n both endometr�al t�ssue and blood plasma �n pat�ents w�th a h�story of rpl compared to a control group [33]. in the current study, the lif levels of the rpl pat�ents were determ�ned to be stat�st�cally s�gn�ficantly lower than those of the control group. these results were cons�stent w�th the find�ngs of several stud�es �n l�terature that lif levels, wh�ch have a very �mportant role �n the �mplantat�on process, can be expected to be lower �n pat�ents w�th a h�story of rpl. in a study by cheg�n� et al, endometr�al il-15 synthes�s was shown to be �ncreased �n pat�ents w�th a h�story of rpl [143]. mar�ee et al also showed �ncreased levels of endometr�al il-15 synthes�s �n pat�ents w�th recurrent �mplantat�on fa�lure compared to a control group [10]. in the current study, the blood plasma levels of the rpl pat�ent group were determ�ned to be h�gher than those of the control group, wh�ch was cons�stent w�th the find�ngs of prev�ous stud�es that have measured endometr�al levels. il-15 �s known to be effect�ve on the prol�ferat�on of unk cells and �ncreases the cytotox�c�ty of these cells [34]. it has been suggested that il-15 plays an �mportant role �n the transformat�on of nk cells to unk cells [35, 36] and the number of unk �s known to be �ncreased �n pat�ents w�th a h�story of rpl [37, 38, 39]. from th�s po�nt, �t can be thought that the greater transformat�on of nk cells to unk cells could be a reason for �mpa�red �mplantat�on. th�s could even be a reason for the loss of �mplanted healthy embryos. in a recent, random�sed, placebo-controlled study, pat�ents w�th a h�story of rpl for whom ivf was planned were separated �nto 3 groups. one group was adm�n�stered w�th �ntrauter�ne g-csf, one group w�th low-molecular we�ght hepar�n, acetylsalıcyl�c ac�d and predn�solone and one group w�th a placebo. the results showed that the rates of l�ve b�rths were h�gher and pregnancy losses were lower �n the g-csf group than �n the other groups [13]. in the current study, �t was a�med to evaluate how the g-csf serum values d�ffered �n the rpl pat�ents from the control group. the results of the study showed that although the serum g-csf values were lower �n the rpl group than �n the control group, the d�fference was not stat�st�cally s�gn�ficant. strong aspects of the current study can be sa�d to be that �n l�terature the stud�es made on the concept of endometr�al recept�v�ty and the molecules that have a funct�on �n that, have generally been conducted on pat�ents who have undergone ivf w�th �mplantat�on fa�lure. there �s a l�m�ted number of stud�es that have exam�ned these molecules �n pat�ents w�th a h�story of rpl. in l�terature, although muc-1 has been prev�ously exam�ned �n rpl, �t has been exam�ned �n uter�ne �rr�gat�on �u�d and endometr�al b�ops�es. to the best of our knowledge, there has been no prev�ous study that has exam�ned blood plasma muc-1 concentrat�ons �n rpl compared w�th a healthy populat�on. therefore, the current study �s the first �n th�s respect. however, there �s a need for further stud�es to be made of the muc-1 blood plasma levels �n rpl pat�ents to support the results of th�s study. the only study �n l�terature to have stud�ed gda serum levels �s that by tulppala et al [27]. the s�m�lar results obta�ned �n the current study suggest that th�s molecule has an �mportant role �n rpl. nevertheless, further stud�es are requ�red on th�s subject to support the results. only 1 study could be found that has exam�ned lif blood plasma levels �n rpl, the results of wh�ch were s�m�lar to those of the current study. further stud�es are requ�red on th�s subject. another strong aspect of the current study �s that �t �s the first to have exam�ned il-15 blood plasma levels �n rpl pat�ents. in the 2 prev�ous stud�es that evaluated the relat�onsh�p between il-15 and rpl, express�on levels were exam�ned �n endometr�al t�ssues. although the results of the current study are cons�stent w�th the find�ngs of those 2 stud�es, there can st�ll be cons�dered a need for further research to shed l�ght on th�s subject. as th�s study exam�ned the molecules �n the plasma levels obta�ned from venous blood samples rather than us�ng an �nvas�ve method such as endometr�al b�opsy, th�s can be cons�dered a useful method for the exam�nat�on of endometr�al recept�v�ty �n rpl. although there are dozens of molecules that funct�on �n embryo �mplantat�on, the plasma levels of only 5 were exam�ned �n th�s study because of t�me and financ�al restra�nts. if a study could be conducted wh�ch could evaluate all these molecules, �t could be determ�ned wh�ch molecules were related to rpl and could be used as pred�ct�ve markers. conclusi̇on accord�ng to the results obta�ned �n th�s study, stat�st�cally s�gn�ficantly low levels of muc-1, gda and lif were determ�ned �n rpl pat�ents, wh�ch was cons�stent w�th prev�ous find�ngs �n l�terature, and these could be cons�dered for use at both the d�agnos�s and treatment stage �n future cl�n�cal pract�ce. s�m�larly, that the il-15 values were found to be h�gher �n the rpl pat�ents than �n the control group �s of cl�n�cal value. although the g-csf levels of the rpl pat�ents were lower than those of the control group, the d�fference was not of a stat�st�cally s�gn�ficant level, and as �t has been shown �n l�terature that the use of th�s molecule �mproved results �n cases of recurrent ivf fa�lure, there can be cons�dered to be a need for further more extens�ve stud�es of the effects of th�s molecule on pat�ents w�th a h�story of rpl. the et�ology of rpl has not been fully clar�fied and therefore a pat�ent group of approx�mately 50% who cannot be d�agnosed w�th known causes do not have full access to treatment opt�ons. in th�s context, �t can be cons�dered that further descr�pt�ve and random�sed, controlled stud�es w�ll s�gn�ficantly contr�bute to �mplementat�ons �n cl�n�cal pract�ce. endometr�al recept�v�ty �s an �mportant part of embryo �mplantat�on and can be thought to play an �mportant role �n the clar�ficat�on of the et�ology of th�s d�sease. generally, samples are taken w�th endometr�al b�opsy �n the �mplantat�on w�ndow to evaluate endometr�al recept�v�ty. the samples taken are usually exam�ned under electron m�croscope or w�th �mmunoh�stochem�cal methods. these exam�nat�ons are both expens�ve and �mpract�cal and �nclude the �nvas�ve method of b�opsy. the use of venous blood samples to evaluate endometr�al recept�v�ty, as �n the current study, can be cons�dered a more pract�cal, cheaper and less �nvas�ve method. further s�m�lar stud�es to th�s �nvest�gat�ng the et�ology of rpl, conducted on more extens�ve pat�ent ser�es, are necessary and �mportant �n respect of contr�but�ng to l�terature and the development of new d�agnost�c and treatment methods for th�s d�sease. compl�ance w�th eth�cal standards: confl�ct of �nterest: all authors (nad� kesk�n, murat polat, and ghan�m khat�b) declare that there �s no confl�ct of �nterest. x 59gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 eth�cal approval: all procedures performed �n th�s study �nvolv�ng human part�c�pants were �n accordance w�th the eth�cal standards of the �nst�tut�onal research comm�ttee and w�th the 1964 hels�nk� declarat�on and �ts later amendments or comparable eth�cal standards. informed consent: informed consent was obta�ned from all �nd�v�dual part�c�pants �ncluded �n the study. references 1stirrat gm. 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(2003) coexpression of pinopodes and leukemia inhibitory factor, as well as its receptor, in human endometrium. fertil steril 79 (1): 808–14. 32laird sm, tuckerman em, dalton cf, dunphy bc, li tc, zhang x. (1997) the production of leukaemia inhibitory factor (lif) by human endometrium: presence in uterine �ushings and production by cells in culture. hum reprod 12: 569–74. 33comba c, bastu e, dural o, et al. (2015) role of in�ammatory mediators in patients with recurrent pregnancy loss. fertil steril 104 (6): 1467-74.e1. 34carson we, giri jg, lindemann mj, et al. (1994) il-15 is a novel cytokine that activates human natural killer cells via components of the il-2 receptor. j exp med 180: 1395–403. 35croy ba, esadeg s, chantakru s, et al. (2003) update on pathways regulating the activation of uterine natural killer cells, their interactions with decidual spiral arteries and homing precursors to the uterus. j reprod immunol 59: 175–91. 36manaster i, mizrahi s, golman-wohl d, et al. (2008) endometrial nk cells are special immature cells that await pregnancy. j immunol 181: 1869–76. 37clifford k, flanagan am, regan l. (1999) endometrial cd56+ natural killer cells in women with recurrent miscarriage. hum reprod 14: 2727–30. 38quenby s, bates m, doig t, et al. (1999) pre-implantation endometrial leukocytes in women with recurrent miscarriage. hum reprod 14: 2386–91. 39tuckerman e, laird sm, prakash a, li tc. (2007) prognostic value of the measurement of uterine natural killer (unk) cells in the endometrium of women with recurrent miscarriage. hum reprod 22: 2208–13. 60 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 introduction: diabetic nephropathy is the single most common cause of chronic renal failure in the united states, accounting for 45% of patients receiving renal replacement therapy and is rapidly growing problem worldwide. clinically it is characterized by persistent albuminuria that is conrmed on at least two occasions 3-6 months apart associated with progressive decline in the gfr and elevated arterial blood pressure. appropriate correlation of diabetic nephropathy in ayurveda is not mentioned. so,an approach has been made with the following to establish the possible aetiological factors responsible for developing diabetic nephropathy from an ayurvedic perspective for a preventive and curative purpose. materials and methods: a clinical study on 60 patients of diabetic nephropathy was conducted at govt. ayurvedic college and hospital, guwahati-14,assam,india, as per necessary formalities under strict protocol to prevent bias and to reduce the error in the study. detailed history regarding diet and lifestyle habits as mentioned in ayurveda were taken in a specially designed proforma prepared for the study incorporating all relevant points. all subjective parameters were statistically evaluated using proper statistical tools. assesment criteria: 1. all selected patients were recorded as per specially design performa. 2. selection of the patients were done based on prior history of diabetes mellitus or with a family history of diabetes mellitus. 3. all diabetic patients with increased serum creatinine level were undertaken for the study. 4. for assessment of excessive intake of specic food products, food frequency questionnaire for a period of seven days have been employed. variation was done as follows— a) frequency of intake once in a month = 0 b) once in a week=1 c) 2-3 times in a week=2 d) 4 times in a week= 3 e) 5 times in a week= 4 f) everyday intake = 5 fishes considered for the study are fresh water shes, meat of commonly consumed birds/animals such as chicken , duck, pork, beef , pigeon, goat have been included in the study.leafy greens considered for the study are the commonly available edible plant leaves in the northeastern region. milk of cow and buffalo milk is considered for the study. chilli refers to intake of green chilli along with diet. eggs laid by paultry and duck mainly is considered for the study. assessment of viharaja nidanas like ativyayam, diwaswapna and avyayam were done as per lifestyle and profession. daily sleep at day time for more than 1 hour is considered as diwaswapna for the study. for better scientic evaluation of such lifestyle factors, energy intake per day is calculated out as follows: bmr (female) = (weight in kg)×4.35+(height in cm)×4.7-(age in years)×4.7+655 bmr (male) = (weight in kg)×6.23+(height in cm)×12.7-(age in years)×6.8+66 to rule out activity level, no activity =sedentary light activity=1-2 days/week moderate activity=3-5 days/week very active=daily activity factor: for sedentary=1.2 for light=1.375 for moderate=1.55 for very active=1.725 factor the bmr by the activity factor to give you the number of calories per day. 5. data above 40% of occurrence rate have been taken i n t o consideration for the study. a. observation and statistical analysis the data of subjective of adjective parameters were tabulated and analysed using appropriate statistical tools. table 1: prevalence of aharaja nidanas in the study an aetiopathological study on diabetic nephropathy in ayurveda with special reference to some laboratory parameters original research paper dr. gitismita borah pg scholar, dept. of roga nidan, govt. ayurvedic college, guwahati-14, assam x 63gjra global journal for research analysis ayurveda diabetic nephropathy is one of the most long term complications in terms of mortality and morbidity for individual patients with diabetes. it is due to long standing diabetes mellitus and is characterized by persistent albuminuria associated with progressive decline in the glomerular filtration rate and elevated arterial blood pressure. though, there is no direct nomenclature of the disease mentioned in ayurveda, but there are references of diseases with manifestation of symptoms suggestive of diabetic nephropathy. the present study aims at ruling out the possible aetiological factors responsible for developing diabetic nephropathy from an ayurvedic perspective and establishing a relation between the aetiological factors in ayurveda and some most sensitive tests. the study is performed in 60 patients of known and newly diagnosed cases of diabetic nephropathy in a specially designed proforma. after assessing all the ayurvedic parameters, the aetiological factors-both dietary and lifestyle factors responsible are evaluated. abstract keywords : diabetic nephropathy, dietary factors, lifestyle factors volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. hemen kalita* assistant professor, dept. of roga nidan, govt. ayurvedic college, guwahati-14, assam * corresponding author no. of observation percentage meat 35 57 fish 50 84 64 x gjra global journal for research analysis fig. 3: prevalence of aharaja nidanas in the study(n=60) fig. 4: prevalence of aharaja nidanas in the study (n=60) study shows meat, sh, salt, red chilli, ginger, garlic and leafy greens as the most prevalent aharaja hetus ( g.3 & g. 4) table 2: prevalence of viharaja nidanas in the study fig. 5: prevalence of viharaja nidanas in the study (n=60) study shows diwaswapna and chinta as the most prevalent among all the viharaja nidanas discussion: a. discussion on aharaja nidan: analysis on aetiological factors based on food habit: over 90 varieties of different food products were evaluated in a specially designed proforma to know the consumption rate of the same in a known case of diabetic nephropathy based on ayurvedic parameters. study shows consumption of sh (84%) with the highest incidence rate followed by chilli (65%), leafy greens (60%), meat (57%), salt (56%), onion (42%), ginger (53%), garlic (51%) respectively. here, the above dietary factors can be considered as viprakrista nidanas. rest of the items with an incidence rate below 40% are considered as insignicant and hence not recorded as predominant in the study. these particular food items can be taken as vyabhichari nidanas in the study. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra leafy greens 36 60 guda 4 7 milk 23 38 egg 8 13 yogurt 8 13 cheese 0 0 honey 3 5 mustard 12 20 mushroom 0 0 apple 3 5 banana 3 5 fruit juice 0 0 guava 0 0 mango 0 0 papaya 0 0 sauces 0 0 vinegar 3 5 turmarind 3 5 tea 8 13 pickles 4 7 dosa idli 0 0 amlavetas 0 0 dadim 0 0 lemon 7 11 broccoli 0 0 capsicum 0 0 spinach 10 16 cabbage 0 0 sweet potato 0 0 pumpkin 16 27 squash 0 0 cucumber 0 0 soda 4 6 eggplant 3 5 carrot 0 0 beet root 0 0 pizza 0 0 tomato 9 16 grapes 0 0 cold drinks 0 0 biscuit 3 5 chips 0 0 noodle cracker 3 5 salad 1 2 chat 0 0 salt 33 56 saindhav lavana 0 0 rice 9 16 maize 0 0 cereals 0 0 bread 1 2 sugar 3 5 sweets 3 5 red chilli 39 65 capsicum 0 0 puri 0 0 coriander 5 9 garlic 31 51 drumstick 12 20 mint 0 0 ginger 32 53 mustard oil 4 7 onion 25 42 papad 1 2 spices 4 7 ghee 4 7 mandak 0 0 tikshna 0 0 no. of observation percentage abhojana 12 20 rukshabhojana 5 9 ajeernabhojan 4 7 adhyasan 3 5 ativyayam 12 20 avyayam 0 0 diwaswapna 31 51 krodh 3 5 bhaya 0 0 soka 4 6 chinta 29 49 analysis on fish: fish occupies the highest predominance in the study with a considerably higher incidence rate of 84%. fish consumption in the study has been considered as per the food consumption score with a score of 4 and 5 being taken into consideration for 2the study. river water shes are termed as nadeya matsya in classics .in context of guna, karma, dosa association with consumption of sh, susruta mentions that shes are guru, 3snigdha, raktapittakara and alpavarchasah . susruta cons iders , shes typ ical ly r iver water shes as 4mahaabhisyandi i.e, it produces kleda in the dosas, dhatu,, mala and srota . in charaka's opinion, shes are 5guru,usna,,snigdha and bohudosakara .as we know guru guna is kaphavardhak where as snigdha and usna gunas are 6pittakarak . hence, association of pitta and kapha dosas can be taken into consideration. in context of dhatupradosaja vikaras,it is been mentioned that guru and snigdha gunas are 7responsible for rasa,rakta and mamsa dusti whereas usna 8guna is directly associated with rakta dusti . in context of 3mala, sushruta has considered shes as alpavarchasah i.e, it generates mala inside the body that can be related to increased production of excretory products or toxic metabolites inside the body. hence, vitiation of pitta and kapha dosa along with rasa, rakta and mamsa dusti can be considered from the increased consumption of sh in the study. the nutritional value of sh contains moisture 65-80%,protein 15-20%,fat 5-20%,ash 0.5-2%, along with that it contains micronutrients that include fat soluble vitamins a,d,e,k as 9well as thiamine, niacin and riboavin .fish is a good source of protein. however receipt of these high protein diets may heighten diabetic patient's risk of developing impaired renal function. from recent studies it is known that incrementally higher animal protein consumption is strongly associated with increasingly higher risk of esrd in a dose dependent 10manner . this suggests improper consumption of protein rich foods such as sh may increase protein load in the body which in turn affect kidney in order to excrete protein derived nitrogen metabolites increasing glomerular ltration rate in a diabetic patients. analysis on meat: meat consumption (43%) also shows predominance signicantly in the study. meat consumption in these areas is apparently heterogeneous comprising of poultry,red meat,pork, beef, duck, pigeon, etc. as per charak samhita 11kukkuta mamsa is snigdha, usna . sushrutha has also 12considered it as snigdha, usna and guru . however charak has considered meat of prasaha, bhusaya, anupa, varija in 13general as usna, snigdha, kapahpittavardhak . again, chagala mamsa is considered to be natisheeta, natiguru, 14natisnigdha and hence adoshakara as per charak , whereas 15sushrutha denes chagala mamsa as manda pitta kapha i.e, it slightly increases pitta and kapha dosa. pork meat is 16described as snigdha and guru as per charak . sushruta has 17considered pigeon meat as rakatapitta prasamak and guru , 18whereas duck meat is considered to be guru, usna, snigdha . similar description has been put forwarded by charak as well. careful analysis of the gunas attributed to the the different varieties of meat in the samhitas, indicates involvement of pitta and kapha dosa along with rasa, rakta and mamsa dhatu dusti. the nutritional value of meat consist of roughly 75% water, 90% protein,2.5% intramuscular fat.1.2% carbohydrate and 192.3% other soluble non protein substance . as mentioned earlier irrational indulgence of protein has got higher risk of occurrence of nephropathy, hence higher incidence rate of meat consumption among diabetic nephropathy patients can be taken into consideration in the study. moreover, meat is again a good source of fats, which can be either adipose tissue or intramuscular fat. example of foods containing a high proportion of saturated fats include animal fat products such as cream, cheese, butter and fatty meals which also contains dietary cholesterol. from recent studies, it has been established that hypercholesterolemia is considered to be one 20of the high risk factor for developing nephropathy . vascular lesions, where atheroma of renal arteries is considered to be very common and severe in diabetes mellitus patients and considered as one of the pathology involved in diabetic nephropathy. hyaline arteriosclerosis is known to affect the afferent and efferent arterioles of glomeruli. atherosclerosis is a specic form of arteriosclerosis where the major acquired 21risk factor is hyperlipidaemia . hence, consumption of of animal fat, mostly saturated fat in excessive manner connects a relationship in the occurrence of the disease diabetic nephropathy. analysis on leafy greens: leafy greens accounts for 60% of consumption among rest of the food items considered in the study. these contributes to the eating behaviour of people from this particular geographical distribution. here, leafy greens indicate a heterogenous group of traditionally available plant leaves which are considered as food in this geographical area of north eastern region. some of the common leafy greens which are consumed in this particular geographical area are spinach(spinacea oleracea,paleng), mustard plant( brassica juncea, xoriyoh xak),mustard green( brassica chinensis var. parachinensis, lai), indian spinach(basella alba, morisa), water spinach (ipomoea aquatica, kalmou), fenugreek greens (tr igonel la foenum graecum, methi xak) , green amaranth(amaranthus viridis, khutura) . in ayurvedic treatises description of a wide variety of leafy greens are mentioned under saka varga. in charak samhita, the general qualities of all the various groups of leafy greens that comes under saka varga, are considered as guru, ruksha, 22vistambhi, madhura rasa predominant and sita in veerya . guru and vistambhi guna is kaphakarak whereas ruksha 23guna vitiates vata . susruta opines that all varieties of sakas 24are pittaghna in general, vatakarak and mandakapha i.e, it alleviates kapha. moreover, as per sushruta consumption leafy greens results in generation of mala and mutra. (sristamutrapurishani). on average, the leafy vegetables contains proteins and bres. ca,mg,na and k are the most abundant minerals in the leafy meals and leaf protein concentrates, while p and cu are the 25least abundant . prior data has shown that low dietary sodium intake is associated with reduction in blood pressure and proteinuria in chronic kidney diseases patients, which may be extrapolated for diabetic kidney disease patients. current nutritional guidelines for diabetic kidney disease patients uniformly recommend restriction of dietary sodium 26intake to less than 1.5-2.3 g/day. (5gm of sodium chloride) . hence, limiting sodium intake in a diabetic patient to prevent occurrence of nephropathy is well-established. therefore, leafy greens which contain abundance of electrolytes as sodium, potassium etc. may have a relationship with nephropathy at a high consumption rate, by interfering with the normal functioning of the nephrones in a known case of diabetes mellitus. analysis on salt: percentage of taking added salt with meal or consumption of salty food at a relatively higher rate is recoded as 56% among the given population selected to conduct the study. affect of excess sodium consumption in a diabetic patient and it's relation with subsequent development of nephropathy has 26already been discussed in context of leafy greens . which is also evident from the study. on the other hand, ayurveda has described lavana as visyandi, sristamala, vataghna, paki and x 65gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 27kaphapittakrita. visyandi guna is related to the production of kleda in the srotas along with kaphavriddhi. lavana itself is said to vitiate kapha and pitta dosa. hence, salt intake in an excessive manner can be linked with the involvement of kapha and pitta dosa along with production of kleda in the srotas. analysis on spices: spices comprises of chilli, garlic ginger and onion in the present study. different proportions of spices consumption have been recorded in the study, where chilli accounts for approx. half of the consumption i,e. 65% followed by ginger (53%), onion (42%), garlic (51%), respectively. chilli accounts for the habit of consuming fresh green chilli (capsicum annum) with food in the study. in ayurveda an elaborate description regarding the dosa association, guna and karma of green chilli could not be found. biochemical composition of green chilli shows high pottasium level 28.(95.5mg) which may be nephrotoxic if consumed excessively in context of gradation of onion intake,consumption of raw onion is taken into consideration for the study. onion i.e, palandu is mentioned to vitiate kapha along with pitta dosa in 29charak samhita whereas sushrutha describes palandu as 30katurasatmak, tikshna and guru guna pradhan . hence, involvement of pitta and kapha dosa can be considered. while analysing the nutritive values of onions, found to be low 31sodium and low pottasium in content . hence, can be considered to be wholesome to a patient of diabetic nephropathy. in the present study, the higher % of intake of onion may be due to the food habit of the geographical area. in relation to intake of ginger and garlic, mixed consumption of ginger and garlic together is considered for the study. according to charak, ardrak is vrisya, deepaniya and 32rochak . it helps in alleviation of vata and kapha by the prabhav of it's rasa. similar description could be found in susrut samhita as well. lahsun is considered as snigdha, 33usna,katu and guru . snigdha ,usna and katu guna vitiates 34pitta dosa whereas guru guna vitiates kapha dosa . it is also considered as krimikustha kilasaghna, vataghna and 34gulmanasak . rakta dhatu along with rasa and mamsa can be taken into consideration due to excessive consumption of it 35alone . although, ginger and garlic shows some relation from the present data. but, from a recent study it is known that garlic and ginger attenuates the progression of structural 36nephropathy in experimental animals . so, the relation of garlic ginger mixture with nephropathy could not be established in the present study. hence, the aetiological factors responsible for developing diabetic nephropathy from an ayurvedic perspective that can be considered from the study are sh, meat, salt, leafy greens and spices like chilli and onion. b. discussion on viharaja nidan: among the 11 lifestyle factors taken into consideration for the study, diwaswapna (51%) and chinta (49%) shows some prevalency, but due to their less inuencial occurrence rate as compared with the other dietary factors ,their effect on the disease could not be justied. out of 30 surveyed samples, 51% of the sample gave history of indulging in day sleep and among them most of the samples were having sleep in afternoon just after intake of lunch. the calorie intake/day for those patients is calculated out to be in the range of 45-50 kcal/kgbw/day. as per nkf-kdoqi guidelines and the international society of renal nutrition and metabolism recommend a total energy intake of 30-35 kcal/kgbw/day 37which should be tailored to physical activity level . as the level of physical activity can be considered to be minimal in patients giving history of diwaswapna i.e, excessive day sleep, it can be assumed to be developing nephropathy in a diabetic patient. as per ayurveda, diwaswapna leads to increased snigdhata 38in the body and hence kapahakarak . again, diwaswapna is considered as one of the aetilogical factor responsible for 39medovaha srota dusti . similarly, studies suggest that long term stress can cause long term high blood glucose levels. ayurveda mentions that 40excessive indulgence in chinta, soka etc . psychological stress leads to improper digestion of food and hence to the 41production of ama along with rasavaha srota dusti . conclusion: 1. the possible aetiological factors responsible for developing diabetic nephropathy from the study indicates both aharaja and viharaja nidanas. the aharaja nidanas relating to the disease in the study are found to be excessive consumption(i.e 4 to 5 days in a week) of sh (fresh water shes), meat (commonly consumed in ne region), leafy greens ( commonly available in ne region of india), salt (common salt), spices (chilli). the viharaja nidanas relating to the disease in the study are found to be excessive indulgence in diwaswapna (daysleep) and chinta(stress). these hetus can be considered as viprakrista hetus as per ayurveda in the study. hence, the study indicates , for prevention of diabetic nephropathy, a patient of diabetes mellitus may avoid the excessive intake and indulgence of the above aetiological factors . similarly , for a curative purpose of diabetic nephropathy the above aetiological factors can be taken into consideration from an ayurvedic perspective . references: 1. harrison’s principles of internal medicine,17th edition,vol-ii,published by mcgraw-hill,pg-1791,ch-277 2. sushruta samhita of maharishi sushruta edited with ayurveda tattva sandipika by kaviraj ambikadutta shastri published by chaukambha sankrit sansthana,edition 2012,sutra sthan,chapter 46,verse no.112 3. sushruta samhita of maharishi sushruta edited with ayurveda tattva sandipika by kaviraj ambikadutta shastri published by chaukambha sanskrit sansthana,edition 2012,sutra sthan,chapter 46,verse no.114 4. sushruta samhita of maharishi sushruta edited with ayurveda tattva sandipika by kaviraj ambikadutta shastri published by chaukambha sanskrit sansthana,edition 2012,sutra sthan,chapter 46,verse no.125 5. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,sutra sthan,chapter 27,verse no.82 6. bhavprakash 7. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,viman sthan,chapter 5,verse no.13-15 8. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,sutra sthan,chapter 24,verse no.5-10 9. b.p.mohanty,www.researchgate.net nutritional value of food sh 10. www.ncbi.nlm.nih.govt(dietary approaches in the management of diabetic patients with kidney diseases) 11. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,sutra sthan,chapter 27,verse no.66 12. sushruta samhita of maharishi sushruta edited with ayurveda tattva sandipika by kaviraj ambikadutta shastri published by chaukambha sanskrit sansthana,edition 2012,sutra sthan,chapter 46,verse no.60 13. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,sutra sthan,chapter 27,verse no.57 14. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,sutra sthan,chapter 27,verse no.61 15. sushruta samhita of maharishi sushruta edited with ayurveda tattva sandipika by kaviraj ambikadutta shastri published by chaukambha sanskrit sansthana,edition 2012,sutra sthan,chapter 46,verse no.87 16. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi 66 x gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,sutra sthan,chapter 27,verse no.79 17. sushruta samhita of maharishi sushruta edited with ayurveda tattva sandipika by kaviraj ambikadutta shastri published by chaukambha sanskrit sansthana,edition 2012,sutra sthan,chapter 46,verse no.70 18. sushruta samhita of maharishi sushruta edited with ayurveda tattva sandipika by kaviraj ambikadutta shastri published by chaukambha sanskrit sansthana,edition 2012,sutra sthan,chapter 46,verse no.107 19. www.sciencedirect.com(meat composition and nutritional value) 20. www.ncbi.nlm.nih.gov(lipids ,protein intake and diabetic nephropathy) 21. textbook of pathology by harshmohan ,published by jaypee brothers medical publishers,6th edition,chapter 22,pg 678 22. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,sutra sthan,chapter 27,verse no.103 23. bhavprakash of sribhava misra ,edited with the vidyotini hindi commentary,notes and appendix by sri brahmasankar misra and sri rupanjali vaishya,purvardha,chapter 6,verse no.103 24. sushruta samhita of maharishi sushruta edited with ayurveda tattva sandipika by kaviraj ambikadutta shastri published by chaukambha sanskrit sansthana,edition 2012,sutra sthan,chapter 46,verse no.212 25. chemical composition of common leafy vegetables and functional properties of their leaf protein concentrates(agris.fao.org) 26. ko gj,et al.nutrients.2017,dietatry approaches in the management of diabetic patients with kidney diseases, www.ncbi.nlm.nih.gov 27. dr.brahmananda tripathy,editor. astanga hridaya of vagbhata,sutra sthana,chapter 6,verse 143, chaukhamba sanskrit pratisthan 28. nitesh s.litoriya,jayant talati,nutritional composition of different chilli,www.researchgate.net 29. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,sutra sthan,chapter 27,verse no.175 30. sushruta samhita of maharishi sushruta edited with ayurveda tattva sandipika by kaviraj ambikadutta shastri published by chaukambha sanskrit sansthana,edition 2012,sutra sthan,chapter 46,verse no.246 31. https://en.m.wikipedia.org 32. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,sutra sthan,chapter 27,verse no.166 33. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,sutra sthan,chapter 27,verse no.176 34. bhavprakash of sribhava misra ,edited with the vidyotini hindi commentary,notes and appendix by sri brahmasankar misra and sri rupanjali vaishya,purvardha,chapter 6,verse no.103 35. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,sutra sthan,chapter 24,verse no.5-10,viman sthan,verse no.13-15 36. k h a l e d – a l q a t t a n , m u s l i m a l i , https://doi.org/10.106/j.eclnm.2007.12.001,garlic and ginger attenuate structural nephropathy progression in streptozocin induced diabetic rats. 37. g ko,k kalantar-zadeh.j goldstein-fuches,c rhee-nutrients,2017mdpi.com,www.ncbi.nlm.nih.gov,dietary approaches in the management of diabetic patients with kidney disease. 38. dr.brahmananda tripathy,editor. astanga hridaya of vagbhata,sutra sthana,chapter 7,verse 55, chaukhamba sanskrit pratisthan 39. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,viman sthan,chapter 5,verse no.16 40. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,viman sthan,chapter 2,verse no.9 41. charak samhita of agnivesha revised by charaka and dridhabal with the ayurvedic deepika commentary of chakrapani dutta and with vidyotini hindi commentary by kashinath sastri edited by ganga sahaya pandeya,edition 2015,viman sthan,chapter 5,verse no.13 x 67gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction urinary stones seem very common disease burden in the world with the incidence of 10% in developed world and this number even approaching 37% in certain places, with geographical condition, ethnicity, diet, and genetic factor play an important role for urinary stone disease. urinary stones usually can be detected with x-ray because of the common calcium composition in most of urinary stone, with non-contrast ct-scan (ncct) being the gold standard 1 diagnostic procedure for detecting urinary stones. because of calcium composition in most of urinary stone, chua et al. were trying to evaluate the stone radiopacity character as hounseld unit (hu) using ncct. they assumed stone > 4 mm have 498.5 hu as the threshold to describe an urinary stone as radiopaque or radiolucent with 89.3% sensitivity and 2 87.3% specicity. huang et al. described that stone with density > 800 hu can be visualized clearly at x-ray, on the other hand, urinary stones with < 200 hu cannot be seen in x3 ray. spettel et al also use hu for predicting uric acid stone. they utilize hu and urinary ph as predictor whether urinary stone composed by uric acid. they concluded urinary stone that has> 4 mm size, < 500 hu and < 5.5 ph have 90% positive predictive value for having uric acid component as its 4forming substance. this study aims to describe relationship between hu with urinary stone analysis outcome in kidney stone patients. we also try to assess the possibility of hu as urinary stone composition predictors. material and methods a retrospective cross-sectional study was conducted in universitas sumatra utara hospital from march to august 2018. we enrolled 30 patients with kidney stones that have been examined with ncct. demographic data from each patients were collected and summarized. all ncct scans were interpreted by the same urologist. bone window settings were used in visualizing the stones. the longest diameter of the stone was measured in milimeters to describe the stone size. then the stones' hu was calculated automatically from the acquired images. the patients then had operative treatment for their urolithiasis. post-operative extracted stone than had stone composition analysis characterization done in laboratory setting as the gold standard. while urinary ph was not collected in our study. statistical analysis was done by spss 23.0 (ibm corp. released 2015. ibm spss statistics for windows, version 23.0. armonk, ny: ibm corp.). receiver operating characteristics (roc) curve was constructed with 500 hu value as the cut off value. finally, the sensitivity, specicity, positive predictive value and negative predictive value of the ncct with 500 hu cut-off level were used as a diagnostic tool to predict stones composition. all data analyses were conducted at the 0.05 level of signicance and 95% condence interval. result from march to august 2018, there were 30 patients with urolithiasis that diagnosed both by ncct and kub (kidney ureter bladder) x-ray. all of these patients undergone urinary stone extraction either by open lithotomies procedures or by endoscopic (percutaneous nephrolithotomy or pcnl). all the extracted stone than analyzed for its composition in laboratory. the mean age of patients was 51.0 + 10.4 years, with 15 patients were male (50%) and 15 others were female (50%). stone extraction was done with open procedures in eight patients (26.7%) and pcnl in 22 patients (73.3%). the median value of hu level was 661 (range 200-1499). table 1. characteristics of study subjects in our study, 16 stones (53.3%) were composed predominantly relationship between abdominal non-contrast ct scan hounsfield unit value with stone composition analysis in kidney stone patients original research paper dhirajaya dharma kadar* division of urology department of general surgery, faculty of medicine, university of sumatera utara hospital, medan, indonesia. *correponding author x 45gjra global journal for research analysis general surgery introduction: hounseld unit (hu) is used to indicate the radiodensity of urinary stones. our study aims to describe the relationship between hu with urinary stone. material methods: a retrospective cross-sectional study was conducted with thirty patients with kidney stones that have examined with ncct. results: the mean age of patients was 51.0 + 10.4 years, with 15 patients were male (50%), and 15 others were female (50%). the median value of hu level was 661 (range 200-1499). thirty patients in our study, 16 stones (53.3%) were composed calcium, while 14 others (46.7%), were composed mostly of uric acid. roc analysis that hu criteria to predict stone composition have sensitivity 71,4% specicity 87,5% ppv 83.33% and npv 77.78%. conclusion: the threshold of 500 hu on the ct scan determined as the optimal cut-off point in deciding whether a urinary stone composition is predominantly calcium stone or uric acid stone. abstract keywords : hounseld unit, ncct, calcium stone, uric acid stone volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra ginanda putra siregar division of urology department of general surgery, faculty of medicine, university of sumatera utara hospital, medan, indonesia. variables n (%) mean + sd, median (min-max) no. of patients 30 age (years) 51.0 + 10.4 gender male 15 (50%) female 15 (50%) stone extraction procedures open procedures 8 (26.7%) pcnl 22 (73.3%) houndseld unit 661 (200-1499) 46 x gjra global journal for research analysis by calcium, three stones composed of pure calcium oxalate monohydrate, 12 stones of mixed-predominantly calcium oxalate monohydrate, and one calcium phosphate stones. on the other hand, 14 others stone that analyzed in this study (46.7%), were composed predominantly by uric acid, with 7 stones were pure uric acid and 7 stones were mixedpredominantly uric acid. table 2. composition of extracted renal stones from receiver operating characteristics curve we concluded that hu criteria alone to predict stone composition either calcium dominant or uric acid dominant gave sensitivity and specicity of 71,4% and 87,5% respectively. hu also gave ppv of 83.33% and npv of 77.78%. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra stone composition mean age (y) mal n (%) median (minpredominantly uric acid 55.6 57.1 14 (46.7) 440.7 (200-699) pure uric acid 7 (23.3) mixed-predominantly uric acid 7 (23.3) predominantly calcium 46.2 43.8 16 (53.3) 941.6 (460-1499) pure calcium oxalate monohydrate 3 (10) mixed-predominantly calcium oxalate monohydrate 12 (40) pure calcium oxalate dehydrate 0 mixed calcium oxalate dehydrate 0 calcium phosphate 1 (3.3) hounseld unit cut auc threshold sensitivity specicity ppv npv hu 0.931 < 500 71,4% 87,5% 83,33% 77,78% table 3. receiver operating characteristics analysis figure 1. area under the curve table 4. result variable(s): hu the test result variable(s): hu has at least one tie between the positive actual state group and the negative actual state group. statistics may be biased. a. under the nonparametric assumption b. null hypothesis: true area = 0.5 discussion demographic data from our study are comparable to the global picture of kidney stone prevalence and incidence, with a peak incidence of urinary stone is occur in 50-60 years of age. the 1: 1 male-female ratio described in our study differs 5from other asia-based study conducted by shirazi et al. and 6michaels et al. , with a ratio of male and female was 1.98:1 and 1.8:1 respectively. this gender difference can be attributed to the protective effect of estrogen on stone formation in premenopausal women under the age of 45 years. estrogen will improve kidney calcium absorption and it also will reduce bone resorption. this metabolic mechanism will cause a 6,7reduction of calcium that excreted into the urine. the mean subjects age in our study was comparably higher compared with the average age of other comparative studies. our results show that the median attenuation rate of nccts radiolucent stone is 661 (200-1499) hu, whereas the median attenuation rate for radio-opaque stones is 941.6 (460-1499) 3hu. this nding is like the study conducted by huang et al. which also described the rate of attenuation of ct hu and its predictive value on whether a radio-opaque calculus (calcium predominant stone) or radiolucent (predominant stone of gout). they do a multivariate analysis of 84 ureteric stone detected by ncct and found that hu level, and not stone size, was the most signicant factors to predict whether urinary stone would be seen on kub. they concluded that all urinary tract stones with a density of > 800 hu could be seen in the kub, while 17 (74%) of 23 stones with a density of < 200 hu 8could not see in the kub. correlation of ct attenuation rates with stone composition has been widely studied in some of the latest literature. a 9study by patel et al. explained that stone that has hu level in the range of 879 ± 230 consisted mainly of calcium oxalate monohydrate, while stone with lower hu level (338 ± 145) 8usually consisted of uric acid stones. another study by demirel et al. describes a similar range of hu for calcium 10oxalate stones (812 ± 135) and uric acid stones (413 ± 143) . our study ndings along with these two other studies described previously, support the idea radio-opaque stones tend to have a higher calcium oxalate composition and radiolucent stones tend to composed by uric acid. cut-off value of hu which is determined with optimal sensitivity and specicity in predicting stone radio-lucency or radio-opacity expected to change the clinical management of urinary stone, which expected to decreased demand for kub examination after ncct, thus will prevent patients from unnecessary radiation exposure. the cut-off roc value of 500 hu which was used in our study had proven to have good predictability. chua et al, concluded that roc curve would produce the best cut value at 498.5 hu for identifying urinary tract stones. urinary tract stones that had hu level below this threshold were more likely to be radiolucent with a sensitivity of 71.4% and specicity 87.5%. on the other hand, urinary stones with hu above this threshold value is to predict to be radio-opaque stones with a sensitivity of 289.3% and specicity of 87.3%. signicant statistical differences were noted (p < 0.001) on the sensitivity and specicity of hu value with a 500 cut-off. besides used to predict the composition of urinary stone, hu value was examined further by other studies, with stone size 10categorization either above 4 mm or below 4 mm, to further determine the success rate of several urinary stones treatment 11modalities such as urs ; extracorporeal shock wave 12lithotripsy (eswl) ; and pcnl. we suggest of further study examining the utility of hu values, not only for predicting area std. aerror asymptotic bsig. asymptotic 95% condence interval lower bound upper bound .931 .045 .000 .843 .000 x 47gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra urinary stone composition but also for predicting success rate and complication rate of urinary stone treatment with a bigger study subject. conclusion based on the roc curve, the threshold of 500 hu on the ct scan is determined as the optimal cutoff point in determining whether a urinary stone composition is predominantly calcium stone or uric acid stone. hu below 500 is suitable to be used to predict uric acid stones, and hu value above 500 was used to identied calcium stone with an overall sensitivity of 71.4%, specicity 87.5%, positive predictive value 83.3% and negative predictive value 77.8 %. stone size but not stone location is the variable that affects sensitivity and specicity hu value. references 1. curhan g, goldfarb d, trinchier a. 2008. epidemiology of stone disease. in: denstedt jd, khoury s (eds) stone disease.health publications, paris, pp 9–20 2. chua m.e, gatchalian g.t, corsino m.v, reyes b.b. 2012. diagnostic utility of attenuation measurement (hounseld units) in computed tomography stonogram in predicting the radioopacity of urinary calculi in plain abdominal radiographs. int urol nephrol 2012; 44: 1349-55 3. huang c.c, chuang c.k, wong y.c, wang l.j, wu c.h. 2009. useful prediction of ureteral calculi visibility on abdominal radiographs based on calculi characteristics on unenhanced helical ct and ct scout radiographs. int j clin pract 2009; 63: 292-8 4. spettel s, shah p, sekhar k, herr a, white md. 2013. using hounseld unit measurement and urine parameters to predict uric acid stones. urology 2013; 82: 22-6 5. shirazi f, shahpourian f, khachian a, hosseini f, rad a, heidari s, sanjari m (2009) personal characteristics and urinary stones. hong kong j nephrol 11(1):14–19 6. michaels ek, nakagawa y, miura n et al (2004) racial variation in gender frequency of calcium urolithiasis. j urol 152:2228–2231 7. nordin be, need ag, morris ha, horowitz m (2009) biochemical variables in preand postmenopausal women: reconciling the calcium and estrogen hypotheses. osteoporos int 9:351–357 8. mckane wr, khosla s, burritt mf (2015) mechanism of renal calcium conservation with estrogen replacement therapy in women in early postmenopause—a clinical research center study. j clin endocrinol metab 80: 3458–3464 9. patel sr, haleblian g, zabbo a, pareek g (2009) hounseld units on computed tomography predict calcium stone subtype composition. urol int 83(2):175–180 10. demirel a, suma s (2013) the efcacy of non-contrast helical computed tomography in the prediction of urinary stone composition in vivo. j int med res 31(1):1–5 11. kim jw, chae jy, kim jw, oh mm, park hs, moon du g, yoon cy. computed tomography-based novel prediction model for the stone-free rate of ureteroscopic lithotripsy. urolithiasis 2014; 42: 75-79 [pmid: 24162952 doi: 10.1007/ s00240-013-0609-0] 12. hameed da, elgammal ma, elganainy eo, hageb a, mohammed k, el-taher am, mostafa mm, ahmed ai. comparing non contrast computerized tomography criteria versus dual x-ray absorptiometry as predictors of radioopaque upper urinary tract stone fragmentation after electromagnetic shockwave lithotripsy. urolithiasis 2013; 41: 511-515. introduction:to understand the ecology of any wild animal, several environmental components need to be considered such as avaibility of food, water, den or nesting site to survive in any habitat (nikunj gajera et al., 2009). scats provide an essential sample of carnivore diets, but where several comparable size carnivores co-occur, unfailing identication of the proper donor species required (laura e. farrell et al., 2000). the scat analysis remains the crucial tool used to assess carnivore diets, particularly when focusing on individual prey items (unn klare et al., 2011). prey availability and distribution can persuade prey selection and hunting success (fuller et al., 1992), with activity patterns and spatial distribution (henschel & skinner, 1990). there are a number of different methods for the scat analysis. one of the nest methods used for scat analysis is through hair identication of various preys. mammal hair plays a signicant role in many aspects such as thermoregulation, body shape maintenance, waterproong and protection from pollution. there are generally two types of mammal hairs: guard hairs that are generally thick and bristly and ne hairs that are curled and thin (eunok lee et al., 2014). in particular, the study of predator feeding habits from the analysis of prey hairs found in scats has been widely used for describing the diet of mammalian carnivores, because this technique is non-destructive and scats are easy to collect throughout the year (anna maria de marinis and alessandro asprea, 2006). the scat analysis done by separating the (undigested) food items present in it such as hairs, feathers, seeds, bone pieces, claw, nail & hoof pieces, plant material etc. precise knowledge of a carnivore's diet is crucial to assess the species' role in the ecosystem, potential competition with other carnivores and impact on prey populations. results of diet analyses therefore might have extensive impact on the development of carnivore management plans, especially if economically important or endangered species are involved. but direct observations of feeding behaviour are often impossible under eld conditions. this scat analysis techniques are noninvasive and effective method in which the hair identication of various prey species carried out by considering and comparing their morphometric features under microscope. study area:fig. a: map of the ® image of coastal forest-rajula the coastal forest of rajula situated in the amreli district of the gujarat state, india. it is located in the eastern part of the gir protected area and occupies the vast areas of the coastal habitats. it comprises around 120 km² within the rajula tehsil of amreli district. it lie between the parallels of latitude north 21° and meridians of longitude east 71°. it comprises around seventy two villages. the whole study area further divided into ve different categories namely (1) shrub forest (2) saline pan (3) mixed forest (4) industrial areas (5) rural & agriculture land. there are very small patch of reserve forest found, and thus majority areas are revenue. the area mainly comprises the scattered shrubs with different elevation and habitat ranges. it consist coastal areas of arabian sea with salty pan at several sites. the area is at but little undulating at some villages. it occupies gauchar lands, agro-pastoral lands, industrial zones and forest areas. the agariya are one of the scheduled tribes of india. agariyas also reside around, chanch bander, pipavav and devaka. there are three seasons namely winter from november to february, summer from march to june and monsoon from july to october. the maximum temperature in summer ranges 30 37°c whereas minimum temperature around 20-25°c found. the annual rainfall ranges around 350 mm. due to coastal land the temperature ranges intermediate in all around year neither too cool nor hot. feeding ecology of asiatic lion (panthera leo persica) in the coastal forest of rajula, guajrat state of india. original research paper dr. vibhuti b. raval saurashtra university, rajkot 360005 gujarat, india x 93gjra global journal for research analysis ecology the food habits of animals determine a number of life history strategies such as habitat selection, movement and success of reproduction. to study the feeding ecology of asiatic lion the widely used technique is the scat analysis. scat analysis was done by identication and comparison of hairs of various prey species available within the selected study area. asiatic lion mainly depredated on livestock due to easy catch and availability. seasonal diet composition revealed that asiatic lion preferred livestock mainly during summer season and wild prey in winter season. the habitat preferences revealed that the asiatic lion often used open or scattered shrub-land area which increases the prey visibility. abstract keywords : depredated, livestock, scat, feeding ecology etc. dr. bhupat b. radadia * shri m. & n. virani science college (biology department), saurashtra university, rajkot 360005, gujarat, india *corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 94 x gjra global journal for research analysis methods: asiatic lion scats were collected regularly along roads and forest tracks. lion scats were clearly distinguishable from leopard scats based on their much larger size. however, carnivore signs associated with scats were too recorded from the site of collection. all scats were stored in polythene bags with proper code and later washed using a sieve to separate undigested prey remains such as hair, bone fragments, hooves, feathers, quills and claws etc. all residues were ovendried for further examination. for a reliable estimate of lion's diet, standard prescribed protocols – examination of a minimum of at least 20 prey hairs per scat and minimum 30 scats – were adopted (mukherjee, goyal & chellam, 1994). carnivore scats were collected in and around coastal forest of rajula along with several details such as, recording location with gps, date of collection. total 36 scats collected from the coastal forest – rajula, all over nineteen months of extensive eld study in all three seasons. all scats were systematically analyzed to assess the diet composition of the lions. microscopic slides of at random picked hair from a sample were rst washed in running water several times to get rid of dirt and then preserved in acetone for overnight. after that randomly picked thirty hairs/scat samples taken up for microscopic examination. then the hairs were xed in gelatin layered microscopic slide for obtaining casts of surface structure of hairs. then the slide was observed under light microscope or fluorescence light microscope with inbuilt measurement software and attached camera for capturing images in better scale. photographs of surface structures were taken at rst in 10 x magnications and then in 40x magnication. other characteristics such as cuticular structure, medullary conguration, scale pattern and cross-sectional details were studied after (brunner & coman, 1974). trichological features of the hair were thoroughly studied by using advance microscopic techniques. preys were identied by comparing medullary & cuticular characteristics of prey hair with known standard reference hair (karanth & sunquist, 1995, vibhuti et al., 2018). result and discussion:fig.1 food composition of asiatic lion in scat study of coastal forest-rajula in coastal forest 36 scats analyzed and out of which, 6 scats comprised single prey species evidences. on other hand 10 scats comprised two different prey species evidences, while remaining 20 scats contained more than two different prey species evidences. totally seven wild prey species and ve domesticated species identied from the scat analysis in the study area (fig. 1). fig.2 seasonal variation in food composition by asiatic lion in coastal forest-rajula on the basis of availability of different prey species along with its population within the study area and the scat analysis in coastal forest-rajula revealed that the cattle consumption contributed maximally almost 53%, followed by bluebull (34%), followed by wild boar (7%), and followed by goat (5%). on other hand blackbuck consumed less comparatively (1%) by lions (fig. 2) in the areas. dharaiya in the year 1998, reported that the coastal lion depends mainly on livestock (67.23%) and 33% depends on the wild prey comparatively. fig. 3 frequency of occurrences of prey species & diet composition of asiatic lion from scat analysis in coastal forest –rajula the seasonal variation in food composition by asiatic lion in and around coastal forest-rajula revealed that the livestock consumed the most throughout the year almost 57.22% and higher in summer (85%), followed by monsoon (60%), and followed by very less in winter (53.3%). whereas wild prey consumption found around 42% throughout year and increased in winter (47%), followed by monsoon (30%) and decreased in summer (10%) comparatively (fig. 3). the seasonal food consumption by lions in both the study area found similar. earlier study by dharaiya revealed that the maximum wild prey consumed in winter season (31.75%) while livestock consumption increased in summer season (69.01%) inside coastal forest area. fig. 4 habitat use by asiatic lions in coastal forest-rajula on the basis of direct and indirect evidence. the habitat use pattern by asiatic lion in coastal forest rajula, on the basis of direct and indirect evidences found in the study area revealed that the lion frequently use and preferred the scattered shrub land areas (35), followed by mixed forest area as well as industrial areas visited occasionally by lions (6), followed by rural/ revenue area (5). the area of salty pan preferred very rarely by lions (04). the direct sighting found maximally in shrub land and rural areas as well (3) followed by industrial areas and salty pan (2). simultaneously direct sighting in mixed forest areas occurred once. total 11 events occurred for direct sighting in gwls. although the kill data, vocalization and fresh pugmark trails found only in only some occasion (fig. 4). conclusion:in the study area it was found that lions mainly chosen the livestock as it's found easily available throughout year and also easy to catch. whereas, seasonal food composition study revealed that the livestock depredated most in summer season as it lead to human dominated areas which provide volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra continuous source of water as well as food. on other hand wild prey base preferred more during winter season because during this season leaf fall occurs which increases the visibility of prey in the study areas. the dependency on livestock by lions was also found to increase in recent years in coastal forest area compare to previous studies carried out by n. dharaiya. so, it was concluded that the lions inhabiting outside the gir protected areas found more dependable on livestock, one possible reason was less wild prey populations in that satellitic areas and more availability of easy prey base of livestock. the lions preferred the large sized prey base like domesticated cow and bluebull more compare to other prey base as livestock readily available in revenue areas of villages (bagchi et al., 2003) and bluebull also preferred the open habitat mostly the agriculture eld (d. mehta and v. c. soni., 2014). references:1. bagchi, s.p., goyal, p. & sankar, k. (2003) prey abundance and prey selection by tigers (panthera tigris) in a semi-arid, dry deciduous forest in western india. j. zool. (lond.) 260, pages 285–290. 2. brunner & coman (1974) a key for the identication of guard hairs of some ontario mammals, canadian journal of zoology, volume 71(3), pages 587591. 3. chellam, ravi (1993) ecology of the asiatic lion (panthera leo persica), ph.d. thesis, saurashtra university, rajkot. pages170. 4. dharaiya, n. & soni, v.c., (2000) study on the satellitic population of lion around gir pa, final project report submitted to department of forest, wildlife division, sasan gir. 5. dhawal mehta and v. c. soni (2014). study on the ecology of nilgai (boselaphus tragocamelus) in saurashtra, ph.d. thesis, saurashtra university, rajkot. 6. eunok lee, tae-young choi, donggul woo, mi-sook min, shoei sugita and hang lee (2014) species identication key of korean mammal hair, journal of veterinary, medical science, vollume 76, issue 5, pages 667-675. 7. fuller, t.k., kat, p.w., bulger, j. b., maddock, a.h., ginsberg, j.r., burrows, r., mcnutt, j.w. & mills, m.g.l. (1992) population dynamics of african wild dogs in: wildlife 2001: populations (eds d. r. mccullough and h. barrett). elsevier science publishers, london 8. henschel, j.r. & skinner, j.d. (1990) the diet of the spotted hyaena (crocuta crocuta) in kruger national park, afr. j. ecol. 28, pages 69–82 9. joslin, p. (1973) the asiatic lion – a study of the ecology and behaviour, ph. d. thesis, university of edinburgh. pages 249 10. karanth, k. u., sunquist, m. e. (1995) prey selection by tiger, leopard and dhole in tropical forests. – journal of animal ecology 64, pages 439-450. 11. laura e. farrell, joseph romanand melvin e. sunquist (2000) dietary separation of sympatric carnivores identied by molecular analysis of scats, molecular ecology, pages 1583–1590 12. mukherjee. s., goyal s. p. and chellam, r. (1994) rened techniques for the analysis of asiatic lion scats, acta theriologica, volume 39(4), pages 425-430 13. nikunj gajera, s. m. dave, and nishith dharaiya (2009) feeding patterns and den ecology of striped hyena (haeyena haeyena) in north gujarat, india, tiger paper, volume 36, issue 1, pages 13-17 14. vibhuti b. raval, bhupat b. radadiya, arun kumar roy mahato and a. p. singh (2018) tricho-taxonomic study of guard hairs of three species of bovidae of saurashtra region of gujarat, india, international journal of zoology and applied biosciences, volume 3, issue 3, pages 393-398. 15. unn klare, jan f. kamler, david w. macdonald (2011) a comparison and critique of different scat-analysis methods for determining carnivore diet, mammal review. 2011, volume 41, no. 4, pages 294–312. 16. anna maria de marinis and alessandro asprea, (2006) hair identication key of wild and domestic ungulates from southern europe, wildlife biology, volume 12, issue 3, pages 305-320. x 95gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: amoebic liver abscess is the most common extra-intestinal manifestation of entamoeba histolytica infestation and it is associated with signicant morbidity and mortality. the common complications of liver abscess include rupture into peritoneal cavity and pleural cavity, rarely vascular complications are seen in liver abscess in the form of thrombosis or compression resulting in either hepatic venous outow obstruction or inferior vena cava obstruction. i am presenting a case of liver abscess where patient present with signs of ivc thrombosis and radiological conrmation of the ivc obstruction by thrombosis and /or external compression. case report: a 30 year old male patient presented at civil hospital thahmedabad in emergency surgical department on 13 october 2018 with chief complain of pain in epigastric region and fever from 6 days and loose stool for 2 days. vitals were pulse-86/m, blood pressure-130/86 mmhg. on physical examination abdomen mildly distended and mild epigastric tenderness present. in blood investigations ;hb-12 gm/dl,wbc-37000,plt-91000, inr-1.52, s.bilirubin-total5.98,direct bilirubin-1.52, s.creatinine-4.78. chest xray within normal limit,abdominal xray within normal limit.usg (abdomen+pelvis)-liver appears enlarged in size and bright in echotextureand shows 144 cc sized partially liqueed abscess in right lobe. on day of admission usg guided aspiration was done ,approximately 30cc encovy sauce pus aspirated, post tapping chest xray-normal .after 2 days of admission patient developed abdominal distention and bilateral pedal edema . ryeles tube inserted and catheterization done, and further evaluation done. chest xray showing bilateral cp angle blunted s/o-minimal pleural effusion. expert usg done-s/o280 cc solidied liver abscess and supra hepatic ivc thrombosis. cvts reference done ,they advised conservative management with short acting heparin for 10 days and overlapped with tab warfarin on day 8. while starting heparin inr was 1.6 and after starting tab warfarin inr was 2.10 . expert medicine reference done, they adviced ct pulmonary angiography+abdomen and pelvis. ct s/o-liver abscess extending in hepatic ivc causing thrombosis in hepatic ivc and right atrium. no evident pulmonary thrombo embolism. 2decho was normal. patient shifted in icu and kept on bipap mode for 2 days then shift to o2 mask .pedal edema and abdominal distension reduced on day 8 of giving short acting heparin. follow up usg(a+p) done s/o-approx. 120cc sized predominantly solidied abscess is noted in right lobe of liver. wall of ivc appears thickened and shows normal color ow within p/orecanalization of ivc thrombosis. patient started orally and shift to ward. patient was discharged in stable condition after 25 days with tab warfarin (5 mg) for 6 month according to inr report with proper advice to see for gum bleeding, bleeding per rectum .follow up after 15 days patient was alright and inr was 2.3 .then patient follow up every month and fol low up usg(abdomen+pelvis) s/o recanalisation in ivc thrombosis. figure 1:showing ivc thrombosis figure 2:showing recanalization ct plates showing ivc thrombosis discussion though amoebic and pyogenic liver abscesses are commonly encountered in india , ivc thrombosis secondary to liver abscess is quite rare . as ivc thrombosis are life threatening ,it requires high clinical suspicion followed by cect in appropriate clinical setting. rupture of the abscess into a vascular ivc ,predisposed to localized luminal thrombosis which may act as a source of pulmonary emboli and septicemia.vascular complications in liver abscess should be considered in patients with fever,tender liver or signs of portal hypertension,more so in patients with diabetes.cect is an excellent method for diagnosing liver abscess as well as its complications ultra sonography may also be helpful in detection and characterization of venous extenson ,especially a case report on liver abscess causing inferior vena cava thrombosis original research paper dr. nina m. shah associate professor & hou, department of general surgery, b.j.medical college, civil hospital, ahmedabad. general surgery keywords : dr. manish chaudhari* rd3 year resident, department of general surgery, b.j.medical college, civil hospital, ahmedabad. *corresponding author dr. priyanka warde st1 year resident, department of general surgery, b.j.medical college, civil hospital, ahmedabad. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. hiral c. chauhan assistant professor, department of general surgery, b.j.medical college, civil hospital, ahmedabad. 62 x gjra global journal for research analysis for follow up. echocardiography is useful in assessment in cases of intracardiac extension.treatment includes conservative management with antibiotics, aspiration, anticoagulant.venography is important when transluminal interventional treatment such as lter insertion or venoplasty is considered. conclusion: whenever a liver abscess is seen adjacent to a vascular channel or in the caudate lobe,it is imperative for the radiologist to look for vascular complications,as venous involvement may not be very symptomatic in some cases.treatment of the abscess improves the recanalization of thrombosed vessels with anticoagulants. if abscess is drained then it improves the recanalization of thrombosed vessels even without anticoagulation. references 1. lee kw, kim hy, kim cw, kim yk, kwon o, kim ma et al. hepatogastric stula as a rare complication of pyogenic liver abscess. clin mol hepatol 2017; 23(1): 87-90. 2. lal h, thakral a, sharma ml, kumar t. liver abscesses with venous extensionrare complication of a common problem. turk j gastroenterol 2014; 25 (suppl 1): 223-8. 3. sarda ak, mittal r, basra bk, mishra a, talwar n. three cases of amoebic liver abscess causing inferior vena cava obstruction, with a review of the literature. korean j hepatol 2011; 17(1): 71-5. 4. sodhi ks, ojili v, sakhuja v, khandelwal n. hepatic and inferior vena caval thrombosis: vascular complication of amebic liver abscess. j emerg med 2008; 34(2):155-157. 5. syed ma, kim tk, jang hj. portal and hepatic vein thrombosis in liver abscess: ct ndings. eur j radiol 2007; 61(3): 513-9. 6. mafolo c, novellas s, chevallier p, brunner p, mourou my, bruneton jn. thrombophlebitis of the hepatic veins: complication of a klebsiella liver abscess. clin imaging 2006; 30(1): 63-5. 7. wi jw, cho ea, jun ch, et al. clinical characteristics and outcomes of pyogenic liver abscess in elderly korean patients. korean j gastroenterol 2015; 66(1): 27-32. 8. bagri n, yadav d, hemal a. inferior vena caval and right atrial thrombosis: complicating pyogenic liver abscess. indian pediatr 2013; 50(7): 701-3 9. nayak hk, kumar k, saraswat va, pandey g, mohindra s, singh a. an unusual complication of pyogenic liver abscess. j clin exp hepatol 2016; 6(4): 337-38. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 63gjra global journal for research analysis introduction normal mental health is a state where mental health condition is productive and good relationship with others, and sufcient effort to overcome difculty (knopf d, 2008). in children, this denition include variety emotional and behaviour problem in which doesn't correlate with mental health disorder or psychiatry (warner la, 2010) from the survey of national health policy showed us that the mental health and emotional ratio in children, ages were 4-15 years old, was 104 / 1000 children in 2001-2005. in a prevalence study in jakarta in 2003, the prevalence of emotional and behaviour problem in primary school students were 27% by using child behavior checklist instrument. boys prevalence was greater than girls (30.5% vs 22.6%) (widya w, 2008) the prevalence of mental health disorder patients in indonesia was 11,6% according to riskesdas 2007. these patients reached 1.7 million people in 2013 in indonesia (riskesdas, 2007; riskesdas 2013) a study in jakarta stated that the mental health disorder prevalence in junior high school in central jakarta by using mini for kids instrument was 26.5%. the mental health disorder was mostly found in girls rather than boys (widya w, 2008) nail biting in children and teenager is commonly referred to mental health clinic. nail biting often happens in children and undertreated. the incidence is higher in 4 to 6 years old children compared to younger children. the incidence increases in teenager and decreases in adult. nail biting is not inuenced by sex in children less than 10 years old. but the male teenagers often have this habit (ghanizadeh a, 2011) nail biting can cause complications such as front dental malocclusion, dental root resorption, intestinal parasite infection, bacterial infection, and alveolar destruction. a study in iran by ahmad ghanizadeh, et al, in 2011, showed that prosocial, emotional, and conduct score in strength and difculty questionarre (sdq) are statistically different between the nail bitng children compared to non nail biing children. prosocial score inchildren with nail biting is lower than the others. emotional score and conduct score are higher in nail biting children. from that result, it is suggested that mental health disorder is more common in nail biting children. but a study in poland in 2014 didn't show any correlation between nail biting and obsessive-compulsive disorder or anxiety disorder (przemyslaw p, 2014) material and methods this was an observasional cross-sectional study in singkuang, muara batang gadis district, north sumatera, indonesia. it was conducted in march 2016. the target population was students of primary, junior high school, and senior high school who had nail biting habit. psychiatric patients, children with previours nail biting, skin infection before were excluded from this study. the subjects were required to ll in sdq and nail biting questionarre. this study had been approved by universitas sumatera utara ethic committee. all subjects were required their parents' consent. subjects' age 11-17 years old could ll in the sdq and nail biting questionarre by themselves. as the others by their parents. then the scores of sdq were evaluated by the researcher. the score consisted of emotional, conduit, hyperactivity, peers, and prosocial problems. all of the data were evaluated, analyzed by chi-square, multivariate analysis by logistic regression where p < 0.05 was statistically signicant in 95% condence interval. the data was analyzed by spss software (version 22). nail biting was dened as an act of inserting nger into the mouth or a contact between nails and mouth. strength and difculties questionnaire was a questionnare that should be relationship between mental health disorder and nail biting in children original research paper willy winata department of child health, faculty of medicine, universitas sumatera utara, indonesia x 119gjra global journal for research analysis clinical research background: it is imperative to acknowledge mental health disorder in order to improve human resources, especially children and teenages because they are nation's next human resources. nail biting is suspected as a sign and symptom that someone has mental health disorder or suffers certain psychiatric condition. objective: the aim of this study is to evaluate the relationship between mental health disorder and nail biting in children. methods: a cross-sectional study was conducted in march 2016 in singkuang village, muara batang gadis district, north sumatera, indonesia. the samples were elementary, junior high school, senior high school students. all samples were required to ll in two questionarres, those are nail biting and strength and difculty questionarre. univariate, bivariate (chi-square), and multivariate analysis by logistic linear regression was performed with condence interval 95%. p<0.05 was statistically signicant. result: there were 583 samples and 140 (23.6%) among themselves had nail biting habit. there were relationship between emotional problem (p = 0.004; pr = 1.803) and peers problem (p = 0.021; pr 1.639) to nail biting habit. the nail biting risk factors in this study were nail biting family history (pr = 4.575; 95% ci 2.451-8.539) and emotional mental disorder (pr = 1.741; 95% ci 1.062-2.855). conclusions: there were relationship between emotional disorder and peers problem to nail biting habit. we found nail biting family history and emotional disorder as the risk factors of nail biting in this study. abstract keywords : mental health disorder, nail biting, children, risk factors munar lubis* department of child health, faculty of medicine, universitas sumatera utara, indonesia*corresponding author elmeida effendy department of child health, faculty of medicine, universitas sumatera utara, indonesia volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 120 x gjra global journal for research analysis lled in 5 minutes by parents or by respondents. it consisted of 25 questions. it included 5 sub-scale such as emotional, conduct, hyperactivity, peer, and prosocial problem. the scores were interpreted as normal, borderline, and abnormal. in this study, the borderline scores were interpreted as abnormal. results there were 606 students in this population and 593 samples met the inclusion criteria. there were 140 students had nail biting habit. there were 48,6% male students who had nail biting habit while 51,4% female students who had nail biting habit. table 1. samples characteristics the sdq evaluation showed the majority was normal results. the amount of abnormal scores was 28.8% in emotional problem, 24.1% in peer problems, 23.4% in conduct problems, and 8.8% in hyperactivity problems. table 3. characteristics of sdq evaluation bivariate analysis by using chi square showed that there were a statistically signicant relation between emotional problem and nail biting (p = 0.004), between peer problem and nail biting (p = 0.021). volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra characteristics n=593 age average, years (sd) 12,28 (3,142) sex, n (%) male female 253 (42,7) 340 (57,3) school grade, n (%) primary school junior high school senior high school nail biting habit, n (%) yes no 305 (51,4) 184 (31) 104 (17,5) 140 (23,6) 453 (76,4) nutritional status, n (%) well nourish mild malnutrition severe malnutrition overweight obesity 297 (50,1) 155 (26,1) 24 (4) 73 (12,3) 44 (7,4) family income, n (%) < 500,000 idr 500,000 to 1,000,000 idr >1,000,000 idr parents education, n (%) primary school junior high school senior high school college none 57 (9,6) 305 (51,4) 231 (39) 401 (67,6) 106 (17,9) 64 (10,8) 11 (1,9) 11 (1,9) frequency of nail biting n=140 frequency of nail biting / day, n (%) frequent (5-6 times / day) rarely (1-4 times / day) frequency of nail biting / week, n (%) 30 (21,4) 110 (78,6) frequent (4 days in 1 week) rarely (1-3 days in 1 week) 34 (24,3) 106 (75,7) sdq charcteristics n=593 emotional problem, n (%) normal abnormal conduct problem, n (%) normal abnormal 422 (71,2) 171 (28,8) 454 (76,6) 139 (23,4) hyperactivity problem, n (%) normal abnormal peer problem, n (%) normal abnormal prosocial problem, n (%) normal abnormal 541 (91,2) 52 (8,8) 450 (75,9) 143 (24,1) 511 (86,2) 82 (13,8) total scores, n (%) normal abnormal 394 (66,4) 199 (33,6) table 2. the frequency of nail-biting habit. table 4. relationship between mental health problem parameter and nail biting. nail biting p* prevalence ratio 95% condence interval yes no emotional problem abnormal (%) 38.6 25.8 0.004 1.803 1.209 – 2.69 normal (%) 61.4 74.2 conduct problem abnormal (%) 29.3 21.6 0.062 1.5 0.979 – 2.3 normal (%) 70.7 78.4 hyperactivity problem abnormal (%) 12.1 7.7 0.106 1.651 0.894 – 3.048 normal (%) 87.9 92.3 peer problem abnormal (%) 31.4 21.9 0.021 1.639 1.076 – 2.496 normal% 68.6 78.1 prososial abnormal (%) 17.9 12.6 0.114 1.51 0.903 – 2.525 normal (%) 82.1 87.4 total score abnormal (%) 39.3 31.8 0.101 1.388 0.938 – 2.056 normal (%) 60.7 68.2 *chi square bivariate analysis between other factors and nail biting showed there was relation between nail biting history in family and nail biting habit (p < 0.001). tabel 5. other risk factors and nail biting nail biting p* prevalence ratio 95% condence interval yes no sex male (%) 48.6 40.8 0.106 1.368 0.935-2.002 x 121gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra female (%) 51.4 59.2 school grade primary school (%) 50 51.9 0.819 junior high school (%) 30.7 31.1 senior high school (%) 19.3 17 nail biting in family yes (%) 20 5.3 <0.001 4.469 2.493-8.010 no (%) 80 94.7 live among family yes (%) 97.9 95.6 0.224 2.109 0.617-7.206 no (%) 2.1 4.4 nutritional status severe malnutrition (%) 7 5.1 0.118 mild malnutrition (%) 27.1 25.8 well nourish (%) 55.7 48.3 overweight (%) 10.7 12.8 obesity (%) 5.7 7.9 family's income < 500,000 idr (%) 7.1 10.4 0.482 500,000 to 1,000,000 idr (%) 54.3 50.6 >1,000,000 idr (%) 38.6 39.1 parents' education primary school (%) 70 66.9 0.661 junior high school (%) 15.7 18.5 senior high school (%) 12.1 10.4 college (%) 7 2.2 the logistic regression analysis showed that emotional problem and nail biting in family were the risk factors of nail biting in this study. the prevalence ratio were 4.225 (95% ci 2.282-7.821) and 2.261 (95% ci 1.228-4.164). tabel 6. risk factors of nail biting p pr 95% ci sex 0.110 0.701 0.453-1.083 nail biting in family 0.0001 4.225 2.282-7.821 live among parents 0.134 2.836 0.727-11.067 mild malnutrition 0.459 0.724 0.308-1.703 severe malnutrition 0.474 0.714 0.284-1.795 overweight 0.128 5.509 0.610-49.726 obesity 0.800 0.880 0.328-2.363 emotional problem 0.009 2.261 1.228-4.164 conduct problem 0.270 1.375 0.781-2.422 hyperactivity problem 0.754 1.122 0.546-2.308 peer problem 0.160 1.446 0.864-2.421 prosocial 0.459 1.238 0.704-2.178 discussion according to who in 2007, mental health was dened as a welfare state where every individu aware his potential, can resolve stressor in daily living, can work productively, and can contribute to his community. (kessler rc, 2009; kelsay k, 2009). a study in india showed that the prevalence of mental emotional disorder child ages under 16 years old was 12.5% (warner la, 2010). our study didn't perform a research to a specic mental disorder. we perform a research of mental health parameter such as emotional, conduct, hyperactivity, peer, and prosocial problem. the prevalence of emotional disorder in our study was 28.8%. the other problems were conduct, hyperactivity, peer, prosocial problems. the prevalence of each of them was 23.4%, 8.8%, 24.1%, 13.8%. sdq is a screening tool for children ages 4-16 years old. there are several versions to meet researcher, clinician aspect. it is widely used as a screening tool. the benet of sdq are that it includes a variety of ages, it is available in multilingual. its sensitivity is 85% and specity is 80% (strength and difculty questionarre, 2016; nothern california training academy, 2008) according to international classication of diseases and health related problems – 10 (icd-10), nail biting is classied as emotional and health disorder that starts since kids and teenage. this habit is also accompannied with other habits such as excessive masturbation, nose picking, and thumb sucking (przemyslaw p, 2009) nail biting is dened as an act of inserting any nger into the mouth or an act of inserting at least one nger and or bite it. (james sb, 2007) this habit usually starts when a child is 3-4 years old. the prevalence increases as the age increases. the prevalence of nail biting in children age 7-10 years old and in teenagers is approximately 20%-33% and 45% (ghanizadeh a, 2011). the prevalence in our study was 23.6% nail biting can cause several complications such as relationship problem because of shame, often receive abuse from friends, higher oral infections that can be caused by enterobacteriaceae, dental root resorption (ghanizadeh a, 2011) it was stated in a study in iran in 2011 that boys with nail biting had lower prosocial score than the one without this habit. it also showed that age and prosocial score was associated with nail biting (ghanizadeh a, 2011). while a study in kuba stated that the risk factors of nail biting were low birthweight, a child who didn't exclusively breastfed, and disharmony family (romagosa der, 2014). our risk factors ndings were different with other studies. those were nail biting in family and abnormal emotional problem score. nail biting can be associated with other psychiatric conditions such as anxiety, obsessive compulsive disorder. the relationship between nail biting with anxiety is still controversial because several studies fail to show the increment of anxiety disorder prevalence. this result is consistent in obsessive compulsive disorder (halteh p, 2017). but a study in usa showed that there was an increment in prevalence of psychiatric disorder in nail biting groups compared to the other group (18% vs 6%), unfortunately, there wasn't any specic psychiatric disorder stated in that study (winebrake jp, 2018). this study still had several limitations. we didn't analyze complete risk factors of mental health disorder, that was, psychiatric disorder in the family. identication of mental health risk factors in this population had never been performed before. we still hadn't analyzed other risk factors of nail biting in this study. we used questionarre to evaluate parameters of nail biting and mental health disorder. it is encouraged to perform a better study design to analyze the relationship between mental health disorder and nail biting. conclusion mental health disorder is a state when someone cannot realize the potential of himself, overcome stressor in daily living, work productively, and contribute to his community. we can use sdq questionarre to analyze one's mental health. it is assumed that prosocial score is lower in nail biting group. we found that the prevalence of nail-biting group was 23.6% and the percentage in female sex was higher. we found that emotional and peer problem were signicantly correlated with nail biting habit (p = 0,004 and p = 0.021). the risk factors of nail biting in our study were nail biting in family and abnormal emotional score. references 1. knopf d, park j, mulye tp. (2008). the mental health of adolescents: a national prole. nahic. 1-15. 2. warner la, bott c. (2010). epidemiology of mental disorders in girls and female adolescents. in: levin bl, becker ma (eds). a public health perspective of women’s mental health. (pp 11). new york. springer. 3. widya w, setya oa. (2015). deteksi dini kesehatan jiwa anak yang mengalami penurunan prestasi belajar. jurnal keperawatan. issn 20863071. 4. badan penelitian dan pengembangan kesehatan kementerian kesehatan ri. (2007). riset kesehatan dasar. 5. badan penelitian dan pengembangan kesehatan kementerian kesehatan ri. (2013). riset kesehatan dasar. 6. ghanizadeh a, sheekoohi h. (2011). prevalence of nail biting and its association with mental health in a community sample of children. bmc research notes. 116,1-5. 7. przemyslaw p, magdalena g, adam r, jacek sc, monika kj. (2014). onychophagia and onychotillomania: prevalence, clinical picture and comorbidities. acta derm venereol. 94,67-71. 8. kessler rc. (2007). sociology and psychiatry. in: saddock bj, saddock v (eds.). kaplan & saddock’s comprehensive textbook of psychiatry (7th ed., pp.1065-1081). lippincott williams & wilkins publishers. 9. kelsay k, talmi a. (2016). child and adolescent psychiatric disorders and psychosocial aspects of pediatrics. in: hay ww, levin mj, deterding rr, abzug mj (eds.). current diagnosis and treatment pediatrics (23rd ed., pp.185-187). usa. mcgraw hill edication. 10. strength and difculty questionarre. (2006, september 1). retrieved march 4, 2018, from http://sdqinfo.com 11. williams st. (2008). mental health screening and assessment tools for children: literature review. uc davis extention center for human services (pp.1-116) 12. ghanizadeh a. (2011). nail biting: etiology, consequences and management. iran j med sci. 36(2),73-79. 13. romagosa der, gamboa mrp, muniz ya, olivia lmq, olivia de, naranjo st. (2014). risk factors associated with deforming oral habits in children aged 5 to 11: a case-control study. medwave. 14(2),e5927. 14. halteh p, scher rk, lipner sr. (2017). onychophagia: a nail-biting conundrum for physicians. journal of dermatological treatment. 28(2),166172. 15. winebrake jp, grover k, halteh p, lipner sr. (2018). pediatric onycophagia: a survey-based study of prevalence, etiologies, and co-morbidities. am j clin dermatol. 19,887. 122 x gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 1.1introduction: cardiac myxoma is the most common primary cardiac tumour. it is a benign tumour. occasionally it may have malignant potential causing extensive local invasion or rarely even metastasis to distant organs .it commonly occurs as sporadic in women age between 3 and 6 decade. in rd th sporadic type , it occurs as single in 94% and in left atrium in 75% .in familial type which accounts for 5% of cases, multiple (23%) is common and is common in young men and left atrium site is less common (only 62%). 1.2materials and methods : the medical records of the patients who underwent surgery for cardiac myxoma in our hospital during the period of august 2014 to july 2016 were retrospectively studied. during this period 8 patients were operated. out of 8 patients, 6 were females and 2 were males. the age of the patient was between 40 and 67 years, with mean of 50.5 years and median 50 years. the gender and age distribution are depicted in figures, g.no.1 and g.no.2 respectively. they presented with various symptoms of dyspnea , syncope , congestive cardiac failure, cerebro -vascular accident, etc. one patient presented with acute pulmonary edema and one another patient with psychiatric illness. the percentage of various symptoms is represented in the table no.1 below. fig.no.1: gender distribution fig.no.2: age distribution: table no.1: percentage of various symptoms the mean duration of onset of symptoms to hospital admission was 3 months. clinical ndings were pedal edema, mid diastolic murmur in mitral area, loud s1 in left atrial mass, systolic murmur in pulmonary area in right ventricular outow tract mass, crackles in respiratory system, ascitis, left hemiparesis. chest x-ray of one patient had bilateral pleural effusion , right more than left. some showed mild cardiomegaly , increased pulmonary blood ow and others were normal. elecrocardiogram ndings were atrial brilla tion in one, left ventricular hypertrophy in one another with t wave inversion. others had normal sinus rhythm with normal axis and low voltage complex. echocardiography ndings in all conrmed the diagnosis of cardiac tumour. the size of the mass varied from 2cm to 6.9 cm, with average size of 4.7 x 3.2 cm. site of location of the mass was in left atrium in 7 patients and in right ventricle outow tract in one patient, which is shown in g.no.3. in three of the cases mass was entering in and out mitral valve. two patients underwent cardiac catheterization. both had normal coronaries and one showed tumour blush. ultrasound abdomen of one patient showed mild hepatosplenomegaly with freeuid in abdomen. high resolution ct chest was done for one patient which showed well dened mass of size 4.6 x 3.8 cm in left atrium arising from inter atrial septum near fossa ovalis. surgery was done for all 8 patients electively after a median period of 22 3 days of admission by median sternotomy + with cardiopulmonary bypass. cpb was established by aortic and bi-caval cannulation. myocardial protection was given by antegrade root cardioplegia. the approach was through left atrium (la)in one , right atrium(ra) and inter atrial septum (ias) in 2, biatrial approach in 4 other cases of left atrial mass. for right ventricle mass , the approach was through right atrium and tricuspid valve. the different approaches are a series of cardiac myxoma in our experience original research paper dr n kavitha m.s; mch assistant professordept of cardiothoracic surgery tirunelveli medical college, tirunelveli x 27gjra global journal for research analysis cardiology background and objectivescardiac myxoma are the most common primary cardiac tumour. mostly it is a benign tumour and occasionally it can have malignant potential. materials and methods – a retrospective study on cardiac myxoma surgeries done in our hospital was done between august 2014 and july 2016. a total of 8 patients underwent surgery for myxoma. all were diagnosed as having cardiac myxoma by echocardiography and all underwent complete excision of the tumour.. resultsrd thcardiac myxoma is a rare disease and it most commonly occurs in the 3 to 6 decade , in the females, sporadically. out of 8 patients operated, six were females and two were males. the mean age of the patients was 50.5years.the location of tumour was left atrium in 7 cases and right ventricle in one case. one patient expired in postoperative period. none of the 7 patients had recurrence till 6months of follow up. conclusion – simple transthoracic echocardiography is sufcient for making the diagnosis. complete excision of the tumour reduces the recurrence rate. there is no need for urgent intervention and elective sugery has good results. abstract keywords : cardiac myxoma, cardiac tumour, left atrial myxoma volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr c elavarasan* m.s; mch assistant professor dept of cardiothoracic surgery madras medical college, chennai *corresponding author s.no. symptoms no.of cases perc entage 1. dyspnoea 4 50% 2. orthopnoea 2 25% 3. chest pain 1 12.5% 4. pedal edema 1 12.5% 5. abdominal distension 1 12.5% 6. syncope 3 37.5% 7. weakness of limbs 1 12.5% 8. psychiatric behaviour 1 12.5% 28 x gjra global journal for research analysis shown in table no. 2. the size of the masses ranged from 4x 3cm to10x3cm . all left atrial mass were invariably attached to inter atrial septum. in all cases, the mass was excised completely with a part of inter atrial septum. the defect in inter atrial septum was closed directly in only one and all others were closed with pericardial patch. cardiopulmonary bypass time range was between 70 to 125 minutes and that of cross clamp time was 30 and 94 minutes . table no.2: various methods of surgical appro aches: fig.no.3: various locations of mass routine histopathological examination was done in all patients. all 7 patients were followed for an average period of 6 months. 1.3-results : one patient had status epilepticus in rst post operative day and developed cardiac tamponade on third post operative day, for which re-exploration was done and the patient expired of low cardiac output syndrome/ acute kidney injury/status epilepticus/cerebro vascular accident. all other 7 patients were discharged between 9 and 13 post operative days. th th post operative complications were acute kidney injury (aki) in two and seizures in two which includes the patient who expired. post operative echocardiograph showed no residual mass in all 8 patient , with mild global hypokinesia in two and pericardial effusion in two. 2.1discussion: myxoma are the most common primary cardiac tumour and usually benign. presents in both genders in all age groups. but, most common in women between 3 and 6 decade. in rd th [1] this study females were more affected, with male: female ratio of 1:3. the mean age of presentation was 50.5 years and median of 50 years. myxoma generally occurs sporadically and only in 5-7% occurs as familial in this series no familial .[1,2] incidence could be made out. the symptoms are due to obstruction to blood ow in cardiac chambers and leading to congestive cardiac failure or due to embolic episodes or constitutional symptoms. in this study dyspnoea, pedal .[3,5] edema , abdominal distension, and syncope were due to haemodynamic dearrangements by causing obstruction and one presented with embolic manifestation with left hemiparesis. the mean duration of onset of symptoms to hospital admission was 3 months. natural history of myxoma is if failure symptoms has occurred , death occurs in 1-2 years. [4] electrocardiographyndings (ecg) are not speci , we had only one patient with atrial brillation. chest x-ray ndings were mild cardiomegaly , increased pulmonary vascularity and pleural effusion in one, none is specic for myxoma. all [5,8] were diagnosed by echocardiography(echo). cardiac catheterization was done in two patients and hrct chest in one. cardiac catheterization should be done for coronary evaluation. in selective cases , right heart study can be done in la tumour cases. in sporadic cases, single (94%) mass is common. in literature la accounts for 75% of cases and ra 15-20% and ventricle 510%. in our study, the commonest site was left atrium [1,6,7] attached to inter atrial mass. only one patient had mass in rvot. surgical removal is indicated whenever diagnosis is made historically, it was considered as an urgent .[9] procedure, particularly if the patient had a history of embolism or syncope, because it had been noted that 8-10% of patients died of embolic complications while awaiting operation. however, more recent experience suggests that elective operations as opposed to urgent has resulted in no greater mortality or morbidity. in this study all were operated with a [10,12] median period of 22 + 3 days after admission by using cardiopulmonary bypass with average cpb time of 90 minutes and cross clamp time of 44 minutes. there should be minimal handling before cross clamping aorta. la vent was not used .[1,7] tumour morphology is, it arises from endocardium, has smooth surface of size between 1 to15 cm. most commonly pedunculated of about 5cm, weighing about 70 grams in .[1,5,12] our study, out of 8, 5 masses were pedunculated and 3 were sessile. the approach was through la in one, ra and transseptal in 2, ra and trans tricuspid valve in 1 (rvot mass), biatrial approach in 4 other cases. right ventricle mass is approached through ra itself. direct ventricular approach is done only if atrial approach is inadequate. the [8] average size of the masses intra-operatively was 5.8 x 4.1 cm, which is more or less corresponded to the sizes given by echocardiography. the comparison of sizes of the tumour between echo and intra operative ndings is given in table no.3. all left atrial mass were invariably attached to inter atrial septum. in all cases, the mass was excised completely with a part of inter atrial septum. direct closure of ias was done in 1 case and all other were closed with pericardial patch. early deaths are < 5%, due to old age, advanced disability, coexisting cardiac or degenerative disease or ventricle site .[11'13] in this study, post operative mortality was 1 due to low cardiac output syndrome with cva with status epilepticus with aki .post operative complications were aki, seizures. table no.3: comparison of sizes of the tumour between echo and intra operative finding histologically it is composed of cells of primitive capillaries and foci of extra medullary hematopoiesis with in a myxoid matrix of acid mucopolysaccharide. stroma contains reticulocyte, elastin, smooth muscle, collagen. periphery contains monolayer of endothelium, clustering in crevices simulating primitive capillaries. stalk contains artery, vein, lymphocyte, plasma cells.10% have foci of calcium and metaplastic bone. nucleus are polygonal, without mitosis. tumour biology there is no sufcient information to determine the cell of origin. it has “vasoformative” tendency. some shows malignant potential like extensive local invasion, .[1,10,11]metastasis to distant organs in this series, all the tumours volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra methods no. approach left atrial 1 right atrial 3 bi-atrial 4 ias closure direct closure 1 pericardial patch closure 7 s.no. size of the mass ( in cm) by echo intra operative finding 1. 5.4x4.9 6.0x5.0 2. 5.8x3.6 6.0x4.0 3. 3.0x2.5 5.0x4.0 4. 2.7x2.3 4.0x3.0 5. 3.6x2.6 4.0x3.0 6. 4.9x2.0 4.0x5.0 7. 6.9x5.7 8.0x6.0 8. 6.0x2.5 10.x3.0 were conrmed as myxoma by histopathology. the histological features were common in almost all the case like myxoid stroma consists of spindle shaped, stellate shaped cells or polyhedral cells with congested vessels without malignant potential. recurrence occurs in 1-3 % of sporadic cases and 30-75% in familial type. recurrence are due to tumour implantation, incomplete removal or from new foci. in our study with [8,9,11] average of six months follow up, none had recurrence. 2.2conclusion: myxoma is the most common primary and benign tumour of the heart. females of age 50years are most commonly affected. simple transthoracic echo, being noninvasive,not expensive and practical technique, plays a crucial in the diagnosis and assessment of myxoma and is sufcient. there is no need for other investigations , except in special situations. the diagnosis per se is an indication for surgery. bi-atrial approach is mostly needed for la tumour . complete excision of the tumour is always mandated to reduce the recurrence rate. there is no need for urgent intervention and elective surgery has good results. references: 1. sabastine ms, collucci ws, schoen fs. primary tumors of the heart. in: braunwald e, zipes dp, libby p, et al. the heart disease. philadelphia, saunders co., 2004: 17411755. 2. burke a, virmani r. more on cardiac myxomas. n engl j med. 1996;335(19):1462-63. doi:10.1056/nejm199611073351912; pmid:8927083 3. newman ha, cordell ar, prichard rw. intracardiac myxomas. literature review and report of six cases, one successfully treated. am surg. 1966;32(4):219-30. pmid:5326200. 4. suvarna sk, royds ja. the nature of the cardiac myxoma. int j cardiol. 1996;57(3):211-6. doi:10.1016/s0167-5273(96)02827-6. 5. durgut k, gormus n, ozulku m, ozergin u, ozpinar c. clinical features and surgical treatment of cardiac myxoma: report of 18 cases. asian cardiovasc thorac ann 2002;10(2):111-114.[medline] 6. angleu g, carrion d, gimenez l, camacho g, ortega t. diagnosis by echocardiography of a case of myxoma in left ventricle. an esp pediatr. 1996;45(4):415-6. 7. bahnson ht, newman ev. diagnosis and surgical removal of intracavitary myxoma of the right atrium. bull johns hopkins hosp. 1953;93(3):150-63. pmid:13094264. 8. gawdzinski mp, sypula s. the long term results of treatment of heart myxomas with special attention to very rare myxoma of the right ventricle. j thorac cardiovasc surg. 1996;37(6 suppl 1):121-9. 9. jelic j, milicic d, alrevic i, anic d, baudoin z, bulat c, et al. cardiac myxoma: diagnostic approach, surgical treatment and follow-up. a twenty years experience. j thorac cardiovasc surg. 1996;37(6 suppl 1):113-7. 10. bjessmo s, ivert t. cardiac myxoma: 40 years' experience in 63 patients. ann thorac surg 1997;63(3):697-700. [medline] [crossref] 11. dein jr, frist wh, stinson eb, miller dc, baldwin jc, oyer pe, et al. primary cardiac neoplasms. early and late results of surgical treatment in 42 patients. j thorac cardiovasc surg. 1987;93(4):502-11. pmid:3560997. 12. reynen k. cardiac myxomas. n engl j med 1995;333(24):1610-1617. [medline] [crossref] 13. senning a. developments in cardiac surgery in stockholm during the mid and late 1950s. j thorac cardiovasc surg. 1989;98(5 pt 2):825-32. pmid:2682018. x 29gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction treatment of axillary osmidrosis, from the simplest, includes [1-3]botox injection , antiperspirant, deodorant, 1444nm: [4] [5-6]nd:yag yttrium chrome laser, microwave thermolysis , radio frequency, etc. the aforementioned methods are relatively non-invasive treatments. however, total removal of axillary osmidrosis requires a radical surgical procedure to be totally eradicated. the current surgical treatment includes the minimally invasive surgery by performing a subcutaneous incision and using a liposuction-assisted curettage to excise the apocrine gland and the traditional surgery by removing the apocrine glands through a large subcutaneous incision. in the course of operation, the most concerned acute complication is hematoma. when the operation causes trauma in the skin tissue, there will be blood accumulation in the dead space. if the blood accumulates in the dead space and the hemostasis is bad, it is easy for blood to accumulate in the dead space. because of the presence of blood clot between the skin ap and the subcutaneous tissue, hematoma causes the wound to fail to heal smoothly. in addition, the poor blood ow in the skin ap is usually accompanied by skin necrosis. the blood clot gradually becomes brotic in the later stages and the axillary brosis becomes harder. hence, the postoperative hematoma is a relatively serious complication for patients. common complications after the axillary osmi drosis surgery acute and subacute stage hematoma hematoma are the most common postoperative complications of axillary osmidrosis surgery. it is possible not to treat contusion. however, with hematoma, there is usually a large accumulation of blood. if not treated well or if not treated in time, it may lead to severe skin necrosis of the ap, wound infection, scar contracture, and delayed healing. why does hematoma occur? one reason is that the hemostasis in the operation is not thorough enough, electrocautery is not enough to stop the bleeding, the quilting suture fell off and so on. another possible reason for hematoma is the inappropriate excessive activity of the upper limbs after the surgery. acute and subacute stage subcutaneous eff usion because the ap and the tissue does not close up well coupled with an excessive movement of the upper extremities, a subcutaneous uid under the skin forms into subcutaneous effusion. when touched, the skin ap gives an undulating sensation. a pale yellowish serum can be seen with a needle aspiration. the cause of the occurrence of subcutaneous effusion is mainly due to the existence of a cavity between the ap and the subcutaneous tissue at the early stage after the operation. skin necrosis skin necrosis is the worst postoperative complication of axillary osmidrosis surgery. it is generally believed that the main reason for this complication is that the aps are trimmed too thin resulting in the destruction of the dermis and the subdermal vascular network. another reason is understand to be caused by the improper xation of the postoperative study on new modified techniques to reduce hematoma rate on osmidrosis surgery original research paper noi-siong, lau department of dentist, kang-shuan dental clinic, new taipei city, taiwan, roc. x 63gjra global journal for research analysis dental science background: the removal of axillary osmidrosis requires a surgical procedure to be totally eradicated. the current surgical treatment includes the minimally invasive surgery by performing a subcutaneous incision and using a liposuction-assisted curettage to excise the apocrine gland and the traditional surgery by removing the apocrine glands through a large subcutaneous incision. the course of operation carries adverse effects such as hematoma, subcutaneous infection, subcutaneous necrosis, etc. the most common and bothersome of which is the subcutaneous hematoma. objective: to reduce the occurrence of subcutaneous hematoma by improving the original surgical method in an innovative and easy way. methods: this study intends to use a more innovative and improved method to increase the blood drainage channel. in view of the fact that the occurrence of hematoma is closely related to the skill of the surgeon, we used the same clinician throughout the study to put forth a more reliable research. the research was done on two groups of axillary osmidrosis patients: the rst group, consisting of 28 patients, received the original method of surgery from september 2015 to august 2016; the second group, consisting of 53 patients, received an improved surgical operation, in addition to the original method, from september 2016 to august 2017. in the research, no. 11 blade was used to make a 2-3 mm incision on the axillary ap of 10 patients from the second group after the quilting sutures. tie over bandages are used to reduce the chance of hematoma. results: the second group of patients received a modied small incision method, showing a reduced occurrence of hematoma from 20% (12/56) in the rst group to 4.7% (5/106) in the second group. in spite of the fact that the sample size in the study is small, the statistics show a signicant difference between the two groups. however, there is no statistical difference found between the two groups with regards to ap ulceration, ap necrosis, and abscess infection. the hematoma statistics show that the new and improved approach is effective and worthy of promotion conclusion: according to the physical principle of capillary action and siphon, exudates and blood are “exuded” from the small incision in the ap through the perforation. the capillary action is the ability of a liquid to ow in a conned space without the aid of an external force such as gravity or even vice versa. the siphon principle is the ow of liquid from a higher level to a lower level. the conclusion of this study is that this new and improved method is effective and worthy of promotion. abstract keywords : wen-tsao, ho* department of dermatology, ho wen tsao skin clinic, new taipei city, taiwan *corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 64 x gjra global journal for research analysis dressing. at the early stage, the necrotic skin appears to be pale. after a week, the necrotic skin forms a black callus. comprehensive comparison of methods to prevent hematoma some of the many ways to solve the problem of hematoma are: quilting sutures in this study, the skin ap and the subcutaneous tissue are afxed together by means of suture. this article was published in the journal of dermatology. the study shows that a nylon line is used to evenly stitch the space between the ap and the subcutaneous tissue. this procedure is called simple suture where the skin ap and subcutaneous tissue are [14,15]stitched up to reduce the dead space . looking at the data from this study, quilting suture can signicantly reduce the chance of hematoma. despite that, this method cannot be applied to every operator as the occurrence of hematoma is directly related to the experience of the surgeon and the way the surgery is performed and the method indicated in this paper uses a liposuction-assisted curettage. this study signicantly shows that quilting suture can remarkably reduce the chance of hematoma, the same is true inferentially. fibrin fibrin method was published in an article issued in 2009. the [16-17]study concludes that, whether brin is used or not, there is no statistically signicant difference in the amount of blood ow. hence, the study concludes that the use of brin after axillary osmidrosis surgery does not reduce the postoperative bleeding and that there is no way to increase its adhesion. tie over bandage [18]tie over bandage (fig 1) is used to absorb tissue uid. with the application of external pressure, where the patient clamps the bandage, the skin ap is pressed back to the subcutaneous tissue reducing the dead space and possibility of bleeding. first is to reduce the dead space and the second is to stop bleeding – these two approaches reduce the chance of bleeding. however, there is no particular analysis presented in the literature showing the percentage it can actually reduce the occurrence of hematoma. fig1 tie-over bondage is to prevent hematoma drain tube this method puts a drain tube in the dead space extracting the blood with the tube. this method is used in most surgical procedures. the disadvantage is that when the drain tube is removed, a gap is left in the area where another amount of time is needed to attach the ap and the subcutaneous tissue. the drain tube is usually removed three days after the surgery. after that, additional time is needed for the wound and the path from the drain tube to heal. in rare cases, the dead space is situated far from the drainage tube and the hematoma could not be extracted because of its location. research method in this research, we will be modifying the established methods to reduce the risk of hematoma. research objects patients with osmidrosis who agreed to have surgery at our clinic in taiwan were divided into two groups: 28 in the rst group and 53 in the second group, with a total of 81 persons. grouping of the experimental objects this research compared and analyzed retrospectively the records of the rst group of patients who received the axillary osmidrosis surgery from september 2015 to september 2016 with the second group of patients who received improved axillary osmidrosis surgery from september 2016 to september 2017. among the 28 patients from the rst group of objects, those who received the surgery from september 2015 to september 2016, were found mild to moderate side effects, especially hematoma. consequently, this study modied the surgical approach to reduce the risk of hematoma. on that account, the surgeries performed to the 53 patients of the second group of objects after september 2016 employed additional new modications. methods and procedures established procedures for group one patients after removing the apocrine sweat gland, the wound is stitched together by quilting sutures with bondage gauzed secured on it. modified procedures for group two patients after the removal of the apocrine sweat gland, approximately ten or more 2-3 mm incision was made in between quilting sutures on the axillary ap of the second group objects with the use of no. 11 blade. tie over bandage gauze was in the same manner secured on the wound to reduce the chance of hematoma, as seen in fig. 2. all patients underwent subcutaneous removal of the apocrine glands. the bilateral armpits were sterilized then injected with swelling agent anesthesia on the pre-marked area of the axillary producing a “peau d'orange” effect on the covered tissue. the formula used for the swelling agent anesthesia solution is composed of 500 ml saline, 20ml 2% lidocaine, 1ml 1:1000 epinephrine and 12.5 ml sodium bicarbonate. a 1-1.5cm long incision was made in the center of the creased axillary and the apocrine gland was removed through the incision with the use of a pair of scissors. this process is repeated throughout the axillary until the whole area basically becomes a thin ap. the surgical process starts with the sterilization of the armpit. it is followed by the inltration of anesthesia and the swelling agent, the proportion of which is 500 ml of saline, 20 ml sodium bicarbonate solution and 1 ml epinephrine; about 50-100 c.c. is used on each side. a no. 10 hollow needle is used, matched with a no. 27 needle, to inject the solution between the skin ap and the dermis to hold the skin open. after the inltration, a no. 15 blade is used to make a small incision, about 3-4 mm, at the middle of the armpit. an iris scissor is then used to separate the skin ap from the subcutaneous tissue. after the separation, a rotating knife is used to scrape off all the apocrine glands. the excision of the apocrine glands is done one by one through minimally invasive holes. the incision is closed with quilting sutures. finally, a tie over bandage, about the size of a st, is used to press against the skin ap and the dermis and is fastened with sutures. after the quilting sutures, a no. 11 blade is used on the group 2 patients to make approximately ten 2-3mm incision on the skin ap. afterward, the tie over bandage is used to reduce the chance of hematoma. the patients were asked to return three days after the surgery. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra during the rst visit, the xed suture is cut and the tie over bandage is removed. in this study, we can see that on the third day, the color of the blood on the tie over bandage turned brown or black, not a bright red color, only a few wounds have bright red color, telling us that removing the tie over bandage on the third day, as intended in this study, is reasonable. the brown or black color refers to oxidation, which means that there is no occurrence of bleeding. fig. 2 after the quilting sutures, a no. 11 blade is used on the group 2 patients to make approximately ten 2-3mm incision on the skin ap. post-operative management the tie over bandage was removed 3 days after the operation (fig. 3). the removal of the suture was set 7 days after the surgery and the removal of the wound suture was set 14 days after the surgery. fig 3 blood absorbed by bondage gauzes 3 days after removal. post-operative evaluation possible complications include hematoma, seroma, skin ulceration, infection and delay in wound healing. recording of data lasted for 2 weeks for both group 1 and group 2 patients. experimental results calculation formula and signicance analysis, where t is statistical value: the equation of the degree of freedom is: v = subnumber – 1 t test procedure: the t value of the required statistics is calculated. this study selected different statistical calculation methods for different types of problems. a. to decide the degree of difference between the average of a small sample and the average of its population, the statistical value t is calculated as follows: b. to evaluate the degree of difference between the two groups of samples and their average, the formula for calculating the statistical value t is as follows: this study compares the obtained t value with the theoretical t value and further deduce the probability of occurrence. judgment is made based on the relationship between the t values given in table 1 and the signicance of the difference. table 1 the t and p value denitions result an independent sample t test was used to analyze the results of the two groups of data on hematoma, seroma, infection, skin surface ulceration, and skin necrosis. the results of the analysis are shown in table 2. table 2 shows that hematoma has a signicant value of p<0.05, indicating that there was a signicant difference in the postoperative occurrence of hematoma. the mean value for the rst group of data, calculated as 0.21, is greater than the mean value of the second group of data, computed as 0.05. therefore, it can be said the surgical method on the second group of patients yields a better result than the surgical method on the rst group of patients in terms of hematoma complication. the value of signicance for the seroma, infection, skin surface ulceration and necrosis were greater than 0.05 denoting that there was no signicant difference in the postoperative occurrence of complications in the form of seroma, infection, ulceration and necrosis. that is, the two surgical methods conducted on the two groups of patients does not improve nor does it increase the occurrence of complications such as seroma, infection, ulceration, and necrosis. to sum up, the result of the surgical method on the second group is better that of the rst group. table 2 analysis of outcomes between a-b surgical techniques discussion many doctors use different methods to reduce the risk of hematoma, seroma, and so on with the use of suture, bandages, tissue glue, and drainage tubes. in this study, we can see that the second group of patients, who received a more improved surgical method, showed a reduced occurrence of hematoma at 4.7% (5/106) as compared to the rst group at 20% (12/56). it is interesting to note that the occurrence of hematoma on the right side for both groups of patients is slightly higher. the postoperative complications of the two groups of patients were not related to their profession/activity, age, sex and smoking history. the research encouraged patients with smoking history to quit smoking. it is suspected that those with smoking x 65gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra t p value signicance of difference t ≧t(df)0.01 p≦0.01 difference is very signicant t ≧ t(df)0.05 p≦0.05 difference is signicant t <t(df)0.0 p >0.05 difference is insignicant item group n mean value standard deviation t p hematoma group 1 12/56 0.21 0.41 2.829 .006 group 2 5/106 0.05 0.21 seroma group 1 1/56 0.02 0.13 1.000 .322 group 2 0/106 0.00 0.00 septic infection group 1 2/56 0.04 0.19 1.000 .326 group 2 0/106 0.00 0.00 skin ulceration group 1 20/56 0.36 0.49 0.501 .618 group 2 3/106 0.30 0.46 delayed healing group 1 11/56 0.18 0.39 1.001 .322 group 2 9/106 0.09 0.29 skin necrosis group 1 2/56 0.04 0.19 0.460 .647 group 2 2/106 0.02 0.14 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra history have more problems but found no increased risk. the new surgical approach appeared to have greatly improved hematoma complications but yielded no positive effect on other complications such as infection, ulceration and delayed healing. during the study, once hematoma occurred, no matter in which group, the blood clot is cut and drained. patients are requested to return to the clinic every day until the bleeding stops. prophylactic antibiotics are also given. conclusion the method used here is capillary action or wicking. capillary action is the ability of a liquid to ow in a narrow space without the aid of, or even in opposition to, external forces like gravity. [19-20]the siphon principle is the ow of liquid from a higher level to a lower level. the second group of patients received a modied punctured method that showed the reduced occurrence of hematoma with 20% (12/56) from group 1 patients decreasing to 4.7% (5/106) from group 2 patients. regardless of the small sample size of the study group, the statistics show a signicant difference between the two groups. however, there was no statistical difference between the two groups with regards to skin ulceration, skin necrosis, and abscess infection. the conclusion of this study is that this new and improved method is effective and worthy of promotion. reference: 1. an js, hyun won c, si han j, park hs, seo kk. comparison of onabotulinumtoxina and rimabotulinumtoxinb for the treatment of axillary hyperhidrosis. dermatol surg. 2015 aug;41(8):960-7. 2. jeong jh, hong jm, pak cs, kim jh, heo cy. treatment of axillary osmidrosis using a laser with a 1,444-nm wavelength. dermatol surg. 2014 aug;40(8):851-7. 3. sánchez-carpintero i, martín-gorgojo a, ruiz-rodríguez r. microwave treatment for axillary hyperhidrosis and bromhidrosis. actas dermosiliogr. 2017 mar 8. 4. hsu th, chen yt, tu yk, et al. a systematic review of microwave-based therapy for axillary hyperhidrosis. j cosmet laser ther. 2017 mar 10:1-8 5. toyoda y, gomi t, nakagawa h, et al. diagnosis of human axillary osmidrosis by genotyping of the human abcc11 gene: clinical practice and basic scientic evidence. biomed res int. 2016;2016:7670483. 6. shi ll, sargen mr, chen sc, et al. effective local anesthesia for onabotulinumtoxin a injections to treat hyperhidrosis associated with traumatic amputation. dermatol online j. 2016 jun 15;22(6) 7. de almeida ar, montagner s. botulinum toxin for axillary hyperhidrosis. dermatol clin. 2014 oct;32(4):495-504. 8. ren y, liu w, chen j, et al. a missense variant of the abcc11 gene is associated with axillary osmidrosis susceptibility and clinical phenotypes in the chinese han population.sci rep. 2017 may 9;7:46335 9. sun y, long j, wang y. correlation between abcc11 gene single nucleotide polymorphism and the incidence of axillary osmidrosis in chinese han population].zhong nan da xue xue bao yi xue ban. 2013 nov;38(11):1141-5. 10. ho wt, wang hy, pan jy. genotyping for snp rs17822931 in abcc11 gene can help in the diagnosis of body malodour. malaysia journal of dermatology 2016 jul vol 36 11. toyoda y, takada t, gomi t, nakagawa h, ishikawa t, suzuki h. clinical and molecular evidence of abcc11 protein expression in axillary apocrine glands of patients with axillary osmidrosis. int j mol sci. 2017 feb 15;18(2). pii: e417. 12. caroprese a, gabbanini s, beltramini c, et al. hs-spme-gc-ms analysis of body odor to test the efcacy of foot deodorant formulations. skin res technol. 2009 nov;15(4):503-10. 13. ho wt, lee lj, pan jy. following changes in the axillary secretions of two patients before and after bromhidrosis surgery using liquid chromatography-mass spectrometry. dermatol surg. 2017 mar;43(3):459462. 14. miyamoto e, hayashi a, komoto m, et al. "sea anemone-shaped xation": a feasible tie-over technique for axillary osmidrosis. j plast reconstr aesthet surg. 2012 ;65:e202-203. 15. rho nk1, shin jh, jung cw, et al. effect of quilting sutures on hematoma formation after liposuction with dermal curettage for treatment of axillary hyperhidrosis: a randomized clinical trial. dermatol surg. 2008 ;34:1010-5 5. shimizu y, nagasao t, kishi k, et al. alternative continuous quilting suture technique for preventing hematoma in axillary osmidrosis. dermatol surg. 2014;40:1058-106 16. sajid ms1, hutson kh, rapisarda if, et al. fibrin glue instillation under skin aps to prevent seroma-related morbidity following breast and axillary surgery. cochrane database syst rev. 2013 may 31;(5):cd009557. 17. lim dw, park j, you yc, yang wy, lee w. the effectiveness of fibrin glue using in dermal shaving at osmidrosis. j korean soc aesthetic plast surg. 2005 mar;11(1):93-98. korean. 18. miyamoto e, hayashi a, komoto m, et al. "sea anemone-shaped xation": a feasible tie-over technique for axillary osmidrosis. j plast reconstr aesthet surg. 2012 ;65:e202-203. 19. wikipedia: https://en.wikipedia.org/wiki/capillary_action, accessed nov. 22, 2015. 20. hughes, stephen w. a practical example of a siphon at work. physics education 2010. 66 x gjra global journal for research analysis introduction a pneumatic tool such as blow gun dust cleaner (bgdc) is a tool driven by a gas, usually compressed air supplied through an air compressor. it is popular and readily available in the do it yourself market and common in small family industrial and manufacturing settings in taiwan. the rst case of pneumatic rupture of the colon was reported by stone [1]. industrial accident and perineal blasting with compressed air had been commonly reported in adult and results in colon injury either with or without perforation. we present a case of 15 year old boy with tension pneumoperitoneum and transverse colon perforation associated with multiple site non perforated colon injury secondary to spraying of the perineum using high pressure bgdc. case report (a): blow gun dust cleaner (b):abdomen x ray b aa 15 year old male presented at civil hospital, ahmedabad at 3:24 am on 19 th july 2019 with alleged history of assault by spraying of high pressure and high ow pneumatic tool over perineal region by his co-worker at 1:00 am on 19 july 2019 at lama, devraj mill, ahmedabad. on arrival he had complaint of generalised abdominal distension with generalised abdominal pain,multiple gastric vomiting and difculty in breathing.vitals were pulse:108/min,blood pressure:136/70 mmhg,respiratory rate: 22/min.on physical examination abdomen was distended with generalized tenderness, guarding,hypoactive bowel sound. perianal area did not showed any sign of trauma. (a) blow gun dust cleaner (b) abdomen x ray abdomen x ray standing was suggestive of free gas under both the dome of diaphragm and multiple dilated bowel loops.chest x ray standing was suggestive of free gas under both the dome of diaphragm .his laboratory workup showed a hemoglobin 14.5gm/dl, hematocrit 34.9%, white blood cell count 13.8×103/cmm platelet count 429×103/cmm. intraoperative findinds figure [a]:perforation of transverse colon and serosal tear,[b]:serosal tear in caecum [c]:serosal tear in sigmoid colon emergent exploratory laparotomy was done. on opening the abdomen, signicant foul smelling air whistled out of the abdominal cavity. localized 30cc faecal collection present in splenic fossa and left paracolic gutter.multiple serosal tear of approx 3-5 cm in sigmoid colon, approx 30cm in transverse colon and 5cm serosal tear in caecum. 5*3 cm perforation at transverse colon at junction of right 2/3 and left 1/3 at antemesenteric border. the diaphragm, liver, spleen, and pancreas were normal. primary repair of transverse colon perforation done using silk 2-0 in two layer-one full thickness ndinterrupted and 2 seromuscular interrupted. primary repair a case report of a pneumatic colon injury following high pressure blow gun dust cleaner spray to perineum original research paper dr. nina m. shah associate professor & hou, department of general surgery, b.j.medical college, civil hospital, ahmedabad. general surgery keywords : dr. vipul patel* rd3 year resident, department of general surgery, b.j.medical college, civil hospital, ahmedabad. *corresponding author dr. swati mohanty nd2 year resident, department of general surgery, b.j.medical college, civil hospital, ahmedabad. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. hiral c. chauhan assistant professor, department of general surgery, b.j.medical college, civil hospital, ahmedabad. 60 x gjra global journal for research analysis of serosal tear over sigmoid colon, transverse colon and caecum done using silk 2-0 multiple interrupted.diverting loop ileostomy was done 25cm proximal to ic junction. patient was kept nbm for 4 days and was kept on total parenteral nutritionfor the period of nbm.on pod-5 sips started with rt(ryles tube) in situ.rt removed on pod-7 and was started on liquid diet for two days then soft diet started on pod9.stomy functioning started on pod-5. patient was discharged in stable condition 21 days later.ileostomy closure was done 6 week later after conrming the patency of distal colon by distal loopogram.patient was discharged in stable condition with tolerating all orally and passing stool regularly. discussion external pneumatic insufation of the colon through the anus depends on the air pressure, air ow velocity, anal resting pressure and the distance between the source and anus [1,2]. under normal condition, normal resting anal pressure can prevent the insufation of the colon from a direct external source with low air pressure. duthie and wattes study showed that the mean anal pressure in normal adult subject was 0.87±0.005 kg/cm2 (12.4±0.711 psi/640±50mmhg) with a range 0.06–0.109 kg/cm2 (0.85–1.55 psi/44–80mmhg). andrew have postulated that air at 3.5–8.8 kg/cm2 (50–125 psi/2585–6464mmhg) forms a column which acts like a solid body, forcing to open the anal sphincter [3]. bgdc at 8.2 kg/cm2 (116.6 psi/6031mmhg) pressure,as in our case, can produce an air thrust of tenfold greater than the resting anal pressure and overcome the anal sphincter pressure, resulting in sudden ination of the colon. the bowel wall is elastic,distensible and tolerates certain amount pressure. the mucosa is the most elastic and the serosa and the muscularis, the least.the intraluminal pressure required to result in colon perforation has been estimated through colonoscopic studies and was found to be greater than 0.109 kg/cm2 (1.547 psi/80mmhg) [4].flow represents the quantity of compressed air that passes through a section over a unit of time and varies depending on the diameter of the hose and air pressure. the air ow of gun cleaner is estimated to be 141 l/min (5 cfm), which is 100 fold greater that the safe level airow of 1.46 l/m (at 80mmhg intraluminal pressure) during colonoscopic examination [4] and hydrostatic pressure or air ow pressure of 0.16 kg/cm2 (2.32 psi/120mmhg) during barium[5], saline [6], and air reduction [7] of intussusception,which protects patients from colonic barotrauma.during gradual insufation of colon or in large bowel obstruction distal to the caecum, the caecum is the segment most prone to distention injury which is explain by the law of laplace [8].the caecum has the largest diameter and requires the least amount of pressure to distend [9]. an important corollary to laplace's theorem is that the degree of angulations (sharpness of cylinder curvature) is more important in determining wall tension than its internal volume [5]. the anatomy of the distal colon with the rm lateral support of the rectum makes the rst part of the colon to be struck by a column of pressure from external source and the bending of the sigmoid [10] pose the recto sigmoid to rupture in pressure related colon barotraumas. during rapid air distention, inability to produce a total obstruction by the bending of sigmoid and high pressure allows the ow of air proximally to the next anatomical bending such as splenic exure and hepatic exure and ileocaecal valve resulting in a stepwise closed loop obstruction, resulting in other site of the bowel to be injure and perforate. comparison of different section of the colon shows that the rectum supports the greatest pressure and the sigmoid, transverse colon, caecum in decreasing strength. the pathologic lesions following pneumatic insufation depends on the resultant intraluminal pressure and includes serosal hemorrhage, lacerations of the serosa and muscular coat with bulging of the mucous membrane, or complete rupture of the bowel through the serosa, muscular coat, and mucous membrane as in our case.management of pneumatic colon injury include rectal tube decompression, intraoperative decompression of bowel in the presence of distended bowel, resection of severely injured segment of colon and repair of perforation with proximal diverting colostomy or enterostomy, when the integrity of the bowel is in doubt . careful observation following surgery is often necessary since fullthickness perforation of the colon may have delayed presentation. closure of ostomy can be perform as early as 2–3 weeks of following creation without signicance increase in complications compared to late closure and depends on whether patient had recovered from his initial injuries, which is assess with barium enema or sigmoidoscopic examination. conclusion patient with tension pneumoperitoneum associated with multiple site colon injury and perforation, the importance of history is emphasized. ileostomy should be done to give rest to the extensively traumatised large bowel. after stomy closure gradual graded oral feed should be started. conicts of interest all authors state no conicts of interest. funding no funding. references [1] i.l. rosenberg, f.g. smiddy, insufation injury of the bowel, arch. surg. 105(1972) 113–115. [2] h. kampmann, h. kijewski, perforation of the large intestine caused by compressed air: experimental studies reconstructing compressed air insufation, arch. kriminol. 171 (1983) 173–181. [3] e.w. andrews, pneumatic rupture of the intestine, a new type of industrial accident, surg. gynecol. obstet. 12 (1911) 63. [4] j.a. woltjen, a retrospective analysis of cecal barotrauma caused by colonoscope air ow and pressure, gastrointest. endosc. 61 (2005) 37–45. [5] c.m. brayko, r.a. kozarek, r.a. sanowski, t. howells, diverticular rupture during colonoscopy. fact or fancy? dig. dis. sci. 29 (1984) 427–431. [6] a.j. kuta, r.m. benator, intussusception hydrostatic pressure equivalents for barium and meglumine sodium diatrizoate, radiology 175 (1990) 125–126. [7] t.w. riebel, r. nasir, k. weber, us-guided hydrostatic reduction of intussusception in children, radiology 188 (1993) 513–516. [8] w.e. shiels 2nd, c.k. maves, g.l. hedlund, d.r. kirks, air enema for diagnosis and reduction of intussusception: clinical experience and pressure correlates, radiology 181 (1991) 169–172. [9] r. vick, contemporary medical physiology, addison–wesley, ca, 1984. [10] v.w. vanek, m. al-salti, acute pseudo-obstruction of the colon (ogilvie’s syndrome): an analysis of 400 cases, dis. colon rectum 29 (1986) 203–210. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 61gjra global journal for research analysis introduction: the desire for large families is a unique feature of saudi arabian [1]. however, with the rapid changes in the sociodemographic pattern of the saudi arabian community, primarily with regard to education and work status among women, there have been marked changes in fertility beliefs and behaviors, with a specic focus on age at pregnancy and the use of contraceptives [2]. a review of the relevant literature showed that unplanned pregnancy was common despite contraceptive use; in fact, almost 85 million pregnancies (40% of all pregnancies) worldwide were unplanned in 2012 [3]. in developing countries, approximately 74 million unplanned pregnancies occur annually, and 30% of these result from contraceptive failure among women using traditional or modern contraceptive methods [4]. unplanned pregnancies can have many unfavorable consequences, including undesirable childbearing, recourse to possibly unsafe abortion, and maternal and/or newborn morbidity and mortality [4-6]. fundamentally, unplanned pregnancies result from either lack of use of contraception or contraceptive failure [7]. the effect of contraceptive failure on unplanned pregnancy and abortion may also be related to the specic contraceptive method used and the manner of its usage [7]. nevertheless, the number of studies in saudi arabia on the prevalence and probability of contraceptive failure according prevalence of contraceptive failure among women at the western region of saudi arabia in 2018 original research paper ahmad b. alwazzan obstetrics and gynecology department, king abdulaziz university hospital, saudi arabia x 135gjra global journal for research analysis medicine background: a unique feature of saudi arabian society is the desire for huge families. objectives: this study aimed to identify the contraceptive methods used with a higher risk of unplanned pregnancy, and the correlations between parity status and types of contraceptive methods used and contraceptive failure in women visiting the primary health care clinic of king abdulaziz university, jeddah, saudi arabia. subjects and methods: this cross-sectional study was performed using a self-administrated electronic questionnaire that was distributed to women visiting a primary health care clinic in the western region of saudi arabia. the questionnaire was divided into 4 parts: patient characteristics, use and knowledge of contraceptive methods, relative risk of pregnancy with the use of different contraceptive methods, and the risk of pregnancy in relation to parity. statistical analysis was performed using the spss v.21 software package. results: a total of 959 women visiting the primary health care clinic were enrolled. most of the participants were in the age group 20-35 years (57.00%). a large proportion of women reported using contraception (n= 649, 67.70%). the most common type of contraceptive used in this study was contraceptive pills (31.70%) followed by iud (21.20%).the overall contraceptive failure rate was high in participants used withdrawal (or: 1.822; 95%ci: 0.564-5.884), male condom (or: 1.561; 95%ci: 0.4845.031), lactation (or: 1.202; 95%ci: 0.171-8.464), and contraceptive pills (or: 1.025; 95%ci: 0.500-2.102), while, the overall contraceptive failure rate was low in participants using iud (or: 0.964; 95%ci: 0.440-2.113). primigravida cases had the highest risk of contraceptive failure (8.50%) followed by nullipara (4.80%) then multipara (4.30%). conclusion: usage of withdrawal, male condom, lactation, and contraceptive pills as contraceptive methods had highest risk of failure in women in the western region of saudi arabia. hence, women using these methods of contraception should be so carefully. abstract keywords : contraceptive – failure – pregnant – parity volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra ahmed a. mousa obstetrics and gynecology department, king abdulaziz university hospital, saudi arabia samera f. albasri obstetrics and gynecology department, king abdulaziz university hospital, saudi arabia abdullah mohammed kafy* obstetrics and gynecology department, faculty of medicine, jeddah, king abdulaziz university king abdulaziz university hospital, saudi arabia *corresponding author morouj a. kandil obstetrics and gynecology department, king abdulaziz university hospital, saudi arabia abdulrahman m. alkudsi obstetrics and gynecology department, king abdulaziz university hospital, saudi arabia esraa a. roblah obstetrics and gynecology department, king abdulaziz university hospital, saudi arabia fayda a. alkudsi obstetrics and gynecology department, king abdulaziz university hospital, saudi arabia abdulrahman e. alsaggaf obstetrics and gynecology department, king abdulaziz university hospital, saudi arabia 136 x gjra global journal for research analysis to specic contraceptive methods and the resulting number of unplanned pregnancies is insufcient. the aimed of this cross section study was to identify the contraceptive methods with a higher risk of unplanned pregnancy, and to correlate between parity status and types of contraceptive methods used and contraceptive usage failure in women visiting the primary health care clinic of king abdulaziz university, jeddah, saudi arabia. patients and methods this cross section study was approved by the institutional review board (irb) of king abdulaziz university hospital and faculty of medicine. jeddah, saudi arabia. this study was conducted at 12 primary healthcare centers in the western region of saudi arabia (makkah, jeddah, and altaif), and enrolled women older than 18 years between january and december 2018. those who declined to participate, and those who were unable to answer questions due to their lack of understanding of arabic or lack of education were excluded. a total of 959 participants were nally included in the study. participants were chosen after they completed their clinic visits or while they were waiting for their appointment. study members randomly approached potential participants within the clinic and requested them to participate in the survey. an informed consent was obtained from each participant. participants were administered an electronic questionnaire, and the following data were obtained: demographic data, number of children, use of male or female contraceptive methods, the duration of contraceptive use, and the reason for contraceptive use. the questionnaire assessed whether any of the following 15 contraceptive methods were employed: contraceptive pills, intra-uterine contraceptive devices (iucds), withdrawal method, male or female condoms, calendar method, patch, lactation, injections, cervical rings, cervical mucus methods, body temperature method, diaphragm, spermicidal cream, implants, and tubal ligation. whether the participants experienced pregnancy despite the use of these contraceptive methods was also assessed. statistical analysis: all the values were expressed as number (%) or mean +/standard deviation (minimum–maximum) as appropriate. data were analyzed using statistical package for social sciences (spss inc., version 22, chicago, il, usa), using the chi-square test for comparison between nonparametric data. cross-tabulation was performed to estimate the risk and 95% condence interval (95%ci). a p value ≤0.05 was considered to indicate statistical signicance. results: in total, 959 women participated in the study. most of the participants (57%) were aged 20–35 years, followed by those >35–50 years (31.50%), those >50 years (6.50%), and nally those <20 years (5%). most of the participants were graduates (60.90%), followed by those that had completed primary education (29.50%), postgraduate education (9.50%), and diploma (0.30%). moreover, 82.20% of the participants were married and sexually active (82.20%), whereas 9.00% were divorced or widowed and 8.90% was not married. the duration of marriage was ≤1 year in 9.20%, 2–10 years in 41.60%, and >10 years in 40.40% of participants. with regard to parity, most participants were multipara (64.10%), followed by primigravida (16.40%) and nullipara (10.60%) (table 1). the number of women using contraceptive methods was greater than the number of women who did not use contraceptive methods (67.70% vs. 32.30%). the duration of contraceptive use was ≥1–5 years in 32.40%, <1 year in 22.20%, and >5 years in 13% of participants. the reason for contraceptive use was to avoid pregnancy in most cases (55.10%), followed by medical issues (2.80%). contraceptive pill was the most common type of contraceptive used (31.70%), followed by iud (21.20%), withdrawal method (16.40%), male condom (13.80%), female condom (0.60%), calendar method (5.90%), patch (5.30%), lactation (3.90%), injection (2%), cervical ring (1.40%), cervical mucus method (0.70%), body temperature method (0.40%), diaphragm (0.40%), spermicidal cream (0.30%), implant (0.10%), or fallopian tube ligation (0.10%) (table 2). table 3 showed the risk of pregnancy among the women using the different methods of contraception. in particular, 4.7% of women using contraceptive pills became pregnant with high risk (odds ratio [or]: 1.025 and 95% (ci: 0.5–2.102), whereas 4.9% of women using iud became pregnant with low risk (or: 0.964, 95% ci: 0.44–2.113). the use of the withdrawal method led to pregnancy in 2.8% of women (or: 1.822, 95% ci: 0.564–5.884), whereas use of male condoms led to pregnancy in 3.2% of women (or: 1.561, 95% ci: 0.484–5.031). the calendar method was used by 37 women, and 2 of these (5.4%) women became pregnant (or: 0.877, 95% ci: 0.217–3.533). a total of 38 women used patches as contraceptive methods, and 2 of these (5.3%) became pregnant (or: 0.902, 95% ci: 0.224–3.638). one woman (4%) using lactation as a contraceptive method became pregnant (or: 1.202, 95% ci: 0.171–8.464). injections were used as a method of contraception by 16 women, and 2 of these (12.50%) women became pregnant (or: 0.367, 95% ci: 0.096–1.406). moreover, only 9 women used a cervical ring, and 1 of them (11.1%) became pregnant (or: 0.422, 95% ci: 0.064–2.766). none of the women using the cervical mucus method, female condoms, body temperature, diaphragm, or spermicidal cream reported becoming pregnant. table 4 showed the cross tabulation analysis between parity and pregnancy following the use of contraceptive methods. the proportion of women who did not become pregnant was signicantly greater than the proportion of women with pregnancy in all the groups (p=0.001 for all). data indicated that 9 primigravida women of 106 (8.5%) became pregnant despite the use of contraceptive methods (or: 0.477, 95% ci: 0.226–1.007). among 63 nullipara women, 3 (4.8%) became pregnant (or: 1.003, 95% ci: 0.314–3.207), whereas among 445 multipara women, 19 (4.3%) became pregnant despite the use of contraceptive methods (or: 1.378, 95% ci: 0.682–2.784). in this study, only 5 cases used cervical mucus method; 5 cases used female condom, 1 case used body temperature and 3 cases used diaphragm and 2 cases used spermicidal cream and none of these cases get pregnant. discussion the aim of the present study was to identify the failure rate of different contraceptive methods over 1 year among 649 women. the results obtained by this study revealed that primigravida cases had the highest risk of contraceptive failure (8.50%) followed by nullipara (4.80%) then multipara (4.30%). these results were in partial consistent with another study that indicated that contraceptive failure is strongly associated with younger age and higher parities [8,9]. moreover, a total of 528 (55.10%) patients participated in this study reported that they used contraceptive methods to avoid pregnancy, whereas 27 (2.80%) participants offered medical issues as a reason for contraceptive use. the most common type of contraceptive used in this study was contraceptive pills (31.70%) followed by iud (21.20%), withdrawal method (16.40%) and male condom (13.80%).the results obtained showed that the overall contraceptive failure rate was high in participants used withdrawal (2.80%; or: 1.822; 95%ci: 0.564-5.884), male condom (3.20%, or: 1.561; 95%ci: 0.484-5.031), lactation (4.00%, or: 1.202; 95%ci: 0.171-8.464), and contraceptive pills (4.70%, or: 1.025; 95%ci: 0.500-2.102). while, the overall contraceptive failure rate was low in participants using iud (4.90%, or: 0.964; volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 95%ci: 0.440-2.113), patch (5.30%, or: 0.902; 95%ci: 0.2243.638), calendar method (5.40%, or: 0.877; 95%ci: 0.2173.533), cervical ring (11.10%, or: 0.422; 95%ci: 0.064-2.766) and injection (12.80%, or: 0.367; 95%ci: 0.096-1.406). the fear of becoming pregnant by using contraceptive methods in the western region of saudi arabia led to careful use of iuds to avoid their side effects as repeated infections, slipping of the iuds, bleeding from different types and use the suitable iuds shape for women uterus that result in low level of failure of their usage in this study. comparing the reported 12-month failure rates obtained in this study with those of polis et al. that reported large-scale analysis of contraceptive failure in 43 countries revealed that, failure rate was higher than ours by usage of oral contraceptive pills (5.50% versus 4.70%), male condoms (5.40% versus 3.20%) and withdrawal (13.40% versus 2.80%) [10]. these difference in the failure rate may be due to difference in the knowledge regarding ideal methods for using contraceptive methods and also difference in the number of women participate in the study. poor success rates of the available methods of contraception will result in unplanned pregnancies, which might consequently lead to voluntary termination, orphaned children, and decreased education completion rates (as a result of the mother dropping out of school to take care of the child). in fact, a report by the institute of medicine illustrates that the birth of an unwanted second child is associated dropping out of high school, dependence of welfare, and income below the poverty level [11]. another study found that with the lack of contraceptive failure, the prevalence of unplanned births could be decreased by almost 50%. the data of this study revealed that 33 women out of 649 (5%) get pregnant while using contraceptive methods. in countries with available abortion data between one-third and two-thirds of prompted abortions could be prevented if contraceptive failure was avoided [7]. in conclusion, the most common type of contraceptive used in this study was contraceptive pills followed by iud, withdrawal method and male condom. the overall contraceptive failure rate was high in participants used withdrawal, male condom, lactation, and contraceptive pills; while, contraceptive failure rate was low in participants using iud, patch, calendar method, cervical ring and injection. primigravida cases had the highest risk of contraceptive failure. the use of more effective methods of contraception will help families avoid unplanned pregnancies and its complications. references: 1. farrag oa, rahman ms, rahman j, chatterjee tk, al-sibai mh. attitude towards fertility control in the eastern province of saudi arabia. saudi med j. 1983; 4(2):111–6. 2. al-nahedh nna. the effect of sociodemographic variables on child-spacing in rural saudi arabia. east mediterr health j. 1999; 5(1):136–140. 3. sedgh g, singh s, hussain r, intended and unintended pregnancies worldwide in 2012 and recent trends. studies in family planning, 2014; 45(3):301–314. 4. singh s, darroch je, ashford ls, adding it up: the costs and benets of investing in sexual and reproductive health 2014, new york: guttmacher institute, 2014. 5. brown ss, eisenberg l. demography of unintended pregnancy, in: brown ss and eisenberg l, eds., the best intentions: unintended childbearing and the well-being of children and families, washington, dc: national academy press, 1995. 6. gipson jd, koenig ma, hindin mj. the effects of unintended pregnancy on infant, child, and parental health: a review of the literature, studies in family planning, 2008, 39(1):18–38. 7. bradley sek. the impact of contraceptive failure on unintended pregnancy and abortion . prepared for the annual meeting of the population association of america 2010; 1–19 8. bradley sek, schwandt hm, khan s, 2009. levels, trends, and reasons for contraceptive discontinuation. dhs analytical studies no. 20. calverton, maryland, usa: icf macro. 9. curtis sl, blanc a, 1997. determinants of contraceptive failure, switching, and discontinuation: an analysis of dhs contraceptive histories. dhs analytical reports no. 6. calverton, maryland: macro international inc. 10. polis cb, bradley sek, bankole a, onda t, croft t, and singh s. typical-use contraceptive failure rates in 43 countries with demographic and health survey data: summary of a detailed report. contraception 2016; 94 (1):11–17. 11. brown ss, eisenberg e (eds). the best intentions: unintended pregnancy and the well-being of children and families. committee on unintended pregnancy. institute of medicine, national academy of sciences; 1995:55-59. table 1. demographic characteristics of participants (n=959). data are expressed as number (%). table 2. data on the use of contraceptive methods by all the participants (n=959). *iud: intrauterine device data are expressed as number (%) or mean±standard deviation (minimum–maximum), as appropriate. x 137gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra parameters value age groups <20 years 48 (5.00%) 20–35 years 547 (57.00%) >35–50 years 302 (31.50%) >50 years 62 (6.50%) education levels primary education 283 (29.50%) diploma 3 (0.30%) graduate 584 (60.90%) post graduate 89 (9.30%) marital status not married 85 (8.90%) yes and sexually active 788 (82.20%) divorced or widowed 86 (9.00%) marriage duration ≤1 year 88 (9.20%) 2–10 years 399 (41.60%) >10 years 387 (40.40%) number of children nullipara 102 (10.60%) primigravida 157 (16.40%) multipara 615 (64.10%) parameters value usage of contraceptives no 310 (32.30%) yes 649 (67.70%) duration of using contraceptives <1 year 213 (22.20%) ≥1–5 years 311 (32.40%) >5 years 125 (13.00%) reason for usage of contraceptives to avoid pregnancy 528 (55.10%) medical issue 27 (2.80%) have not used contraceptives 310 (32.30%) type of contraception used contraceptive pills 304 (31.70%) iud* method 203 (21.20%) withdrawal method 157 (16.40%) male condom 132 (13.80%) calendar method 57 (5.90%) patch 51 (5.30%) lactation 37 (3.90%) injection 19 (2.00%) cervical ring 13 (1.40%) cervical mucus method 7 (0.70%) female condom 6 (0.60%) body temperature method 4 (0.40%) diaphragm 4 (0.40%) spermicidal cream 3 (0.30%) implant 1 (0.10%) others (fallopian tube ligation) 1 (0.10%) volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra cross tabulation analysis was used to estimate the relative risk and 95% ci. table 4. risk of pregnancy despite the use of different methods of contraception (n=649). cross tabulation analysis was used to estimate the relative risk and 95% ci. references: 1. farrag oa, rahman ms, rahman j, chatterjee tk, al-sibai mh. attitude towards fertility control in the eastern province of saudi arabia. saudi med j. 1983; 4(2):111–6. 2. al-nahedh nna. the effect of sociodemographic variables on child-spacing in rural saudi arabia. east mediterr health j. 1999; 5(1):136–140. 3. sedgh g, singh s, hussain r, intended and unintended pregnancies worldwide in 2012 and recent trends. studies in family planning, 2014; 45(3):301–314. 4. singh s, darroch je, ashford ls, adding it up: the costs and benets of investing in sexual and reproductive health 2014, new york: guttmacher institute, 2014. 5. brown ss, eisenberg l. demography of unintended pregnancy, in: brown ss and eisenberg l, eds., the best intentions: unintended childbearing and the well-being of children and families, washington, dc: national academy press, 1995. 6. gipson jd, koenig ma, hindin mj. the effects of unintended pregnancy on infant, child, and parental health: a review of the literature, studies in family planning, 2008, 39(1):18–38. 7. bradley sek. the impact of contraceptive failure on unintended pregnancy and abortion . prepared for the annual meeting of the population association of america 2010; 1–19 8. bradley sek, schwandt hm, khan s, 2009. levels, trends, and reasons for contraceptive discontinuation. dhs analytical studies no. 20. calverton, maryland, usa: icf macro. 9. curtis sl, blanc a, 1997. determinants of contraceptive failure, switching, and discontinuation: an analysis of dhs contraceptive histories. dhs analytical reports no. 6. calverton, maryland: macro international inc. 10. polis cb, bradley sek, bankole a, onda t, croft t, and singh s. typical-use contraceptive failure rates in 43 countries with demographic and health survey data: summary of a detailed report. contraception 2016; 94 (1):11–17. 11. brown ss, eisenberg e (eds). the best intentions: unintended pregnancy and the well-being of children and families. committee on unintended pregnancy. institute of medicine, national academy of sciences; 1995:55-59. 138 x gjra global journal for research analysis table 3. relative risk of pregnancy despite the use of different methods of contraception (n=649). contraceptive methods total pregnancy chi-square test odd's ratio (95% ci) no yes contraceptive pills 234 (100.00%) 223 (95.30%) 11 (4.70%) 0.001 1.025 (0.500-2.102) iud method 163 (100.00%) 155 (95.10%) 8 (4.90%) 0.001 0.964 (0.440-2.113) withdrawal 106 (100.00%) 103 (97.30%) 3 (2.80%) 0.001 1.822 (0.564-5.884) male condom 93 (100.00%) 90 (96.80%) 3 (3.20%) 0.001 1.561 (0.484-5.031) calendar method 37 (100.00%) 35 (94.60%) 2 (5.40%) 0.001 0.877 (0.217-3.533) patch 38 (100.00%) 36 (94.70%) 2 (5.30%) 0.001 0.902 (0.224-3.638) lactation 25 (100.00%) 24 (96.00%) 1 (4.00%) 0.001 1.202 (0.171-8.464) injection 16 (100.00%) 14 (87.50%) 2 (12.50%) 0.001 0.367 (0.096-1.406) cervical ring 9 (100.00%) 8 (88.90%) 1 (11.10%) 0.001 0.422 (0.064-2.766) cervical mucus method 5 (100.00%) 5 (100.00%) female condom 5 (100.00%) 5 (100.00%) body temperature method 1 (100.00%) 4 (100.00%) diaphragm 3 (100.00%) 3 (100.00%) spermicidal cream 2 (100.00%) 2 (100.00%) parity total pregnancy odd's ratio (95% ci) signicance no yes nullipara 63 (100.00%) 60 (95.20%) 3 (4.80%) 1.003 (0.3143.207) 0.001 primigravida 106 (100.00%) 97 (91.50%) 9 (8.50%) 0.477 (0.2261.007) 0.001 multipara 445 (100.00%) 426 (95.70%) 19 (4.30%) 1.378 (0.6822.784) 0.001 introduction: polycystic ovary syndrome is a complex heterogeneous disorder of the female endocrine system with uncertain etiology. it affects about 5-10% of the female population who are in the age group of 12–45 years and produces symptoms in approximately 5% to 10% of women of reproductive age and is thought to be one of the leading causes of fertility. the syndrome is characterized by chronichyperandrogenism; polycystic ovaries results in excessive amounts of androgenic (masculinizing) hormones, acne and hirsutism, insulin resistance which is often associated with obesity of bmi >30 2kg/m ,type ii diabetes, high cholesterol levels and anovulation 2resulting in irregular menstruation, amenorrhea. polycystic ovaries contain a large number of harmless cysts that are not bigger than 8mm each. normal ovaries have only about half this number of cysts. the cysts are under-developed follicles which contain eggs that have not developed properly. often in pcos, these follicles are unable to release an egg and results 3in anovulation. these ovaries result in complications such as cardiovascular diseases and endometrial cancer, ovulationrelated infertility as women ages and affects approximately 50% of women population. the rst goal is to eliminate the symptoms and stabilize the body mass. the ongoing goals are to prevent long-term complications and to improve the fertility life of the women. need of the study : the high prevalence of overweight and obesity (bmi ≥30 kg/m2) is signicantly contributing to the overall burden of pcos worldwide. the pcos is reported to be a growing problem with adolescent girls. adolescents may experience the full range of symptoms including irregular or complete absent of menstruation. research has proved that pcos predisposes the women including adolescent girls to additional health problems.4 .most studies showed that polycystic ovaries are present in 3-7% of women worldwide. in india it is estimated that the incidence is higher and probably three times more than that found in the western world. although most patients present in their 20s or 30s, polycystic ovarian disease can affect females of any age, from menarche to menopause.4. polycystic ovarian diseases syndrome (pcos) accounts for –90% of women with oligomenorrhea, 30% of women with amenorrhea and over 70% of women with anovulation. a study was conducted to assess the effect of overweight on pcos by including 52 unmarried girls between 15 to 25 years of age. the result of the study showed that most (88%) of the girls were having oligomenorrhea, 65% girls were obeyed in which 88% girls have hirsutism and menstrual disturbances. the study concluded that polycystic ovarian disease syndrome is affecting the lives of young unmarried girls due to obesity and recommended that, the prevention of obesity is a major factor in reducing the pcos among adolescents.5 based on the review literature available, expert's opinion, the researcher felt the need to teach regarding polycystic ovaries and its effect on adolescents and their crucial role in preventing its complications and thereby improving the reproductive life of adolescents. statement of the problem “a study to evaluate the effectiveness of structured teaching program regarding knowledge on polycystic ovarian disease among the adolescents girls in selected community of bhopal ” objectives of this study: ÿ to assess the existing knowledge on polycystic ovarian disease among the adolescents girls by conducting pretest. ÿ to evaluate the effectiveness of structured teaching programme by comparing pretest and posttest knowledge scores. ÿ to determine the association between the pretest knowledge scores on polycystic ovarian disease among the adolescents girls with their selected demographic variables. hypotheses: h1 there will be signicant differences between pretest and post-test knowledge scores polycystic ovaries among the adolescents girls. h2 there will be signicant association between pretest knowledge scores onpolycystic ovaries among the adolescents girls with their selected demographic variables. research methodology: research approach and design: the research approach adopted for the study evaluative and research design was preexperimental research design. setting: the setting of the study was the shahpura rural community bhopal. effectiveness of structured teaching program regarding knowledge on polycystic ovarian disease among the adolescents girls original research paper prof. venice mairya david chirayu college of nursing nursing the aimed of the study was a) to assess the existing knowledge on polycystic ovarian disease among the adolescents girls by conducting pretest b)to evaluate the effectiveness of structured teaching programme by comparing pretest and posttest knowledge scores c) to determine the association between the pretest knowledge scores on polycystic ovarian disease among the adolescents girls with their selected demographic variables.a evaluative study was carried out with a sample size of 60 adolescents select by purposive sampling methods in sharapura rural community . the result shows that, the mean difference between pretest and posttest knowledge score is 2.5. this indicates an increase in knowledge scores after undergoing structured teaching programme. to nd the signicance of gain in knowledge paired' z value was computed and the obtained value of' z'(59) : 11.6 was found to be signicant at 0.05 level of signicance. association between pretest knowledge scores of adolescent girls regarding pcod with their selected demographic variables were found to be not signicant at 0.05 level of signicance except monthly income, known case of pcod and previous source of information. so researcher partially reject null hypothesis and partially accept research hypothesis abstract keywords : adolescents girls, polycystic ovarian disease volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 50 x gjra global journal for research analysis population: the accessible population of the study was the adolescent's girls of shahpura rural community bhopal. sampling criteria: inclusion criteria: adolescents girls who are willing to participate in the study and present at the time of data collection, adolescents girl who can read and write hindi exclusion criteria: adolescents girls who have undergone educational program on polycystic ovarian disease and adolescents girls who having polycystic ovarian disease. sampling technique: the sampling technique adopted for the present study was purposive sampling techniques. sample size: a total of 60 adolescents were the sample size. tool for data collection: it comprises of two section with demographic categories and section b with structured knowledge questionnaire consist of 30 item. data collection procedure: the study was furthered by obtaining clearance from the research committee of the institution. permission taken from the chief medical ofcer of the community. consent was solicited with the adolescent girls who met the sampling criteria. the demographic data was gathered using structured interview methods and tool was administered to them and self-reports were gathered. the study was conducted in february 2018. result and discussion; the results are organized in accordance to the objectives of the study below: section 1. effectiveness of structured teaching programme: 1: description of adolescent girls knowledge regarding pcod: the pretest and posttest knowledge scores obtained by subjects were tabulated to a master data sheet and mean, median, range, standard deviation of pretest and posttest were computed. the ndings are presented in table.1 ( mean, median, range, standard deviation of pre-test and post-test knowledge scores of adolescent girls regarding pcod). n= 60 data presented in table1 shows that the pre-test knowledge scores ranged from 9-22. the mean pre-test knowledge score is 15.2 with a standard deviation of ±3.7. the median score is 15. the post-test knowledge score is 17.8, the standard deviation of ±4.2 and median of 26. table 2 frequency and percentage distribution of adolescent girls according to their level of knowledge n = 60 data presented in table 2 shows that in pre test majority (85%) of them have average knowledge, 8.3%have poor knowledge and 6.6% have good knowledge were as in the post test majority of them have average knowledge (76.6%), 23.3% have good knowledge and none of them have poor knowledge. section ii: comparison of mean pretest and posttest knowledge scores: signicance of difference between pretest and posttest knowledge scores of adolescent girls:in order to nd out signicance of difference between the mean of pretest and posttest knowledge scores, paired test was computed. the data are represented in the table 3.to test the statistical signicance following research hypotheses were stated.h1: there will be signicant differences between pretest and posttest knowledge scores polycystic ovarian disease among the adolescents girls table 3: mean, mean difference, z test of pretest and posttest knowledge scores of adolescent girls regarding pcod. n = 60 z59= 2.0010 ; p < 0.5 * signicant. the data presented in table 3 shows that, the mean difference between pretest and posttest knowledge score is 2.5. this indicates an increase in knowledge scores after undergoing structured teaching programme. to nd the signicance of gain in knowledge z test value was computed and the obtained value of 'z'(59) : 11.6 was found to be signicant at 0.05 level of signicance section 3: association between pretest knowledge score with selected demographic variable's the data presented in table 4 shows that the computed chisquare values for association between pretest knowledge scores of adolescent girls regarding pcod with their selected demographic variables were found to be not signicant at 0.05 level of signicance except monthly income, known case of pcod and previous source of information. so researcher partially reject null hypothesis and partially accept research hypothesis recommendation of the study: on the basis of nding of the study .it was recommended that; 1. similar study may be replicated on a large scale 2. studies may be conducted to evaluate the effectiveness of alternative therapy on treatment of polycystic ovarian diseases. implications; finding of the study have different implication in the eld of nursing education ,nursing practice , nursing administration and nursing research .based on the nding of study nursing curriculum should lay more emphasis on the community health nursing nurse educators should have the responsibility to upgrading the knowledge of adolescent girls on community during clinical posting . conclusion: in the present study, the pretest nding showed that most of adolescent girls 51 (85%) are having average knowledge, 5 (8.3%) are having poor knowledge and 4 (6.6%) are having good knowledge regarding pcod. the posttest ndings volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra test mean median range sd pre test 15.2 15 9-22 3.7 post test 17.8 26 14-26 4.2 pre test post test knowledge score frequency (f) (%) frequency (f) (%) poor (0-10) 5 8.3 0 0 average(11-20) 51 85 46 76.7 good (21-30) 4 6.7 14 23.3 knowledge score mean mean difference sd difference z' test value pre test 15.3 2.5 ±0.5 11.6* post test 17.8 x 51gjra global journal for research analysis showed that majority of the adolescent girls46 (76.6%) have average knowledge and 14 (23.3%) are having good knowledge regarding pcod. and none of them have poor knowledge. the mean difference between the mean pretest and posttest knowledge score was 2.5 with the standard deviation difference for 0.5. the paired "z” (59) = 11.6 which was signicant at 0.05 level of signicance the ndings of present study concluded that structured teaching program regarding pcod was very effective in increasing knowledge of adolescent girls at 0.05 level of signicance hence the study gave the evidence that structured teaching programme regarding pcod can improve knowledge of adolescent girls and it will help to change in their day to day life. ethical clearance: permission was obtained from the institutional research advisory committee. source of fund: self conflict of interest: the author declares no conict of interest. reference : 1. walter kh. kuchenbecker, henkgroen, et.al. in women with polycystic ovary syndrome and obesity; loss of intra-abdominal fat is associated with resumption of ovulation. [internet] 2011 august [cited 2011 nov 10]; 26(9):2505-2512. 2. dutta d.c. textbook of gynaecology.5thedition, new central book agency publication; 2000.p.268-282 3. myles. textbook of midwives, 14thedition, elsevier publication; 2007.p.177 4. gambineri a, pelusi c, vicennativ,et.al.obesity and the polycystic ovary syndrome.international journal of obesity and related metabolic disorders[internet]2002[cited 2011 nov10];26:883-896 5. rotterdam eshre/asrm-sponsored pcos consensus workshop group:revised 2003 consensus on diagnostic criteria and long-term health risks related to polycysticovary syndrome (pcos). human reproduction. [internet] 2004[cited 2011 nov 8]; 19:41. available from volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 52 x gjra global journal for research analysis introduction: food is very essential for growth and development. 'good food is the right kind of food which is healthy; containing natural substances that body needs for development and to stay healthy. food that can be served ready to eat fast refers to fast food. consumption of energy dense food with high sugar/ fat/ salt content and low nutrient value in terms of protein/ bre/ vitamin/ mineral content constitute junk food. the terms fast food and junk food can be used interchangeably. nutrition transition is the shift in dietary consumption and energy expenditure that coincides with economic, demographic, and epidemiological changes. specically the term is used for the transition of developing countries from traditional diets high in cereal and bre to more western pattern diets high in sugars, fat, and animal-source food. india is experiencing “nutrition transition” characterized by increasing consumption of junk/ fast food. the double burden of undernutrition and overnutrition in developing countries is a public health challenge. high fat and sugary products being addictive in nature attract children over healthy foods. the ready availability, taste, commercial marketing strategies, and peer pressure makes junk food popular among children and adolescents. high consumption of junk food is associated with increased risk of obesity, diet-related non-communicable-diseases (hypertension/ diabetes/ cardio-vascular disease/ dyslipidaemia/ metabolic-syndrome/depression/ cancers) indicating burgeoning health concerns in the near future for children. young generation is getting addicted to junk food indicating a serious public health problem; hence this study was conducted with the aim to nd the prevalence and determinants of junk food consumption among school going children of rohtak district, haryana. methodology: a cross-sectional study was conducted among 200 children, selected randomly by the purposive sampling method, studying in a government school of district rohtak, haryana, using a semi-structured self-administered questionnaire. data was entered in ms excel sheet and analysed using spss-software. results: high prevalence (84.5%) of jf consumption in the last 24-hours among school children was found. (mean age=13.40 ± 1.79 years). out of 200 study participants 169 were the total subjects who had taken junk food in the last 24-hours, of which 53.85% were males and 46.15% were females (table-1). junk food intake was found to be higher among males (p=0.01). the most popular junk food items were chips (68.05%) followed by soft-drinks (66.86%), chocolate (56.80%), bakery-products (46.75%) and others (25.44%) (table-2). however, 64.50% children out of 169 junk food consumers were consuming 2 or more junk food items in the last 24-hours of the survey (table-3). the study found that the jf was consumed mainly as snacks from shops outside the school after the school-hours. table-1: distribution of the study subjects according to the junk food intake in the last 24-hours consumption of junk food by school going children in rohtak district, haryana: a cross-sectional study original research paper dr. ginni agrawal junior resident-department of community medicine, pt.b.d.sharma pgims, rohtak community medicine background: consumption of energy dense food with high sugar/fat/salt content and low nutrient value in terms of protein/bre/vitamin/mineral content constitute junk food which invites various health problems. high consumption of jf is associated with increased risk of obesity, diet-related noncommunicable-diseases (hypertension/diabetes/dyslipidaemia/metabolic-syndrome/cancers/etc) indicating burgeoning health concerns in the near future for children. objective: young generation is getting addicted to jf indicating a serious public health problem; hence this study was conducted to nd the prevalence and determinants of jf consumption among school going children of rohtak district. material and methods: a cross-sectional study was conducted among 200 children, selected randomly, studying in a government school of district rohtak, haryana, by using semi-structured self-administered questionnaire. data was analysed using spss-software. results: high prevalence (84.5%) of jf consumption during the last 24-hours among school children (mean age=13.40±1.79years) was found, out of which 53.85% were males and 46.15% were females. jf intake was found to be higher among males (p=0.01). the most popular jf item was chips (68.05%) followed by soft-drinks (66.86%), chocolate (56.80%), bakery-products (46.75%) and others (25.44%). however, 64.50% children were consuming 2 or more jf items in the last 24hours of the survey. the study found that the jf was consumed mainly as snacks from shops outside the school after the schoolhours. conclusion: there is need to initiate nutrition interventions to reduce the high intake of jf by educating children regarding the possible health consequences. the formation of laws to regulate the marketing and advertising jf around school premises may help in reducing the consumption of jf among children. abstract keywords : dr. piyush jain* junior residentdepartment of forensic medicine, pt.b.d.sharma pgims, rohtak *corresponding author amit kumar mital senior resident-department of paediatrics bps gmc, khanpur kalan, sonepat, haryana volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra gender frequency (n=169) percentage (%) male 91 53.85% 26 x gjra global journal for research analysis table-2: junk food items consumed in last 24-hours. *(multiple response) table-3: distribution of the study subjects according to the junk food consumption. discussion: high prevalence (84.50%) of junk food consumption among school going children was found in the study. it was observed that the junk food was consumed mainly as snacks from shops outside the school during evening time after the end of school and there was no school canteen in the school premises. studies conducted by koteka et al, singh et al and gupta et al (1) (2) (3)also reported high junk food consumption . food items such as chips, soft-drinks, chocolates, bakery productspastries, ice-creams or other junk food items such as samosa, kachori, gol-gappe, pakode, etc were mainly consumed by the school going children. kotecha et al, reported higher consumption of junk food items (56%) such as chocolates, pastries and sweets and soft drinks (39%) by school students (1)in the last 24 hours. consumption of junk food items such as chocolate (28%), bakery items (14%), and ice cream (35%) by school going children was also found in the study by singh et (2)al. harrell et al, likewise reported that soft drinks consumption was daily among 30% of their study population (4)i.e. school going children. in the present study 54.5% subjects were consuming 2 or more junk food items in the last 24 hours. likewise, gupta at al also found that majority (78%) of the children consumed one junk food item in the last 24 hours and 22% children were consuming 2 or more junk food items in the last 24 hours of the (4)survey. high consumption of fried foods and sugary drinks has been observed to be signicantly associated with high body mass index and weight status in children. in addition, diets with high amounts of junk food have overall low quantity of nutrients. hence, high consumption of junk food can contribute to the “double burden of malnutrition,” undernutrition, and overnutrition occurring simultaneously. conclusion: high prevalence of junk food consumption among school going children was observed. the attracting advertisements are largely responsible for the mind make up of children to consume junk food. multinational companies are attracting the new customers by attractive and aggressive marketing strategies. school administrator along with parents has a responsibility to educate the children about junk food. there is need to initiate nutrition interventions to reduce the high intake of junk food by educating children, their parents and teachers regarding the possible deteriorating health consequences of junk food with external support of researchers and public health educators. this may help in inculcating the practice of consumption of healthy foods from young age. the formation of laws to regulate the marketing and advertising junk food around school premises may help in reducing the consumption of junk food among children. references: 1. kotecha pv, patel sv, baxi rk, mazumdar vs, shobha m, mehta kg, et al. dietary pattern of school going adolescents in urban baroda, india. j health popul nutr. 2013;31:490-6. 2. singh m, mishra s. fast food consumption pattern and obesity among school going (9-13 year) in lucknow district. int j sci res. 2014;3:1672-4. 3. gupta a, kapil u, singh g. consumption of junk foods by school-aged children in rural himachal pradesh, india. indian j public health. 2018;62:65-7. 4. harrell m, medina j, greene-cramer b, sharma sv, arora m, nazar g. understanding eating behaviors of new dehli’s youth. j appl res child. 2016;6:8. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra female 78 46.15% total 169 100% items consumed in last 24-hours frequency (n=200) percentage (%) single junk food item consumed 60 30% 2 or more junk food items consumed 109 54.5% none 31 15.50% total 200 100% s.no. items frequency (n=169) percentage (%) 1. chips 115 68.05% 2. soft-drinks 113 66.86% 3. chocolate 96 56.80% 4. bakery products 79 46.75% 5. others 43 25.44% x 27gjra global journal for research analysis 1. introduction let us think about the growing environmental problem in current times. then the answer would be the deterorating air quality in the atmosphere. this is causing serious respiratory diseases to all the living beings living on this planet. here we can take the example of the current air crisis in the capital city of india i.e. new delhi. it is being on the world news since the day it has occurred. many measures has been taken to reduce it but there is only a little success which has been achieved. so, the question arises what causes this insane amount of pollution in our atmosphere. there has to be some particles which are being termed as the air pollutants [1]. the basic air pollutants are being classied in some categories which are listed below: 1) particulate matter 2) bacteria and virus cells 3) odorous gases and aerosols 4) volatile organic compounds (vocs) 5) carbon monoxide 6) sulphur oxides 7) nitrogen oxides 8) radioactive pollutants the above table denes the composition of different particles in air. after studying the above table, it can be examined that not only oxygen is useful, other components of air also have their uses for the humanity to survive. there are basically two major types of air pollutants: 1) gasous compounds 2) compounds in solid form we are basically trying to target the gaseous compounds with the chemical composition which can be neutralized by using the oxygen ions. we are making a device to be rstly used in the cars to reduce the pollution in the atmosphere of the car by generating electricity from the battery of the car and inducing the positive and negative ions of oxygen into the air. air quality can only be improved by increasing the amount of positively as well as negatively charged oxygen ions into the atmosphere [2]. the idea relates to a device for producing active oxygen ions in the air for improved air quality, comprising at least one air ionizer and an electric transformer producing sufcient electrical high voltage for air ionization. the air ionizer is coupled to a sensor which detects the oxidizable gas content in the air (air pollution sensor). on the basis of the detected content of such oxidizable gases, the electrical energy which is guided to the air ionizer is transformed by an electrical control device in such a way that only low-level ionization occurs at low concentration of oxidizable gases. said ionization is sensor-controlled and can automatically be increased to a maximum value when the concentration of oxidizable gases rises. 1. objective invisible and often ignored, indoor air is dangerous to human health and damaging to productivity and cognition. depending on the environment, indoor air can be up to 100 times more polluted than outdoor air – teeming with volatile organic compounds and microorganisms that contain or attach to viruses, bacteria, fungal spores, and pollen. humans spend between 80–95% of their lives inside buildings air pollutant neutralization device original research paper nikhil gupta department of mechanical engineering,iimt college of engineering, greater noida x 119gjra global journal for research analysis mechanical engineering in this morden era we are inhaling air polluted air that needed to puried.as we know there are many air purier present in the market but they can not destroy the air pollutants. the concept of the device is to neutrilize the molecules pulluting the air. for this process we will use the concept of anode and cathode electrodes.positively charged ions will neutrilize the negatively charged pollutant ions and negatively charged ions will neutrilize the positively charged ions of pollutants thus providing a puried and clean air to breath. initially this device is being designed only for cars after that is can use on a large scale. abstract keywords : air pollutant, pollutant neutralization device, mohan sharma* department of mechanical engineering,iimt college of engineering, greater noida*corresponding author mohd. urooj department of mechanical engineering,iimt college of engineering, greater noida volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra mohd. zeeshan ali khan department of mechanical engineering,iimt college of engineering, greater noida component % in atmosphere importance nitrogen 78% – 79% ÿ dilutes the effects of oxygen ÿ very important in the growth of animals and plants oxygen 21.1 % ÿ essential in the lives of animals and plants, for breathing ÿ is the supporter of burning carbon dioxide 0.03% ÿ absolutely essential for photosynthesis (which supports all life on the planet) water vapour variable ÿ controls evaporation and climatic conditions dust particles variable ÿ nuclei for precipitation of rainwater 120 x gjra global journal for research analysis inhaling more than 350 cubic feet of polluted indoor air every day. exposure to these pollutants can lead to infectious disease, asthma, allergies, headaches and irritation [3]. reduction of the air pollutants we are trying to construct a device which is capable of reducing the air pollutants by oxidizing them using the unstable oxygen ions. the problem in today's context is the deteriorating air quality which needs to be given attention at the earliest as it is causing harm to the environment as well as the living organisms. what we are trying to achieve this value of cadr this much reduction of this disease causing bacteria reduction of these breathing problem bacteria reduction of this virus understanding the problem healthy breathing air is described as air without substantial parts of noxious gases or noticeable, in many cases unpleasant odorous substances. healthy inhaled air is to contain a number as low as possible of bacteria, viruses and other germs, which is very important. odorous materials drastically reduce the comfort, the condition and the capability to concentrate and thus the life quality of the exposed human being. it can be easily realized that for example the stink of kerosene and other engine exhaust gases renders impossible the tasting of delicious meals or at least substantially reduces the taste in restaurants, for example at airports or close to the road, because the gustatory nerves and the olfactory nerves are blocked to such an extent by the base load of stink that they are unable to perceive any shades. it is also known that the continuous presence in highly charged air renders tired and fatigued. human beings, which have to work in bad air make after some time signicantly more errors as compared to human beings, which work in problem-free air. it is also known that electrostatic charges are generated to an increased extent, if the air present in the room is poor in ions or, respectively, where positively charged ions or negatively charged ions dominate. such air, commonly designated as “electrically charged” exerts uncontested inuence on the vegetative nervous system. furthermore, damages of electronic apparatus and data carriers can occur based on static charges. in addition, the level of sick people in enterprises, which are not able to offer good breathing air to their co-workers based on bad functioning air conditioning plants, is substantially higher as the level of sick people of enterprises, where attention is paid to perfect air [4]. a xedly set ionization apparatus cannot lead to a satisfactory solution in these cases, because either the ionization power is insufcient and thereby the smells and germs are not effectively combated or however in case of ionization powers set to a high level contaminant load appear interfering in case of a low air contamination by smellable and possibly dangerous ozone concentrations. 1. technical purpose it is an object of the present invention to create an apparatus for the physical processing of air, in particular of breathing air, which corresponding to the load of the air with smelling materials or exhaust gases is capable to perform an ionization of the air depending on the concentration of the smelling materials or exhaust gases. one of the essential technical problems comprises, to adapt the ionization power of the recited ionization apparatus such that on the one hand an effective combating of smells and germs is furnished and on the other hand however, no excess ozone concentration should be generated thereby. literature review 1) in particular when knowing the fact that annually more than 40,000 people become sick with fatal results in germany by airborne infections, for example in hospitals, in restaurants, and in means of mass transport, as was determined by a scientic study of the robert-kochinstitute (bundesgesundheitsblatt issue 7/96, page 246). 2) the cost of these nosocominal infections are estimated by the authors to be more than 3 billion german marks. odorous materials drastically reduces the comfort, the condition and the capability to concentrate and thus the life quality of the exposed human being. 3) it can be easily realized that for example the stink of kerosene and other engine exhaust gases renders impossible the tasting of delicious meals or at least substantially reduces the taste in restaurants, for example volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra at airports or close to the road, because the gustatory nerves and the olfactory nerves are blocked to such an extent by the base load of stink that they are unable to perceive any shades. 4) it is also known that the continuous presence in highly charged air renders tired and fatigued. human beings, which have to work in bad air make after some time signicantly more errors as compared to human beings, which work in problem-free air. it is also known that electrostatic charges are generated to an increased extent, if the air present in the room is poor in ions or, respectively, where positively charged ions or negatively charged ions dominate. such air, commonly designated as “electrically charged” exerts uncontested inuence on the vegetative nervous system. 5) furthermore, damages of electronic apparatus and data carriers can occur based on static charges. in addition, the level of sick people in enterprises, which are not able to offer good breathing air to their co-workers based on bad functioning air conditioning plants, is substantially higher as the level of sick people of enterprises, where attention is paid to perfect air. 6) the passengers in a motor vehicle are annoyed and at times damaged in their health based on the exhaust gases of other motor vehicles. the journal “scientist”, issue september 1996, cites in this context a danish investigation, according to which the risk to become sick with lung cancer is for bus drivers 50 percent higher than in a comparison group of persons. sensible known steps for reducing the emissions of passengers of motor vehicles are for example sensor controlled ventilation systems, wherein the inow of outer air is stopped always then and switched to circulating operation, when the vehicle reaches a zone of increased contaminant concentration. 7) furthermore active carbon lters are known and are employed, which have a limited retaining capacity relative to some gases and vapours and of course dust and pollen. larger concentrations however cannot be retained by the lters. in addition, there exist lter passing gases such as for example the poisonous carbon monoxide and nest dust and soot, such as are given off for example by diesel motors, which are considered to be cancer promoting. 8) in general the known ionization apparatuses are furnished with a hand operated switch, with the aid of which taps at transformers can be switched with the effect, that different voltages are fed to the ionization tube in order to be able to adjust in this fashion the power of ionization. 2. working principle the solution of this object comprises an apparatus of the initially recited kind, wherein the air ionizer is coupled to a sensor, which sensor determines the contents of the air in oxidizable gases (air quality sensor) and based on the determined contents of such oxidizable gases. the fed in electrical energy is changeable by way of an electric control device such that in case of low concentrations of oxidizable gases only a low ionization power is furnished, which can be increased controlled by a sensor and automatically with increasing concentration of oxidizable gases to a maximum value. an ion counter disposed after the air ionizer detects the number of the ions present in the air and acts through an electric circuit such onto the device or, respectively, the air ionizer, that in case of a low ion number the ionization power of the air ionizer is increased sensor controlled and automatic, and preferably continuously, and in case of a high ion number the ionization power of the air ionizer is decreased sensor controlled and automatic, and preferably continuously. thus the control of the ionization power of the air ionizer is connected according to the gas load of the air, in particular of the breathing air. an electrical control unit connected to the electrical supply, to the air ionizer, and to the sensor, which electronic control unit changes the electrical energy fed in to the air ionizer based on the content of oxidizable gases in the air as determined by the sensor such that in case of a low concentrations of oxidizable gases present in the air then only a small ionization power is effected, wherein the ionization power of the air ionizer increases to a maximum value as automatically controlled by the sensor and the control unit when an increase in concentration of oxidizable gases is sensed by the sensor. 3. conclusion as a result of making this device, air can be made sufciently pure so that we can inhale it without causing any harm to our body. initially, we are trying to make this device for a small enclosed area as to be installed in car. if it is successfully been built, then this device can also be made for larger areas like: 1) homes 2) ofces 3) community centers 4) malls 5) clubs etc… there is only one need for this device to work i.e. uninterrupted power supply. this device can cause precautions from many of the diseases caused by the bad air quality residing in the atmosphere. the main motive to make this device is to ensure that the air pollution is minimized, if not completely rectied, so as to make breathing easy and people don't need to wear masks even when they are in a secluded area. references [1] mykkanen us patent 4,757,421, 1988 google patents synchronized 180 degree out-of-phase continuous, simultaneous pulsing is found to produce waves of machines corporation, apparatus and method for neutralizing static charges in sheet/web feeding devices ) cited by 26 related articles all 2 versions [2] dyh pui, dr chen us patent 6,145,391, 2000 google patents, the exit for provision to downstream devices, cited by 59 related articles all 2 versions [3] rs fischer us patent 3,654,534, 1972 google patents cited by 99 related articles all 2 versions [4] l binkowski us patent 3,757,164, 1973 google patents x 121gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction an ectopic pregnancy (ep) occurs when a fertilized ovum 1 implants outside the normal uterine cavity. ectopic pregnancy (ep) is a condition presenting as a major health problem for 2 women of childbearing age. the incidence of ep varies with the population, but it has been accounted for 1-2% of all 3-4reported pregnancies. ectopic pregnancy (ep) is the leading cause of maternal death during the rst trimester of pregnancy, accounting for approximately 10 % of all 5 pregnancy-related deaths. it has been shown to reduce subsequent fertility and increase the chances of subsequent 6 ep. over recent decades, there has been a rise in the incidence 7of ep. approximately 1/100 pregnancies are ectopic, with the 8 conceptus usually implanting in the fallopian tube. approximately 75.0% of deaths in the rst trimester and 9.0% 9of all pregnancy-related deaths are due to ep. almost all eps occur in the fallopian tube (98.0%), the ampulla is the most common site of implantation (80.0%), followed by the isthmus (12.0%), mbria (5.0%), cornua (2.0%), and 10,11 interstitial (2.0-3.0%). the etiology of ep remains uncertain 12although a number of risk factors have been identied. a common factor for the development of such ectopics is the 13 presence of a pathologic fallopian tube. ep may be asymptomatic, and the most common clinical presentation is 14rst trimester vaginal bleeding and/or abdominal pain. in current practice, in developed countries, diagnosis relies on a combination of ultrasound scanning and serial serum beta15human chorionic gonadotropin (�-hcg) measurements. methods this is a retrospective observational study conducted in a tertiary care centre in ahmedabad from november 2017 to november 2018. all patients diagnosed with ectopic pregnancy (by clinical examination, usg and/or b hcg) were included in the study. the aims and objectives of the present study were to determine the demographic distribution of patients presenting with ep, determine the risk factors associated with the patients presenting with ectopic pregnancy, to describe the various locations and stats (ruptured/unruptured/tubal abortion) of ectopic pregnancies to describe the various modalities of treatment used in ep. results the incidence of ectopic pregnancies over one year was 1.17%. the commonest age of presentation was between 3540 years (table 1). table 1: age at presentation. ectopic pregnancy: clinical features, management and complications original research paper dr. pushpa a. yadava professor and head of unit, department of obstetrics and gynecology, smt. n.h.l municipal medical college, ahmedabad. x 29gjra global journal for research analysis obstetrics and gynecology background: an ectopic pregnancy (ep) occurs when a fertilized ovum implants outside the normal uterine cavity. the incidence of ep varies with the population, but it has been accounted for 1-2% of all reported pregnancies. ep is one of the few medical conditions that can be managed expectantly, medically or surgically. surgical methods are still the mainstay in the management of ep, and in developed societies, laparoscopic surgery is currently the gold standard. methods: this is a retrospective observational study conducted in a tertiary care centre in ahmedabad from november 2017 to november 2018. all patients diagnosed with ectopic pregnancy (by clinical examination, usg and/or b hcg) were included in the study. the aims and objectives of the study were to determine the demographic distribution, risk factors, clinical features, treatment modalities and complications in patients presenting with ep. results: the incidence of ectopic pregnancies in one year was 1.17%. the commonest age of presentation of ep was between 35-40 years, most of the patients were gravida 4 (28.57%). majority of patients presented at a gestational age between 6-8 weeks. most patients (64.28%) were found to have ruptured ectopic. 28.57% patients had a previous history of abortion. 14.28% of each ep were cornual and heterotopic as found intra-operatively. there was 1 interstitial and 1 scar ectopic pregnancy. the most common associated risk factor in these patients were a history of some form of pelvic surgeries in the past. most of these patients presented with pain in abdomen and were found to be anaemic. 64.28% of cases were diagnosed by combination of tvs and serum bhcg levels. two cases were managed medically, and obstetric hysterectomy was needed in the patient with ruptured scar ectopic gestation. conclusion: ectopic pregnancy has a rising incidence in today's world. with the use of better diagnostic modalities, ectopic pregnancies can be detected early and treated appropriately. also, because of its subtle presentations, patients often present late in the course of the disease, wherein management of the condition can be sometimes life saving. treatment however is easy and patients respond wonderfully with both medical and surgical management. abstract keywords : bhcg, ectopic pregnancy, tubal pregnancy, ultrasonography dr. apoorva g. patil* 3rd year resident, department of obstetrics and gynecology, smt. n.h.l municipal medical college, ahmedabad. *corresponding author dr. riya r. patel 3rd year resident, department of obstetrics and gynecology, smt. n.h.l municipal medical college, ahmedabad. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra age in years number of cases percentage less than 20 1 7.14 20-25 3 21.42 25-30 3 21.42 30-35 1 7.14 35-40 4 28.57 ≥40 2 14.28 30 x gjra global journal for research analysis table 2: obstetric score at presentation. most patients presented at a gestational age between 6-8 weeks (table 3). table 3: gestational age at presentation. table 4: intra-op (ruptured/unruptured). there was 1 interstitial and 1 scar ectopic pregnancy. 8 other ep were found in other parts of the fallopian tube (table 5). table 5: location of ectopic. 42.85% of patients have had some form of pelvic surgeries in the past. there were two cases (14.28%) of ep after tubal ligation (table 6). table 6: risk factors. table 7: management modalities. maximum cases (85.71%) were managed surgically and only 14.29% cases managed medically. discussion the incidence of ectopic gestation in our study was 1.17%. the incidence of ectopic pregnancy is on a rise due to better diagnostic technologies, iucds, increased incidence of pid and earlier diagnosis and management. in this study, the commonest age group of presentation was between 35-40 years. shafquat et al, showed the peak age of incidence as 26-30 years which was consistent with by 16,17 igbarese et al. aging may result in progressive loss of myoelectrical activity along the fallopian tubes. age related changes in tubal function and tubal diverticula which increases with age, predispose patients to ectopic 18pregnancy. a study conducted at department of the general hospital “george gennimatas” in athens, greece proved statistically signicant positive association between ectopic pregnancy 19rupture and parity. the average gestational age at presentation, in this study was between 6-8 weeks. mean gestational age at diagnosis of ep 20was 7.1 in the study conducted by tahmina s et al . the incidence of ruptured ectopic in our study was 35.71% and unruptured ectopic was 57.15%. however, in a study conducted by jani s et al, 35% of women had an unruptured 21 tubal pregnancy and 26% had a ruptured tube. thus, the incidence of ruptured ectopic pregnancy is lower as compared to unruptured ectopic pregnancy. the reason for this is the early detection and management of cases due to better diagnostic modalities. the incidence of heterotopic pregnancy in this study was 14.28%. heterotopic pregnancy was present in 4.2% of the 22ectopic pregnancies as per yeasmin et al. the commonest predisposing factors in ep were tubectomy, spontaneous and induced abortion and history of infertility, prior history of copper-t insertion and previous lscs in this 23study. similar risk factors were noted in various other studies. there has been one case of caesarean scar ectopic in our study. jurkovic et al. and seow et al. have estimated that the prevalence of caesarean scar pregnancy in their local population of women attending the early pregnancy assessment unit is~1:1800 and 1:2216 respectively. its true incidence, however, has not been determined because so few cases have been reported in the literature: only 18 cases appeared in the literature between 1978 and 2001 (fylstra, 24-262002). serum β-hcg and ultrasound were the diagnostic tools used for diagnosis of ectopic pregnancy in our study. studies have shown that ultrasonography should be the initial investigation for symptomatic women in their rst trimester; when the results are indeterminate, the serum β human chorionic gonadotropin concentration should be measured. the positive identication of a non-cystic adnexal mass with an empty uterus has a sensitivity of 84-90% and a specicity of 94-99% for the diagnosis of an ectopic gestation. in one large prospective study of 6621 patients, ectopic pregnancy was correctly diagnosed by tvs with a sensitivity of 90.9% and 27specicity of 99.9%. in our study, two cases were managed medically. both these cases were of primigravidae for whom medical management was considered for fertility sparing. it was found that the overall success rate for women treated with methotrexate for 27an ectopic pregnancy was 89% surgical management was done in 12 cases which included total salpingectomy. canis m et al in their study concluded that the surgical treatment should be performed if the patient is hemodynamically unstable, ß-hcg is >10 000 miu/ml, the ectopic pregnancy is 4cm in diameter, if there is a medical contraindication to methotrexate, and if the patient may not be 28followed adequately after treatment. no maternal mortality found in our study, consistent with abbas and h. akram 29 study. conclusion: ectopic pregnancy has a rising incidence in today's world. with the use of better diagnostic modalities, ectopic pregnancies can be detected early and treated appropriately. also, because of its subtle presentations, patients often present late in the course of the disease, wherein management of the condition can be sometimes life saving. treatment however is easy and patients respond wonderfully volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra gravida number of cases percentage g1 4 28.57 g2 3 21.42 g3 2 14.28 g4 4 28.57 g5 g6 1 7.14 gestational age (weeks) number of cases percentage 4-6 4 28.57 6-8 8 57.14 8-10 1 7.14 ≥ 10 1 7.14 number of cases percentage ruptured ectopic 5 35.71 unruptured ectopic 8 57.15 tubal abortion 1 7.14 location number of patients percentage cornual 2 14.28 interstitial 1 7.14 other sites on tube 8 57.14 heterotopic 2 14.28 scar ectopic 1 7.14 risk factor number of patients percentage infertility 1 7.14 pelvic surgery 6 42.85 history of tubal ligation 2 14.28 none 5 35.71 management modality number of cases percentage surgical 12 85.71 medical 2 14.29 with both medical and surgical management. wider availability of diagnostic modalities leads to early diagnosis and prompt management of ectopic pregnancy. references 1. berek js. early pregnancy loss and ectopic pregnancy. berek and novak's gynecology. 14th ed. philadelphia, pa: lippincott williams & wilkins. 2007:533-34. 2. zane sb, kieke ba, jr, kendrick js, bruce c. surveillance in a time of changing health care practices: estimating ectopic pregnancy incidence in the united states. matern child health j. 2002;6(4):227-36. 3. shaw jl, dey sk, critchley ho, horne aw. current knowledge of the aetiology of human tubal ectopic pregnancy. hum reprod update. 2010;16(4):432-44. 4. vichnin m. ectopic pregnancy in adolescents. curr opin obstet gynecol. 2008;20(5):475-8. 5. farquhar cm. ectopic pregnancy. lancet. 2005;366 (9485):583-91. 6. chow wh, daling jr, cates wj, greenberg rs. epidemiology of ectopic pregnancy. epidemiol rev. 1987;9(1):70-94. 7. walker jj. ectopic pregnancy. clin obstet gynecol. 2007;50(1):89-99. 8. bouyer j, coste j, fernandez h. sites of ectopic pregnancy: a 10 year population-based study of 1800 cases. hum reprod. 2002;17:3224-30. 9. marion ll, meeks gr. ectopic pregnancy: history, incidence, epidemiology, and risk factors. clin obstet gynecol. 2012;55(2)376-86. 10. bouyer j, coste j, fernandez h, pouly jl, job-spira n. sites of ectopic pregnancy: a 10 year populationbased study of 1800 cases. hum reprod. 2002;17(12):3224-30. 11. stein jc, wang r, adler n, boscardin j, jacoby vl, won g, et al. emergency physician ultrasonography for evaluating patients at risk for ectopic pregnancy: a meta-analysis. ann emerg med. 2010;56(6):67483. 12. shaw jl, dey sk, critchley ho, horne aw. current knowledge of the aetiology of human tubal ectopic pregnancy. hum reprod update. 2010;16(4):432-44. 13. shetty p, sharma n. medical management of ectopic pregnancy. apollo med. 2012;9(3):198-201. 14. alkatout i, honemeyer u, strauss a, tinelli a, malvasi a, jonat w, et al. clinical diagnosis and treatment of ectopic pregnancy. obstet gynecol surv. 2013;68(8):571-81. 15. varma r, gupta j. tubal ectopic pregnancy. bmj clin evid. 2009:1406. 16. shafquat t, wahab s, bawar s, rahim r. relation of age, parity and duration of subfertility as risk factors for ectopic pregnancy, gomal j med sci. 2013;11:171-3. 17. igbarese go, ebeigbe pn, igbekoyi of, ajufoh bi. ectopic pregnancy: an 11 years review in a tertiary centre in the niger delta. trop doct. 2005;35(3):175-7. 18. majhi ak, roy n, karmakar ks, banerjee pk. ectopic pregnancy an analysis of 180 cases. j indian med assoc. 2007;105(6):308-12. 19. anorlu ri, oluwole a, abudu oo, adebajo s. risk factors for ectopic pregnancy in lagos, nigeria. acta obstet gynecol scand. 2005;84(2):184-8. 20. s tahmina, mary daniel and preethy solomon. clinical analysis of ectopic pregnancies in a tertiary care centre in southern india: a six-year retrospective study. j clin diagn res. 2016; 10(10):qc1321. jani r, munshi d, jani s, munshi s. study of 50 cases of modern management of ectopic pregnancy. int j reprod contracept obstet gynecol. 2014;3(2):374-9. 22. yeasmin ms, uddin mj, hasan e. a clinical study of ectopic pregnancies in a tertiary care hospital of chittagong, bangladesh. chattagram maa-oshishu hospital med college j. 2014: 28;13(3):1-4. 23. gupta r, porwal s, swarnkar m, sharma n, maheshwari p. incidence, trends and risk factors for ectopic pregnancies in a tertiary care hospital of rajasthan. jpbms. 2012;16(07):1-3 24. jurkovic d, hillaby k, woelfer b, lawrence a, salim r and elson cj. firsttrimester diagnosis and management of pregnancies implanted into the lower uterine segment cesarean section scar. ultrasound obstet gynecol. 2003;21(3):220-7. 25. seow km, huang lw, lin yh, lin my, tsai yl and hwang jl (2004) a cesarean scar pregnancy: issues in management. ultrasound obstet gynecol. 2004;23(3):247-53. 26. fylstra dl. ectopic pregnancy within a cesarean scar: a review. obstet gynecol surv. 2002;57(8):537-43. 27. kadar n, romero r. hcg assays and ectopic pregnancy. lancet. 1981;317(8231):1205-6. 28. canis m, savary d, pouly jl, wattiez a, mage g. ectopic pregnancy: criteria to decide between medical and conservative surgical treatment? j gynecol obstet biol reprod. 2003;32(7):s54-63. 29. abbas a, akram h. ectopic pregnancy; audit at maula bakhsh teaching hospital sargodha. prof med j. 2011;18(1):24-7. x 31gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction the liver is one of the organs mostly involved in metastatic disease from a variety of cancers, in particular those of the 4,56,7gastrointestinal tract, lung and breast metastatic tumors . are most commonly found in liver during autopsy. 40% of 1,10patients who died of cancer have hepatic metastases . in general patients with hepatic metastases die within 1 year. in the last instance, 5 years survival rate of 25% to 39% have 11been reported after resection of hepatic metastases . in a large series of 10,736 malignant neoplasm, pickren et al 1982 reported that the metastatic tumour in the liver was 41 1,10times more common than the primary hepatic tumour . sometimes, liver metastases can occur even when the primary cancer is removed. common symptoms of metastatic liver cancer are abdominal pain, loss of appetite, weight loss, nausea, jaundice and unexplained fever. liver cancer symptoms often do not appear in the early stages. as a result, liver cancer tends to be diagnosed at a more advanced stage. so, identication of risk factors and early diagnosis are the key issues for effective interventions. information on liver metastases is very limited from this part of the country. keeping all these views in mind, the present study was conducted with the following objectives 1. to study liver metastases in adults in relation to primary malignancy, clinical presentations, age and sex. 2. to correlate gross morphological appearances with histopathological features. 3. to study liver metastases in adults in relation to liver function test (lft) and cause of death with complications. material and methods: the present study was based on autopsy material. this was a descriptive cross sectional retrospective and prospective study carried out for the period of four years at tertiary care hospital. all the adult autopsies during this 4 years period were screened for liver metastases. details of clinical history, examination and results of various investigative procedures with particular reference to liver function tests were obtained from hospital records whenever available. standard routine procedure was used for xation, embedding and sectioning. all sections were stained with hematoxylin and eosin. observation and results: in present study we came across 16 cases of metastasis (80% of cases as compared to 20% of primary malignant tumors). metastatic involvement of liver is far more common than 1primary neoplasia . the commonest clinical presentation were abdominal distention (62.50%), ascites (62.50%), abdominal pain (56.25%), jaundice (56.25%), hepatomegaly 4,5(50%), weight loss (43.75%) primary site of the metastasis . were lung (25%), gastrointestinal malignancy (18.75%), breast (12.5%), gall bladder (6.25%), pancreas (6.25%), urinary bladder (6.25%) and leukemia (25%), which coincide 2,7,8with reports in literature . in present study middle aged predominately male adults were more commonly affected followed by elderly adults. the study 4,5,6,7with male female ratio of 3:1 . in all cases grossly liver was enlarged with more than one nodule distributed randomly in liver with central necrosis in 5nodules (fig. 1, 2, 3) and histologically all metastasis was similar to respective of primary malignancy. (fig. 4, 5, 6). histology pleomorphic inltrate affecting the portal tract and 2,3,9 parenchyma was seen in leukemia (fig. 7) in present study . the commonest cause of death was disseminated malignancy. fig 1: metastasis of breast (idc), showing multiple metastatic nodules fig 2: metastasis of intestine (gist) showing multiple metastatic nodules. autopsy study of liver metastases in adult patients in tertiary care hospital of mumbai. original research paper dr. ujwal k. rathod associate professor, dept of pathology, hinduhridaysamrat balasaheb thackeray medical college, juhu, mumbai-400056. x 117gjra global journal for research analysis medical science silent liver diseases are common amongst apparently healthy individuals and are sometimes diagnosed only at autopsy. in present study we came across 16 cases of liver metastasis. metastasis present in 80% of cases as compared to 20% of primary malignant tumors. it is observed that in adults metastasis in liver from other primary 1,2 sites is much more common than primary hepatic tumors which is also similarly reported in literature the commonest clinical presentation were abdominal distention (62.50%), ascites (62.50%), abdominal pain (56.25%), jaundice (56.25%), 1,2,4,5hepatomegaly (50%), weight loss (43.75%) . clinical features quite inconsistent, patient can be often be asymptomatic. obstructive jaundice, massive intraperitoneal haemorrhages and features mimicking cirrhosis are other unusual 1,3,12manifestations . in liver metastasis, middle age, predominantly male adults were more commonly affected. the liver is 1common site for metastases mainly from breast, lung and colon, stomach and pancreas . however cancer at any site of body 1may spread to the liver . abstract keywords : liver metastases. autopsy. millind patil associate prof., dept of pathology, ltmmc &gh, sion, mumbai-400022. dr. smita santosh chavhan* associate professor, dept of community medicine, hinduhridaysamrat balasaheb thackeray medical college, juhu, mumbai-400056. *corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 118 x gjra global journal for research analysis fig 3: intestine (gist). histological all metastasis was similar to respective primary malignancy (fig. 4, 5, 6). fig 4: metastasis of breast (idc) (h & e 100x) fig 5: metastasis of intestine (gist) (h & e 100x) fig 6: metastasis of pancreas (adenocarcinoma) (h& e 100x) fig 7: aml – leukemic inltrate in portal tract and sinusoids (h & e 100 x) table 1: sites of malignancis in matastatic tumour lung and gastrointestinal malignancies were the common site of primary malignancies. table 2: age and sex distribution of metastatic cases: in present study middle aged predominately male adults were more commonly affected followed by elderly adults. male: female ratio is 3:1. discussion: as seen from present study, liver metastatic cancer is not an uncommon disease in this part of india. in present study we came across 16 cases of metastasis. metastasis present in 80% of cases as compared to 20% of primary malignant tumors. it is observed that in adults metastasis in liver from other primary sites is much more common than primary as 2reported in literature . the commonest clinical presentation were abdominal distention (62.50%), ascites (62.50%), abdominal pain (56.25%) jaundice (56.25%) hepatomegaly 4,5(50%), weight loss (43.75%) . primary site of the metastasis were lung (25%), gastrointestinal malignancy (18.75%), breast (12.5%), gall bladder (6.25%), pancreas (6.25%), urinary bladder 6.25% and leukemia (25%) which coincide 1with reports in literature . grossly, most metastatic carcinoma form multiple, spherical, nodular masses which are variable size with hepatomegaly. the tumour deposits are grey white, well demarcated, soft to rm, with areas of hemorrhages in few cases. the surface of the liver shows characteristic central umbilication. histologically all metastasis was similar to 1,5respective of primary malignancy . in present study middle aged (41-60 yrs) adults were more commonly affected. male predominates in present study with male: female ratio of 3:1. conclusion: it may be concluded from the present study that metastatic involvement of liver is far more common than primary 2neoplasia . metastasis present in 80% of cases as compared to 20% of primary malignant tumors. metastatic tumors are most commonly found in liver during autopsy and if not 1,2detected early may lead to serious outcome . the liver is common site for metastases mainly from breast, lung and 1colon, stomach, gall bladder and pancreas . any cancer 1inside of the body may spread to the liver including leukemia . the study was conducted on the specimen collected from the mortuary and not reect the actual pattern of liver diseases and emphasizes the need for further studies for early detection and treatment of the vulnerable group of people in the local population. autopsy study is a good stepping stone towards achieving good morphological accuracy. in secondary liver cancer, continue to be an important cause of morbidity and mortality in tropical countries. early diagnosis and prompt interventions improve the survival and outcome of the disease. references: 1. ishak kg, goodman zd, stocker jt. tomours of the liver and intrahepatic bile ducts. in rosai j sobin lh, eds.atlas of tumor pathology washington, dc: armed forces institite of pathology,2001. 2. klatskin g. adenocarcinoma of the hepatic duct at its bifurcation of within portal hepatic. am j. 1965; 38: 247-256. 3. shehab tm kaminski ms. lok as. acute liver failure to hepatic involvement hematological malignancy. dig dis sci 1997; 42: 1400-1405. 4. pikren jw,tsukada t,lane ww.liver metastases.analysis of autopsy data.in weiss l, gilber ha (eds): liver metastases . boston, 1982,g.k.hall 5. schulz w. hort w.the distribution of metastases in the liver . a quantitative postmortem study.virchos arch (a)1981,394:89-96. 6. lefkkowitch.jh.the epidemiology and morphology pf primary malignant liver tumors. surg chin north am 1981;61:169-180. 7. iazobuzio –donahue c , ferrell ld secondary tumours of the liver .in of the digestive system .lyon.france:iarc press, 2010;251-253. 8. disibio g. french sw . metasases patterns of cancers;result from a large autopsy study . arch pathol lab med 2008:132:931-939. 9. roquest ml , zafrani es , farcet jp , et al. histopathological lesion of the liver in hairy cells leukemia : a report of 14 cases. hepatology 1985; 5:496-500. 10. tumors of liver and extrahepatic bile ducts. in hamilton s.r., aaltonen la,eds. world health oeganisation classicartion of tumors: pathology and genetics of tumor of the digestive system.lyon france:iarc press,2000. 11. fong y. blumgart lh, cohen am. surgical treatment of colorectal metastases to the liver, ca cancer j. clin 1995; 45:50-62. 12. borja er, hari jm. pugh rp.metastatic ca of liver mimicking cirrhosis cancer 1975;35:445-449. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra sr. no. site of primary malignancy no. of cases % 1. lung 4 25 2. lymph reticular system (leukemia) 4 25 3. gastrointestinal malignancies 3 18.75 4. breast 2 12.50 5. urinary bladder 1 6.25 6. gall bladder 1 6.25 7. pancreas 1 6.25 age group sex: male female 18-40 yrs (young adults) 5 1 41-60 yrs (middle age) 6 2 60 yrs (elderly) 1 1 total 12 4 introduction: in today's world of beauty and glamour, it is a natural tendency that every one of us is highly conscious about our skin. skin is the most visible part of the body that reects personality of a person. skin is the rst organ of the body interacting with the environmental agents like physical, chemical & biological agents. variations in the environmental stimuli & natural ability of body to deal with these factors result in spontaneous remissions & relapses. interaction with these factors results in specic reaction pattern producing characteristic skin lesions in different parts of the body. large community prevalence studies have demonstrated that between 20-30% of the population have various skin problems requiring attention. (davidson 18th ed.) skin is a mirror that reects internal & external pathology & thus helps in diagnosis of diseases. skin complaints affects all ages from the neonates to the elderly & cause harm in a number of ways, such as discomfort, disgurement, disability, etc. skin disorders like urticaria create physical as well as mental stress to an individual. excessive itching sometimes becomes intolerable. shitapitta is disorder in which vata and kapha are two doshas which are primarily disturbed due to doshprakopak hetu and in combination with pitta dosha they create swellings, redness, itching, over the skin. vata dosha is dominant in shitapitta. if one is constantly exposed to certain qualities, the doshic balance can become disturbed and this, in turn, may disturb the digestive re (agni), leading to poor digestion, absorption and assimilation of nutrients, and creating ama as a result. ama can affect the tissues and cells and can clog and obstruct channels. in the case of allergies, ama can be viewed as an antigen. when certain qualities are already in excess and more of these qualities are forced upon the organism, the immune system creates more and more antibodies to contend with the invading qualitative ama. as a result, whenever there is even the slightest exposure to the specic allergen the body responds with all its protective forces. this is what is experienced as an allergic reaction. it is the system trying to rid itself of excess ama (antigens). shitapitta can be co-related with urticaria. urticaria or hives is truly not one disease but reaction pattern of skin. a vascular reaction usually transient involving the upper dermis representing localized edema caused by dilatation and increase permeability of the capillaries and marked by development of wheals. it manifests as pruritic erythmatous raised rash. about 20%of people have urticaria at the same time during their lives. this condition may be caused by contact with an external irritant such as the nettle, physical agents, food, insect bites, pollens, drugs or neurogenic factors. though lot of research work has been done in ayurveda and other pathy, still there is not satisfactory result in current sciences for shitapitta. hence many patient of shitapitta are reported in day to day practice. so emphasis were made to nd out easy method for lowering the incidence of shitapitta by using amrutadi kwath. aims and objectives 1. to study the aetiopathogenesis & symptomatology of shitapitta w. s. r. to urticaria. 2. to assess the efcacy of amrutadi kwath in shitapitta w. s. r. to urticaria. review of literature: complete description about shitapitta is obtained in laghutrayee. in yogatnakardetailed description of disease and its treatment describe under title shitapittadi nidana chikitsa in its uttara khanda. in bhaishjya ratnavalidetailed description of chikitsa for udarda-shitapitta -kotha found in bhaishajyaratnavali in chapter 55. materials and methods: amrutadi kwath described in bhaishajya ratnavali. guduchi consists of dried, matured pieces of stem of tinospora cordifolia. nimbamelia azadirachta linn. haridracurcuma longa linn. dhanvay¡sah consists of dried whole plant of fagonia cretica linn. honey. selection criteria of patient : patient subjected to clinical trials were selected from opd and ipd of kayachikitsa department and also from medical camp. criteria for selection of patient a.inclusion criteria: 1. patient with symptoms like mandalotpatti, kandu, daha, the efficacy of amrutadikwath in shitapitta with special referance to urticaria original research paper dr. nikhil urunkar lecturer, kayachikitsa dept. lrp ayurved medical college, hospital, pg institute & research centre, islampur dist. sangli ayurveda shitapitta is one of the disorder which caused by virudhahara sevan. shitapitta is disorder in which vata and kapha are two doshas which are primarily disturbed due to doshprakopak hetu and in combination with pitta dosha they create swellings, redness, itching, over the skin. vata dosha is dominant in shitapitta. shitapitta can be corelated with urticaria. this condition may be caused by contact with an external irritant such as the nettle, physical agents, food, insect bites, pollens, drugs or neurogenic factors. still today there is no satisfactory treatment for shitapitta. so emphasis were made to nd out easy method for lowering the incidence of shitapitta by using amrutadi kwath. abstract keywords : shitapitta, urticaria, amrutadi kwath. dr. dhairyashil p. patil* associate prof, kaumarbhritya dept lrp ayurved medical college, hospital, pg institute & research centre, islampur dist. sangli *corresponding author dr. sanjy s. patil associate prof., kayachikitsa dept. lrp ayurved medical college, hospital, pg institute & research centre, islampur dist. sangli volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 12 x gjra global journal for research analysis toda, frequent of attacks 2. patient in age group 16 to 60yrs. 3. sex-both sexes. b. exclusion criteria: 1. below 16 and above 60yrs patients. 2. patients suffering from urticarial vasculitis, t.b., hiv, viral infections, diabetes, carcinoma etc. a) subjective parameters 1. mandalotpatti 2. kandu 3. daha 4. toda 5. frequent of attacks b) objective parameters: investigations of all patients were done before and after treatment. 1. haematological tests—cbc, absolute eosinophil count, esr 2. how long does the condition been present? <6wks (acute) >6wks (chronic) 3. measurement of mandal in mm_ cm. (length, bredth) 4. part of skin occupied by mandal in percentage. by using rule of nine. preparation of kwath 1 part of choorna +16part of water → 1/8part kwath each drug5grms + 320ml water → 40ml kwath for preparation of kwatha kalpana the aushadhi dravyas in the form of bharad choorna were taken in given quantity and 16 times the aushadhi dravya, water was taken. this mixture were boiled till 1/8th of the water quantity remains. ratio of ingredients aushadhadi dravya: water 1: 16 matra40ml. sahanupanmadhu. (1 tea spoon) sevan kalavyanodan standardisation, authentification, analysis of drugs: drugs were purchased from gmp certied pharmacy. drugs standardisation, authentication & analysis have been done. after complete examination and investigations all patients were randomly divided into 2 groups experimental group (group a) – in this group 30 patients were kept on amrutadi kwath (40ml) twice a daily. control group (group b)— in this group 30 patients were kept on kwath like detoxifying edible colored water (40ml) twice a daily. duration of treatment60 days. follow upevery week observations and results: observations: 1. maximum no. of patients i.e. 51.67% were from the age group of 26 – 40 years. 2. maximum no. of patients registered i.e. 51.67% were male & 48.33% were female. 3. maximum no. of patients i .e. 55% having h/o vishamasana,38.33% had h/o adhyashana followed by 6.67% having h/o samashana. 4. maximum no. of patients i.e. 41.67% were having visha magni, while 33.33% were having mandagni & 25% were having tikshnagni. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra s. n. symptom group diff. t p value remark comparison 1 mandalotpatti group a 1.4 10.14 <0.001 signicant gp a is better than gp b group b 0.1 1.97 >0.05 insignicant 2 kandu itching group a 1.13 8.49 <0.001 signicant gp a is better than gp b group b 0.13 1.43 >0.05 insignicant 3 toda (pricking pain) group a 1.46 8.57 <0.001 signicant gp a is better than gp b group b 0.26 1.64 >0.05 insignicant 4 daha group a 1.16 6.99 <0.001 signicant gp a is better than gp b group b 0.06 1 >0.05 insignicant 5 frequency of attack group a 1.56 8.76 <0.001 signicant gp a is better than gp b group b 0.13 1 >0.05 insignicant 6 aec group a 85.5 7.65 <0.001 signicant gp a is better than gp b group b -4.5 -1.53 >0.05 insignicant s.n. parameters overall % mean improvement group a group b 1 mandalotpatti 79.62 % 8.47 % 2 kandu itching 79.07 % 7.40 % 3 toda (pricking pain) 88 % 11.32 % 4 daha 89.74 % 5.88 % 5 frequency of attack 80.75 % 7.01 % 6 aec 76.05 % -0.8% overall improvement: in experimental group 13.33% patients got excellent improvement, 40% patients got good improvement, 33.33% patients got moderate improvement, while 13.33% patients got poor improvement. in control group 10% patients got moderate improvement & 90% patients got poor improvement. probable mode of action of trial drugamrutadi kwath: it contains 4 drugsamruta, nimba, dhamasa, haridra. these belong to tikta varga. guduchi & haridra are anti allergic & improves cellular immune function. by rasa viraya & guna they act as tridoshaghna. twak vaigunya relieved by vatapittaghna property of drug. most of drugs are kushtaghna, vayasthapaka, dahaprashaman, shothahara, vedanast hapaka, varnya, kandughna, raktagata vikar shamak, jwaraghna, tridoshghna, chardighna. by tikta rasa act as amapachak, raktaprasadak, by katu rasa agnidipak, by tikta rasa & vaishadyakar guna of vayu mahabhut acts as rasaraktashudhikar & relieves strotodushti by ruksha, ushna guna of drugs, at last vimargag dosha gets prakrut gati & sampraptibhang takes place. amruta (guduchi): guduchi belongs to ganas like vayasthapaka, dahapra x 13gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra shamana, trushnanigrahan so it acts as rasayan, dahas hamak & relieves trushna. dhatu: guduchi causes stimulation to dhatwagni by its tikta rasa & nutrition of dhatu by its madhura vipaka, by its tikta –katu kashaya rasa & dhatu & causes purication. guduchi acts on 7 dhatu thus it is good rasayandravya. guduchi by its tiktakatu rasa & ushna virya act as dipan, pachan. it acts as pittasaraka & anuloman by its tikta katu rasa. with madhu it acts as kaphaghna. it puries rasa & rakta & eliminates kleda, kaphadushti by its tikta, kashay, katu rasa & ruksha guna. nimba: by ruksha & laghu guna it causes wasting of snigdha dhatu & absorbs kleda by tikta rasa & shita virya & thus puries blood which eliminates kleda & kandu from skin. nimba act as amapachak when used in jwar. nimba by its shita virya act as pittaghna, jwaraghna & trushnashamak. daha: it is dahashamak due to its tikta & sheeta guna. it absorbs rasagata pitta & reduses daha. it absorbs kleda & puries dhatu by its tikta & ruksha guna. dhamasa: pittashamaka due to madhura rasa & vipaka so useful in pittaja chardi, trushna. raktashodhana due to tikta & madhura rasa. jwar: useful in jwara & daha shamana due to its tikta & shita guna & eliminates pittaja lakshana such as chardi trushna, daha. mansavaha: eliminates kapha-pitta dushti lakshana such as kandu, redness & daha. dhamasa act as tridoshaghna. by madhura rasa, snigdha guna act as vataghna, by madhura rasa & shita virya act as pittaghna so relieves pitta prakopak lakshana like sruti, daha, kleda. by tikta, kashay rasa, laghu, snigdha guna act as kaphanisarak. by kashay rasa it decreases porosity of vessels, so decreases vascular uid leakage. haridra: it eliminates pathological coating of buccal mucus membrane due to tikta katu rasa & ushna virya & cleaness mouth due to ruksha guna hence used in aruchi. rasa-raktavaha: it digest rasagata doshas by its tiktakatu rasa & causes rasagnidipan & thereby causes prakrut rasanirmiti. because of this all dhatus are nourished well & they become healthy. it causes raktaprasadan by eliminating dushta kapha & pitta. haridra by its tikta rasa, katu vipak, ushna virya & laghu, ruksha guna acts as kaphaghna, shothaghna, deepan, pachan, amapachan, absorbs kleda hence kandughna. madhu: by its kashay, ruksha guna act as kaphaghna, kledaghna, yogavahi. by madhur rasa, shita guna act as pittaghna. conclusion: the treatment with amrutadi kwath is more effective than placebo kwath in shitapitta. references: 1. charaka samhita – (elaborated vidyotini hindi commentary) chaukhambha bharati academy, varanasi. 2001 2. sushruta samhita –kaviraja ambikadutta shastrichaukhambha sanskrit sansthan varanasi. 2005 3. vagbhat samhita (sarth vagbhat) anmol prakashan pune. 2004 4. madhava nidana – madhukosha with vidyotini, hindi comm. by sudarshna shastri. 2005 5. bhavprakash madhyamkhanda, chikitsaprakaranam shitapittodarda utkothadhikar 55/1 vd .brahma sankara misra –choukhamba sanskrit prakashan. 2005 6. yogratnakar – shitapittodardakothadhikar31 vidyotinitika choukhamba sanskrit sirji varanasi 7. bhaishajya-ratnawaliudardashitapittakothchikitsaprakaran 55 govinddas sen tika of kaviraj ambikadatta shastri choukhamba sanskrit sansthan varanasi. 8. chakradattaathoudardakothshitpittaadhikar vd. pandit jagannath prasad sharma 9. sharangdhar samhita dwitiya khanda a.2/1 10. concise textbook of surgery, dr. s. das, burn 11. davidson‘s principles and practice of medicine 18th edition pg888 12. harrison‘s principles of medicine. 13. dr. baghel m.s. �researchers in ayurveda�2nd edition 2005 14. the ayurvedic pharmacopoeia of india 15. jacobson kw, branch lb, nelson hs: laboratory tests in chronic urticaria, jama 1980; 243:1644. 14 x gjra global journal for research analysis introduction the term adolescence comes from the latin verb “adolescere”, which simply means to grow, or to grow to maturity. ncert (1999) dened adolescence as a period of physical, psychological and social maturity from childhood to adulthood. it is a critical period of human development manifested at the biological, psychological and social levels of interaction, of variable onset and duration, but marking the end of childhood and setting the foundation for maturity. maturity as dened by finley (1996) is “the capacity of mind to endure an ability of an individual to respond to uncertainty, circumstances or environment in an appropriate manner”. as emotions do play central role in the life of an individual, one is expected to have higher emotional maturity in order to lead a effective life. it is also true that our behavior is constantly inuenced by the emotional maturity level that we possess. in a study by hiremani, et al, (1994) it is indicated that destitute girls were emotionally unstable due to sociocultural deprivation and parental deprivation. importance of emotional maturity: in the present circumstances, youth as well as children are facing difculties in life. these difculties are giving rise to many psycho-somatic problems such as anxiety, tensions, frustrations and emotional upsets in day to day life. so, the study of emotional life is now emerging as a descriptive science, comparable with anatomy. it deals with interplay of forces with intensities and quantities. as emotions do play central role in the life of an individual, one is expected to have higher emotional maturity in order to lead a effective life. it is also true that our behavior is constantly inuenced by the emotional maturity level that we possess. especially, the adolescents who are observed to be highly emotional in their dealings need to be studied. emotionally intelligent, but emotionally immature: being emotionally mature means we seldom act out on, or suppress our emotions. emotionally intelligent, but "immature" adults are often unable to identify or manage their emot ions . they usual ly avoid thei r emot ions by intellectualizing, explaining, analyzing, disagreeing, attacking, attering, joking, apologizing, evading, going silent, becoming aloof or suspicious, rejecting, criticizing or judging. they often come across as superior, arrogant, stubborn, deant, hostile, people-pleasing, wishy-washy, phony, resentful, intolerant, self-pitying or victimized. because they haven't explored their emotional development, many of them aren't aware that they superimpose their childhood emotions on to their adult life. their past is leaking out in the present. in contrast, the emotionally mature adult understands that "my emotions are not me, but mine – i'm in control, not my emotions". so they are more objective are less judgmental. they are better able to detach themselves from triggers that would normally provoke an emotional reaction. they experience states of equanimity, serenity and inner peace. blaming others is no longer a strategy they use to make themselves feel safe. that's not to say that an emotionally mature individual isn't child-like. in fact they are often lively, excited, adventurous, joyful, happy and open. but they are also nurturing, supportive, rm, fair, helpful, respectful, self-responsible, nonjudgmental, honest, and sincere and focused on the wellbeing of themselves and of others. the emotionally immature adult, however, is often childish, rather than child-like. they are reactive and throw tantrums. they are fearful, scared, needy, angry, resentful, pushy, bullying, jealous or envious. they can be quiet, withdrawn, defensive, argumentative or grandiose. they can come across as overbearing, micromanaging, controlling, disrespectful, fearful, angry, negative, judgmental, critical, abusive (mentally, emotionally, psychologically, physically), dishonest, insincere, narcissistic and focused on the self and the ego. emotional maturity implies proper emotional control, which means neither repression nor violet expression. an emotionally mature person has in his possession almost all types of emotional positive or negative and is able to express them at appropriate time in appropriate degree. in the opinion of murray (2004), an emotional mature person has the following characteristics: 1.the ability to give and receive alone. 2. the ability to face reality and deal with it. 3. just as interested in giving as receiving. 4. the capacity to relate positively to life experiences. 5. the ability to learn more experience. 6. the ability to accept frustration. 7. the ability to handle hostility constructively. 8. relative freedom from tension symptoms. mostly, emotional balance' and 'emotional maturity' is taken as synonymous terms. but actually, they are not. emotional balance emphasizes the value of learning to cope with both pleasant and unpleasant emotions. one can attain emotional maturity without having attained emotional emotional maturity among day scholar and hosteler adolescents: comparitive study. original research paper mrs. sowmyashree k. n. research scholar, department of psychology, jnana bharathi bangalore university, bengaluru x 31gjra global journal for research analysis psychology emotional maturity becomes important in the behavior of individuals. present adolescents are the future leaders they need to have emotional maturity like being emotionally stable, emotional progression, personality integration, being competent and need to have social adjustment etc .but researches have shown that, the present generation lacks it and also few factors like parental bonding ,affection and being with family has connection with increase in emotional maturity ,in this regard this study is intended to compare the day scholar and hosteller adolescents on emotional maturity. result showed that there is signicant difference among day scholars and hostel students on emotional maturity. abstract keywords : emotional maturity, day scholar, hosteller, adolescents. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. sreenivas. m* assistant professor & coordinator centre for psychological counselling department of psychology, jnanbharathi bangalore university, bengaluru * corresponding author 32 x gjra global journal for research analysis balance although the vice versa is not true. an emotionally balanced person will necessarily be emotionally mature person. emotional balance is quality of an adult and not a child. thus, emotional maturity is a relative term. it is directly related to age and stage of development of the individual review of literature chaudhary and bajaj, (1993) compared the emotional maturity adolescents staying at home and at orphanage and concluded adolescents staying with parents at home had high level of emotional maturity as compared with their counterparts staying at orphanage. david j. landry and jacqueline e, darroch (2002) in his research topic 'journal summary on emotional education' says the, environmental factors do affect the physical and emotional maturity of child. kaur, s. (2000) found signicant relationship between emotional maturity, school, home and psychological environment. girls were found to be more emotionally mature than boys. rural students were found to be more emotionally mature than urban students. need for the study: not many studies have done in this eld and also questions were raised that whether day scholars emotionally mature compare with hosteler adolescents. objectives: ÿ to compare the emotional maturity among day scholar and hosteler adolescents. operational definition: ÿ emotional maturity refers to your ability to understand, and manage, your emotions. emotional maturity enables you to create the life you desire. a life lled with happiness and fulllment. you dene success in your own terms, not society's, and you strive to achieve it ÿ adolescent: physical it is a transitional stage of , psychological and emotional, human development that generally occurs during the period from to legal puberty adulthood .age range from 13 to 21 years. hypotheses: ÿ there is no difference on emotional maturity among day scholar and hosteler adolescents. sampling design: the sample consisted of 60 degree students among them 30 day scholar and 30 hostelers randomly selected from the private degree college. tools used: the following tools were adopted to collect the data: ÿ the emotional maturity scale developed by yashvir singh and mahesh bharagava, (2012).): this scale has 48 questions related to the following 5 categories: emotional stability, emotional progression, social adjustment, personality integration and independence. the test-retest reliability has been estimated at 0.75 and validity against the adjustment inventory by singh and bhargava (1980) at 0.46.total score on the scale indicative of emotional maturity where as the greater the total score on the scale expressed in terms of emotional immaturity. procedure: permission was sought from the principal of respective college from which sample was collected. subsequently subjects were personally contacted to participate in the study and rapport was established. before handing over the questionnaire a detailed explanation of the purpose of the study was explained. after obtaining their consent, emotional maturity scale was administered. the subjects were asked to follow the instructions as mentioned in the questionnaire. doubts were claried and they were assured that their responses would be kept condential. after the subjects answered the questions the questionnaire were collected back and subjects were thanked for their cooperation. the data thus collected was subjected to further statistical analysis. statistical analysis: the statistical technique includes mean, s.d, mean difference and 't' test for analysis of data. result and discussion: table 1:showing mean, standard deviation, and't' value of day scholar and hostel students on emotional maturity. note: signicant at 0.05 levels figure1:mean score on emotional maturity among day scholar and hosteler adolescents. discussion the present study is aimed at compare emotional maturity among day scholar and hosteler adolescents and try to nd out whether day scholar is emotionally mature compare to hosteler students. result showed that day scholar is emotionally mature with the mean of 87.43, compare with the hostel students who got the mean score 101.73 on emotional maturity scale. higher the score in the scale indicates the level of immaturity of an individual .so mean score indicates those hostelers are immature compare to day scholar. this study result found to be supporting the earlier studies. studies have proved that good home environment leads to better emotional maturity (shah-1989, thakur (2002) who in her study "emotional maturity as related to home environment" found that there exists a positive relationship between home environment and emotional maturity. some other studies like larsen and juhasz (1985), tyagi (1985), arya a.(1997), kaur s.(2000) etc. also reported the positive relationship of home environment and emotional maturity. chaudhary and bajaj, (1993) compared the emotional maturity of adolescents staying at home and at orphanage and concluded that adolescents staying with parents at home had high level of emotional maturity as compared with their counterparts staying at orphanage which also supports the ndings of present investigation. limitations: ÿ sample size was small when compared with population, so it is difcult to generalize. ÿ not considered socio economic status, gender etc suggestion: ÿ more sample size can be taken. ÿ different geographical area and age group can be considered for study. conclusion: study showed that there is difference among day scholar and hosteler adolescents on emotional maturity. earlier studies proved that 'a positive relationship between home volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra n mean sd 't' value hosteler 30 101.73 14.74 3.78* day scholar 30 87.43 14.51 environment and emotional maturity'. in this study difference among day scholar and hostel adolescent on emotional maturity is may because of the above reason where day scholar students are having everyday meeting with family member and able to share their emotions and making them strong enough to handle the emotional si tuation independently when compare with hostel student where they might not getting proper way and time to bring out their emotions and may be having problem in handling emotions. references: 1. bala; & others.2014 prevalence of emotional maturity and effectiveness of counseling on emotional maturity among professional students of selected institutions at mangalore, south india; journal of biology, agriculture and healthcare ; issn 2224-3208 (paper) issn 2225-093x (online)vol.4, no.6, 2014 2. punithavathi, s.2013 emotional maturity and decision making styles among arts and science and engineering college women students. asia pacic journal of marketing & management review, issn 2319-2836 vol.2 (4), april (2013) online available at indianresearchjournals.com. 3. yashvir singh and mahesh bharagava, (2012),emotional maturity scale, arohi manovigyan kendra.jabalpur. 4. http://shodhganga.inibnet.ac.in/bitstream/10603/8471/13/13_appendices. pdf 5. http://iasir.net/aijrhasspapers/aijrhass14-183.pdf 6. http://www.management-issues.com/opinion/6811/emotional-intelligenceor-emotional-maturity/ 7. http://medind.nic.in/jak/t06/i1/jakt06i1p66.pdf 8. http://shodhganga.inibnet.ac.in/bitstream/10603/7872/12/12_chapter% 205.pdf 9. http://www.globalacademicgroup.com/journals/african%20education% 20indices/sanjeev.pdf x 33gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: thyroglossal duct cysts are one of the most common midline lesions in the paediatric age group. they are epithelial remnants of the thyroglossal tract and present at the level of thyrohyoid membrane. both sexes are equally affected. case history: a 25 yr old male came with complaints of neck swelling and fever for 1 week. he also gave history of neck swelling for past 1 yr which was evaluated elsewhere. he was suggested to do a cect neck and fnac of the swelling elsewhere which suggested thyroglossal cyst. he presented in our hospital with fever with chills, painful and tender neck swelling and restricted neck movement for 3 days following fnac. cect neck was repeated and suggested an infected thyroglossal cyst with abscess formation. he was started on broad spectrum antibiotics empirically. patient underwent incision and drainage of the abscess. about 50 cc of pus was drained and sent for culture and sensitivity. pain and tenderness reduced, but induration was present. antibiotics were changed based on the culture and sensitivity report and was taken up for surgery after 2 weeks. fig. 1. patient presents with infected thyroglossal cyst fig 2. cect neck showing areas of necrosis and abscess formation fig.3. purulent discharge from abscess after incision and drainage of abscess was done. methylene blue was injected through a small granulation tissue in the scar. skin crease incision was made along the scar and all stained areas and tract was incised in toto along with a portion of the hyoid bone. fig. 4. : intraoperative thyroglosasal stula tract was identied by using methylene blue dye injection and tract excised in toto. as there was a lot of brosis of the neck muscles and loss of fascial planes due to inammation. the surgery was challenging. intraoperative blood loss was slightly on the higher side. the postoperative period was uneventful and patient made a slightly delayed but complete recovery. fig. 5. postoperative picture after 45 days postoperative period infected thyroglossal cyst original research paper dr. m. k. rajasekar professor department of ent , sree balaji medical college and hospital x 153gjra global journal for research analysis ent thyroglossal duct cysts are one of the most common midline lesions in the paediatric age group affecting approximately 7% of the population. infection and abscess formation are common complications. infected neck mass is a common presentation of thyroglossal duct cysts in adults. here we present a case of a 25 year old male with neck swelling and fever for 1 week. abstract keywords : dr. sridhara narayanan* professor department of ent , sree balaji medical college and hospital *corresponding author dr. s. thrupthi junior resident department of ent , sree balaji medical college and hospital volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 154 x gjra global journal for research analysis fig.6. histopathology report discussion: the thyroid gland originates at the foramen cecum of the tongue, at the apex of the v-shaped sulcus formed by the circumvallate papillae. during the fourth week of gestation, a ventral diverticulum of the foramen cecum is formed from the rst and second pharyngeal pouches. this diverticulum, with its narrow neck connected to the tongue, descends in the midline of the neck as the thyroglossal tract to the position of the normal thyroid in the base of the neck, where the thyroid lobes separate, by the seventh week. the path of descent is usually anterior to the hyoid bone, but may be posterior to or through the bone and ends on the anterior surface of the rst few tracheal rings. the tract usually atrophies and disappears by the tenth week of gestation, but remnants of the tract and thyroid tissue associated with it may persist at any point between the tongue and the thyroid. a thyroglossal duct cyst arises as a cystic expansion of a remnant of the thyroglossal duct tract. the stimulus for the expansion is not known; one theory is that lymphoid tissue associated with the tract hypertrophies at the time of a regional infection, therefore occluding the tract with resultant cyst formation. the cyst may occur anywhere along the thyroglossal duct tract from the foramen cecum at the base of the tongue to the level of the suprasternal notch. in most cases, the cyst is at or just below the hyoid bone adjacent to the thyrohyoid membrane. cysts below the thyrohyoid membrane are rare. conclusion: our case report indicates that a strict aseptic precaution should be followed during invasive procedures like fnac as fnac is the rst line of investigation for most head and neck swellings. the presence of infection delays the procedure and wound healing with an increase in scarring. references: 1. mondin v, ferlito a, muzzi e, silver ce, fagan jj, devaney ko, rinaldo a. thyroglossal duct cyst: personal experience and literature review. auris nasus larynx. 2008;35(1):11–25. doi: 10.1016/j.anl.2007.06.00 2. dedivitis ra, guimarães av. papillary thyroid carcinoma in thyroglossal duct cyst. int surg. 2000;85(3):198–201. 3. mahnke cg, jänig u, werner ja, rudert h. primary papillary carcinoma of the thyroglossal duct: case report and review of the literature. auris nasus larynx. 1994;21(4):258–263. 4. stell and maran textbook of head and neck surgery – 4th edition 5. thyroglossal duct cyst — more than just an embryological remnant sujatha narayana moorthy and rekha arcot, indian j surg. 2011 jan; 73(1): 28–31. 6. soni s1, poorey vk1, chouksey s1. thyroglossal duct cyst, variation in presentation, our experience. indian j otolaryngol head neck surg. 2014 dec; 66(4):398-400. doi: 10.1007/s12070-014-0724-4. epub 2014 may 15. 7. tamiolakis d1, chimona ts, proimos e, georgiou g, perogamvrakis g, papadakis ce. thyroglossal duct cyst : case series. chirurgia (bucur). 2008 nov-dec; 103(6):699-703 volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction cricothyroid space is the indentation between the thyroid and cricoids cartilages and is covered by the anterior/median cricothyroid ligament, a useful site for emergency access to the airway in cases of obstruction at or above the vocal cords 1(cricothyroid puncture or cricothyroidotomy). in the neonate, the dimensions of the cricothyroid membrane are too small to 1allow safe passage of an airway. the surface anatomy of the region is essential prior to performing a tracheostomy, cricothyroid puncture or cricothyroidotomy. the american society of anes-thesiologists (asa) and the difcultairway society (das) provided frameworks for the anaesthetist to manage the unanticipated difcult airway and both guidelines end with the 'can't intubate, can't ventilate' (cicv) scenario, recommending either a needle or surgical 2, 3cricothyroidotomy as the next step. the laryngeal prominence (adam's apple) of the thyroid cartilage is palpable in the midline neck, and the thyroid laminae can be felt passing posterolaterally. in the male, the prominence is usually visible, whereas in the female it is not usually apparent. the curved upper border of the thyroid cartilage, the midline thyroid notch and the superiorly located depression of the thyrohyoid membrane/ligament are easily 1palpable. the upper border of the thyroid cartilage usually 4lies between the fourth and fth cervical vertebrae. the rm, smooth anterior arch of the cricoid cartilage is palpable below the inferior border of the thyroid cartilage. the inferior border of the cricoid commonly sits at the level of the seventh cervical vertebra (range c5–t1); the posterior cricoid overlaps the 4sixth cervical vertebra. the aim of the present study was to collect data on the cricothyroid space in indian population by measuring the height & width of the cricothyroid space and also measure anterior length of larynx. materials sixty apparently healthy looking specimens (51 males and 9 females) were obtained from embalmed cadavers from a tertiary care teaching institute. all the cadavers were adult ranging between the age group of 18-65 years. the study consisted of meticulous dissection using standard dissection kit. in each cadaver, the larynx was looked for any gross deformity and specimens were selectively included in this study. the study was done only after due permission from the ethics committee of the institution. methods after the mbbs students had nished the dissection of face and the triangles of the neck the specimens were obtained. the sternohyoid and omohyoid muscles were cut and reected down from its insertion near the hyoid bone and after which the sternothyroid and thyrohyoid muscle was separated from the oblique line of thyroid cartilage. the thyroid gland is cut and removed. as the mandible was already removed the styloglossus and stylopharyngeus muscles were cut and then the constrictor muscles of the pharynx were incised. the trachea was transected between the fth and sixth tracheal rings along with the oesophagus. this completes the separation and the larynx specimen was recovered along with tongue, hyoid bone, proximal trachea, pharynx and proximal part of oesophagus. then the epiglottis was separated from tongue by cutting the medial and lateral glossoepiglottic folds. the thyrohyoid membrane was cut to separate the hyoid bone from the thyroid cartilage. the specimen was cleaned to remove the extra laryngeal soft tissue so that all the laryngeal landmarks used in this study were easily seen. at the last the trachea rings were removed from the caudal end of the cricoid cartilage. measurements were made with a vernier caliper (0 – 150 mm with a precision of 0.02 mm). the distance between the lower border of thyroid cartilage to upper border of cricoid arch (height of cricothyroid space) was measured by the vernier caliper in anterior midline as seen in the gure 1 (left side) the linear distance between the midpoint of cricoid & thyroid was measured by the vernier caliper (transverse width of cricothyroid space) the distance between superior thyroid notch to lower border of cricoid cartilage is measured in anterior midline by vernier caliper as shown in gure 1 (right side) fig 1 – measurement of distance between the lower border of thyroid cartilage to upper border of cricoid arch(left side) cadaveric study of cricothyroid space – anatomical perspective original research paper dr. parmanand agarwal assistant professor, department of anatomy, gmc ambikapur x 23gjra global journal for research analysis anatomy cricothyroid space is the indentation between the thyroid and cricoids cartilages and is covered by the anterior/median cricothyroid ligament, a useful site for emergency access to the airway. the aim of the present study was to collect data on the cricothyroid space in indian population by measuring the height & width of the cricothyroid space and also measure anterior length of larynx. sixty apparently healthy looking specimens were obtained from embalmed cadavers. height of cricothyroid space ranged from 6.64 12.56 mm, transverse width of cricothyroid space ranged from 9.8 – 18.9 and length of larynx in anterior midline ranged from 27.12 42.96 mm. understanding of the dimensions and crucial anatomy of the cricothyroid space and related area is important to avoid or manage complications during surgical cricothyroidotomy. the dimensions are variable in different population, there is scope for more such study to corroborate these ndings and its clinical relevance. abstract keywords : cricothyroid space, tracheostomy, cricothyroidotomy, cricothyroid membrane dr. yuvaraj j bhosale* additional professor, department of anatomy, ltm medical college, sion mumbai *corresponding author volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 24 x gjra global journal for research analysis and distance between superior thyroid notch to lower border of cricoid cartilage (right side) results the study pertaining to measurements of dimensions of cricothyroid space and also total length of larynx taking various landmarks on the cartilages as reference points was done in laryngeal specimens obtained from 60 cadavers. of these 60 cadavers, 9 were females. following observations were made: the distance between lower border of thyroid cartilage to upper border of cricoid arch (height of cricothyroid space) in the anterior midline ranged from 6.64 12.56 mm with a mean of 8.98 ± 1.60 mm in males and ranged from 5.18 10.38 with a mean of 7.79 ± 1.61 mm in females. the frequency distribution of the distance showed that 70.1% of the values were between 7-10 mm in males and 77.7% of the values were in the range of 6-10 in mm. the linear distance between the midpoint of cricoid & thyroid was measured by the vernier caliper (transverse width of cricothyroid space) ranged from 9.8 – 18.9 with a mean of 12.38 ± 1.94 in males and ranged from 6.1 – 11.7 with a mean of 8.92 ± 2.17 in females. the distance between superior thyroid notch to lower border of cricoid cartilage ranged from 27.12 42.96 mm with a mean of 34.40 ± 2.83 mm in males and ranged from 24.26 30.18 mm with a mean of 27.10 ± 2.11 mm in females. discussion cricothyroid space is a space in between the lower border of thyroid cartilage and upper border of cricoid. the space has a membrane connecting the two margins. puncture of the membrane is a component of several important clinical procedures. these include cricothyroidotomy, botox injection into vocal cord for patients with adductor spasmodic dysphonia, scintigraphic measurement of tracheal mucus velocity in patients with muco-ciliary dyskinesia, retrograde intubation of larynx, intraoperative neuromonitering of the recurrent laryngeal nerve during thyroid surgery, minitracheostomy for clearance of excess tracheobronchial secretions and percutaneous collagen augmentation for treatment of parkinsonian hypophonia. carcinoma of larynx spreads extralaryngeally by invading the cricothyroid 5membrane. develi et al stated that on the upper half and lower left quadrant of the cricothyroid membrane important vital anatomical structures (cricothyroid vessels, pyramidal lobe of thyroid gland) were mostly located. they further recommend that the lower right quadrant of the membrane is safer for invasive procedures such as needle cricothyroidotomy or 6other cannulation techniques. table 1: comparison of mean distance between lower border of thyroid cartilage to upper border of cricoid cartilage with other studies (height) the mean distance between lower border of thyroid cartilage to upper border of cricoid cartilage was greater than the study 8done on senile population by zieli�ski r and prithishkumar et 11 7 9al and was lesser than the dover et al tayama et al , embate 10 12 13jrs et al , yadav y anand v study. in present study the distance was more in males than females in accordance with 8all other except zieliński r . the mean linear distance between the midpoint of cricoid & 7thyroid (width) was found to be greater than dover et al and 11 13prithishkumar et al but slightly lesser than anand v et al . in present study the distance was more in males than females in accordance with all other study. table 2 : comparison of mean distance from superior thyroid notch to lower border of cricoid cartilage with other studies ( length of larynx in anterior midline) the values of mean distance from superior thyroid notch to lower border of cricoid cartilage in our study are 16approximately similar to eckel et al . it was lower than values 14 15of ajmani and williams rg et al . there was a difference of 6 to 7 mm in male and female as evident from the above table. williams rg et al also measured the distance on volunteers it 15was 46.1 mm in males and 38 mm in females. joshi et al reported the distance as 32.42 ± 3.41 mm which was the 18inclusive of both genders. williams rg et al stated that measurement of superior thyroid notch to lower border of cricoid cartilage acts as a surface landmarks in humans and because the vocal fold reach across the two cartilage and therefore if either of them were abnormally large or small this might affect the size of vocal fold, such a change in vocal fold could therefore be missed 15only if one cartilage was measured. conclusions whenever rapid access to the airway is required, especially in case of trauma or difcult thyroidectomy, cricothyroidotomy is the procedure of choice. placing outsized tubes results in fracture of the laryngeal cartilages and later dysphonia and 19-21subglottic stenosis. so, understanding of the dimensions and crucial anatomy of the cricothyroid space and related area is important to avoid or manage complications during surgical cricothyroidotomy. the dimensions are variable in different population of different countries, so there is scope for more such study to corroborate these ndings and its clinical relevance. references: 1. standring s. gray’s anatomy, the anatomical basis of clinical practice. 41th ed. philadelphia: london: churchill livingstone; 2008. 413 & 586 2. caplan ra, benumof jl, berry fa, et al. pratice guidelines for management of the difcult airway: an updated report by the american society of anesthesiologists task force on management of the difcult airway. anesthesiology 1993; 98: 1269–77. 3. henderson jj, popat mt, latto ip, pearce ac. difcult airway society guidelines for management of the unanticipated difcult intubation. anaesthesia 2004; 59: 675–94. 4. mirjalili sa, mcfadden sl, buckenham t et al 2012b vertebral levels of key landmarks in the neck. clin anat 25:851–7. 5. prithishkumar ij, felicia c. histology of the cricothyroid membrane: a clinical perspective. indian journal of otolaryngology and head and neck surgery : ofcial publication of the association of otolaryngologists of india. 2014;66(suppl 1):316-9. 6. develi s, yalcin b, yazar f. topographical anatomy of cricothyroid membrane and its relation with invasive airway access. clin anat. 2016;29:949–54. 7. dover k, howdieshe r, colborn dl. the dimensions and vascular anatomy of the cricothyroid membrane: relevance to emergent surgical airway access. clin anat. 1996;9:291–5. 8. zielinski r. morphometrical study on senile larynx. folia morphologica. 2001;60(2):73-8. 9. tayama n, chan rw, kaga k, titze ir. geometric characterization of the volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra study year country male female 7dover et al 1996 usa 10.9 9.5 8zieliński r 2001 poland 6.82 7.40 9tayama et al 2001 usa 10.16 8.06 10embate jrs et al 2003 philippines 9.80 8.00 11prithishkumar et al 2010 india 6.53 5.74 12yadav y 2014 india 9.91 8.70 13anand v et al 2018 india 9.61 7.26 present study india 8.98 7.79 study year country male female 14ajmani 1990 nigeria 45.06 38.08 williams rg and 15eccels r 1990 united kingdom 36.50 30.60 16eckel et al 1994 germany 34.60 28.20 17jain and dhall 2008 india 33.7 31.2 present study india 34.40 27.10 laryngeal cartilage framework for the purpose of biomechanical modeling. the annals of otology, rhinology, and laryngology. 2001;110(12):1154-61. 10. embate jrs, romualdez j, lim w. anatomic measurements of the laryngeal framework in filipino adult cadavers. philippine journal of otolaryngology head and neck surgery. 2003;18(3-4):121-9. 11. prithishkumar ij, david ss. morphometric analysis and clinical application of the working dimensions of cricothyroid membrane in south indian adults: with special relevance to surgical cricothyroidotomy. emergency med australasia. 2010;22:13–20. 12. yadav y, tuli a, kakar s, choudhry r, murari a. geometric characterization of thyroid cartilage in adult humans for biomechanical modeling. american multidisciplinary international research journal. 2014;1(3):6-13. 13. anand v, sharma h, sethi a, sahoo s. surgical anatomy of cricothyroid membrane with reference to airway surgeries in north indian population: a cadaveric study’. int j otorhinolaryngol head neck surg 2018;4:xxx-xx. 14. ajmani ml. a metrical study of the laryngeal skeleton in adult nigerians. journal of anatomy. 1990;171:187-91. 15. williams rg, eccles r. a new clinical measure of external laryngeal size which predicts the fundamental frequency of the larynx. acta otolaryngologica. 1990;110(1-2):141-8. 16. eckel he, sittel c, zorowka p, jerke a. dimensions of the laryngeal framework in adults. surgical and radiologic anatomy : sra. 1994;16(1):31-6. 17. jain m, dhall u. morphometry of the thyroid and cricoid cartilages in adults. journal of anatomical society of india. 2008;57(2):119-23. 18. joshi mm, joshi ss, joshi sd. the morphological study of adult human larynx in a western indian population. journal of laryngology and voice. 2011;1(2):50. 19. boon jm, abrahams ph, mering jh, welch t. cricothyroidotomy: a clinical anatomy review. clin anat. 2004;17:478–86. 20. narrod ja, moore ee, rosen p. emergency cricothyrotomy: technique and anatomical considerations. j emerg med. 1985;2:443–5. 21. sise mj, shackford sr, cruickshank jc, murphy g, fridlund ph. cricothyroidotomy for long term tracheal access. a prospective analysis of morbidity and mortality in 76 patients. ann surg. 1984;200:13–7. x 25gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: perforative peritonitis is a type of peritoneal inammation caused by perforation of hollow viscus and subsequent bacterial proliferation inside the peritoneal cavity. patients with perforative peritonitis are commonly presented as surgical emergency. though the advances in supportive care including higher generation of antimicrobial agents has resulted in improved outcome but mortality still ranges from 5% to 50 percent. hence patients should be categorized according to their mortality risk which is very important to institute proper management and utilization of valuable intensive care unit (icu) resources and supportive care. mortality again depends upon disease severity, age, nutrition, 1preexisting organ dysfunction etc . the apache ii scoring system was devised by knaus and colleagues in 1985. the primary purpose of the system was to predict mortality and categorize patients according to their 2mortality risks in intensive care unit (icu) setup . later the system was evaluated all over the world in different patient populations including surgical patients and the system was proved to be useful. the apache ii score has three parts; aps (acute physiology score), chronic health points and age points which is usually calculated on admission of the patient to the hospital. the total of the three scores makes the nal apache ii score. the score ranges from 0 to 71. a good number of studies have been carried out to evaluate and utilize the apache ii scoring system in different patient populations in different countries since it's development. but there are few studies which evaluated this system involving surgical patients and almost all of the studies were done in developed countries where the patient prole, presentation and available resources differ from the patients we treat in our setup. the present study was carried out in the emergency surgical ward of medical college, kolkata, a government teaching hospital over a period of 21 months to evaluate the usefulness of apache ii score in categorizing the patients into different risk groups and predicting outcome in patients with perforative peritonitis. in 1989 moshe schein and colleagues conducted a study including 162 patients of perforated peptic ulcer to evaluate the usefulness of apache ii score and observed 0% mortality in the group 0-10, 30.5% in the group 11-20 and 75% mortality in the group >20. they concluded that when measured preoperatively, it stratied accurately these patients into 3various risk groups . naved and associates showed that apache-ii scoring system was found useful for classifying 4icu patients according to their disease severity . van le and colleagues showed a signicant correlation between apache ii scores and mortality among the gynaecologic oncology 5patients . gupta and associates showed that predicted mortality did not correlate with observed mortality for critically 6ill patients admitted to an indian respiratory icu . several studies have been conducted till date on different patient populations including surgical, medical, gynecology, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18respiratory patients etc . not all group of patients are comparable to each other because of differences in patient prole, nature of the disease, affection of different organ systems etc. so the present study could not be compared to many such studies. this prospective study was undertaken to justify the usefulness of the apache ii scoring system in categorizing the patients with perforative peritonitis into various risk groups and predicting the outcome. materials and methods: the study was conducted in the emergency surgical ward and emergency operating room, medical college &hospital, kolkata, west bengal over a period from january, 2013 to september, 2014 including 72 patients with a diagnosis of peritonitis due to perforation of hollow viscus who gave consent to be included in the study. inclusion criteria: patients admitted to the emergency surgical ward with a diagnosis of perforative peritonitis due to various etiologies who gave consent to be included in the study. exclusion criteria: patients with blunt injury abdomen who had other associated solid organ, vascular, neurological injury and fracture were excluded from the study. diagnosis was established with the following: a. history b. physical examination c. free gas under diaphragm found in plain radiograph of abdomen in erect posture. d. intraoperative conrmation. all biochemical investigations needed for the scoring system were done immediately after admission and the proforma was lled. then the apache ii score was calculated based on the single reading taken on admission according to the method of evaluation of apache ii score in patients with perforative peritonitis as a predictor of outcome. original research paper dr. rajarshi gayen assistant professor, department of general surgery, midnapore medical college, vidyasagar rd, midnapore, west bengal, india 721101 general surgery patients with perforative peritonitis are commonly encountered in hospitals and frequently require icu support. a scoring system that can accurately stratify the patients into various risk groups is very helpful to predict the outcome. the apache ii score has been used previously in patients of various diseases for the same purpose. this prospective study has been undertaken to evaluate the usefulness of apache ii score for risk stratication and prediction of mortality in patients suffering from perforative peritonitis. the study involved 72 patients admitted with perforative peritonitis over two years. the apache ii score was calculated and assigned to each patient on admission and the clinical outcome was observed. the scoring system predicted mortality fairly well especially in the score range of 11-20. so it may be concluded that this scoring system can be used in patients with perforative peritonitis as a predictor of outcome. abstract keywords : apache ii score, peritonitis, emergency surgery, critical care volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. biswajit mondal* senior resident,department of plastic surgery, medical college kolkata, 88, college street, kolkata 700073, wb, india*corresponding author 40 x gjra global journal for research analysis 1knaus et al . the surgical procedure followed was to perform closure of perforation in duodenal and gastric ulcer perforation with omental (graham's) patch, appendicectomy in perforation due to appendicitis and limited resection and end-to-end anastomosis in perforation of gangrenous bowel. then the patients were divided in three groups according to their apache ii score; 010, 1120 and >20 for the convenience of analyzing results. predicted risk of mortality was calculated according to apache ii death equation for each group. mortality was dened as any death occurring during the hospital stay. the term 'morbidity' included local and systemic complication and length of hospital and icu stay. observed death rate was compared with predicted death rate for each study group. the accuracy of outcome prediction by the apache-ii system was assessed by using receiver operating characteristics (roc) curve and pearson 19correlation coefcient and its signicance test . a roc curve was constructed from the patients predicted and observed hospital outcomes. area under the curve was computed using the trapezoidal rule to nd the predictive value of apache-ii score in prediction of mortality and survival. pearson correlation co-efcient and its signicance test were used to investigate whether the difference between the sample correlation coefcient and zero is statistically signicant. the statistical software spss 22.0 was used for the analysis of the data and microsoft word and excel was used to generate graphs, tables etc. results and discussion table 1: etiology table 2: comorbid conditions table 3: local complications table 4: systemic complications table 5: hospital stay and icu stay table 6: survival according to the apache ii score table 7: complications and apache ii score table 8: overview table 9: prediction of mortality graph 1: correlation of apache ii score and predicted death rate (pdr) pearson correlation coefcient and its signicance test were applied to investigate whether the difference between sample correlation coefcient and zero is statistically signicant. it showed perfect correlation of apache-ii score and predicted death rate. [r=0.96]. the second degree polynomial was able to correlate well with predicted death rate with r2 = 0.96084517. graph 2 : receiver operating characteristic curve volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra etiology total patients % non survivors (%) appendicitis 25 35 0 peptic ulcer disease 20 28 4(5.55%) typhoid 4 5 1(1.39%) tuberculosis 7 10 3 (4.17%) blunt trauma abdomen 6 8 2 (2.78%) bowel strangulation 6 8 3 (4.17%) malignancy 4 6 1 (1.39%) total 72 100 14(19.44%) co-morbidities no. of cases ischemic heart disease 5 chronic obstructive pulmonary disease (copd) 8 pulmonary tuberculosis 4 chronic liver disease 2 hiv infection 1 wound infection only 14 wound dehiscence with wound infection 12 anastomotic leak with wound infection 6 fecal stula with wound infection 3 total 35 complication number of patients adult respiratory distress syndrome (ards) 23 sepsis 12 acute renal failure (arf) 4 total 39 apache ii score mean hospital stay mean icu stay 0 10 10.31 1.31 11-20 16.73 3.65 >20 15.62 6.62 apache ii score survivors non survivors percentage of mortality 0-10 36 2 5.26 1120 20 6 23.07 >20 2 6 75 mean apache ii score =9.89 mean apache ii score =18.92 apac he ii score no. of patie nts pts. developing local complications perce ntage pts. developing systemic complications percen tage 0-10 38 11 28.94 11 28.94 11-20 26 18 69.23 21 80.76 >20 8 6 75 7 87.5 variables apache ii score group 0-10 11-20 >20 mean age 30.10 38.88 61.37 male : female 2.8 : 1 2.25:1 1.66: 1 mean hospital stay (days) 10.31 16.73 15.62 mean icu stay (days) 1.31 3.65 6.62 percentage of local complications 28.94 69.23 75 percentage of systemic complications 28.94 80.76 87.5 mortality percentage 5.26 23.07 75 a ii score group mean a ii score no. of cases observed death predicted death standard mortality ratio 010 6.76 38 2 (5.26%) 2.80 (7.38%) 0.71 1120 15.69 26 6 (23.07%) 5.89 (22.68%) 1.01 > 21 21.75 8 6 (75%) 3.32 (41.54%) 1.80 023 (overall) 11.65 72 14(19.44%) 10.07 (13.99%) 1.39 x 41gjra global journal for research analysis a receiver-operating characteristic curve was constructed from the predicted and observed outcome of patients and is shown in graph 11. the area under the curve computed using the trapezoidal rule was 0.824 which indicates good 19correlation. conclusion: in conclusion the apache ii score is a reliable scoring system in stratifying patients with perforative peritonitis in various risk groups and predict mortality accurately in the score range of 11-20. however predicted mortality did not correlate well with the observed mortality in the other two groups. in the group with score 010 the system overestimates the mortality risk whereas in the group with score >20 it underestimates the risk. overall the scoring system has shown to be a reliable tool in predicting outcome and categorizing the patients with perforative peritonitis into various risk groups. moreover the variables required are simple and almost universally available in any standard icu setup. also the score is easy to calculate in a very little time. there is scope for further evaluation of this scoring system in larger patient population and different group of patients. if the score can be standardized it can also be used to evaluate the quality of care provided by an icu setup. there is also scope for further modication. references 1. rajandeep singh bali, sushant verma, p. n. agarwal,rajdeep singh, and nikhil talwar (2014) perforation peritonitis and the developing world. isrn surgery volume 2014, article id 105492, 4 pages http://dx.doi.org/ 10.1155/ 2014/105492 2. knaus wa, draper ea, wagner dp, apache ii : a severity of disease classication system. crit care med 1985; 13 : 818-829. 3. moshe schein, gary gecelter, zeev freinkel. apache – ii in emergency operations for perforated ulcers am j surg 1990; 159 ; 309 – 313 4. naved sa, siddiqui s, khan fh, j coll physicians surg pak. 2011 jan;21(1):48. doi: 01.2011/jcpsp.0408 5. l. van le, s. fakhry, l.a. walton, d.h. moore, w.c. fowler, r. rutledge. use of the apache ii scoring system to determine mortality of gynecologic oncology patients in the intensive care unit. obstet gynecol. 1995 jan;85(1):53-6 6. gupta r, arora v. k, performance evaluation of apache ii score for an indian patient with respiratory problems. indian j med res. 2004 jun;119(6):273-82 7. h. j. s. jones andmrs l. de cossart (2003) risk scoring in surgical patients. br j surg 10.1046/j.1365-2168.1999.01006.x 8. sobol julia b, wunsch h.(2011) triage of high-risk surgical patients for intensive care. critical care 2011, 15:217 doi:10.1186/cc9999 9. hariharan s1, zbar a (2006) risk scoring in perioperative and surgical intensive care patients: a review. curr surg. 2006 may-jun;63(3):226-36. 10. knaus wa, draper ea, wagner dp. prognosis in acute organ system failure. ann surg 1985; 202: 685-693. 11. knaus wa, zimmerman je, wagner dp. apache – acute physiology and chronic health evaluation : a physiologically based classication system. crit card med 1981 ; 9 : 591-597. 65 12. knaus wa, draper ea, wagner dp. evaluation outcome from intensive care : a preliminary multihospital comparison. crit care med 1982; 10 : 491-496 13. knaus wa, legall jr, wagner dp. a comparison of intensive care in the usa and france. lancet 1982; 2 : 642-646. 14. meakins jl, solomkin js, allo md. a proposed classication of intra abdominal infections. arch surg 1984; 119 : 1372-1378. 15. dellinger ep, wertz mj, meakins jl. surgical infection stratication system for intra abdominal infection. arch surg 1985; 120 : 21-29 16. skau t, nystrom p-o, carlsson c. severity of illness in intra – abdominal infection. arch surg 1985; 120 : 152 – 158. 17. nystrom po, bax r. dellinger ep, et al. proposed denitions for diagnosis, severity scoring, stratications, and outcome for trials on intra-abdominal infection. world j surg 1990; 14:148-158. 18. wong, david t. md ; crofts, sally l. evaluation of predictive ability of apache – ii system and hospital outcome in canadian icu patients. crit care med ; 1995 ; 23 (7); 1177 –1183. 19. hanley j, mc neil b: the meaning and use of the area under a receiver operating characteristic curve. radiology 1982; 143: 29-36. 68 volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 42 x gjra global journal for research analysis 21.dr. herojit naorem.cdr introduction: oro-cutaneous stulas or cutaneous sinus, a tract of dental origin, is an unusual, but the well-documented condition that usually needs dental treatment. the only way of reducing the possibility of further complications such as sepsis and 1osteomyelitis is well-timed diagnosis and prompt treatment. in the root canal system the presence of microorganisms is clearly associated with the development and progression of endodontically induced periapical lesions. to manage such cases there are surgical and non-surgical methods. ideally, a non-surgical method should initially be performed. the rate of success of the non-surgical endodontic management method is totally centered on proper cleaning, shaping, asepsis and lling of the root canals. several studies described that good healing of periapical diseases can only be achieved by proper 2 sterilization of the root canal and periradicular region. in order to sterilize the infected root dentine, especially the deep layers, antibacterial medicaments are benecial. in a retrospective study by bose et al., showed that ca(oh) and 2 triple antibiotic paste, can aid further in development of the pulp dentin complex when used as an intracanal medicament in immature necrotic teeth and mature teeth because of their 3antibacterial properties. coronal microleakage and incomplete biomechanical preparation of canals have been identied as another major cause of persistent periradicular disease and failure in endodontic therapy. case report a 10-year-old patient reported to the department of pediatric and preventive dentistry, inderprastha dental college and hospital, sahibabad, with a chief complaint of extra oral swelling in the right submandibular posterior region of face [figure 1]. patient went to the local dentist and was given symptomatic treatment for the same and later root canal therapy was figure 1: extraoral pre-operative photograph lateral view. carried out. after one month swelling along with pain was noticed on the right side of the face and later it subsided after taking medication. again the same conditions occurred after 3 months. on intraoral examination swelling on the buccal side right permanent mandibular rst molar caries on the distal side of rst permanent premolar was seen. an intraoral periapical radiograph revealed associated periapical infection with incompletely iiled canals irt 36 [figure 2]. access opening was done on the same day and gp cones were taken out using hles [figure 3] followed by working length determination and intracanal medicament were placed. figure 2: radiograph showing incomplete obturation figure 3: retrieved gp cones non-surgical endodontic treatment of extraoral orocutaneous sinus tract: a case report original research paper dr. herojit naorem post graduate, department of pediatric and preventive dentistry, inderprastha dental college and hospital, ghaziabad. x 5gjra global journal for research analysis pediatrics the development and progression of endodontically induced periapical lesions is clearly associated with the presence of microorganisms in the root canal system. the present case report discusses diagnosis and treatment of an extraoral cutaneous sinus tract of odontogenic origin in relation to a mandibular right permanent rst molar with closed apex (diagnosed as non-suppurative periradicular periodontitis with an extraoral cutaneous sinus tract opening in the left side of mandibular posterior region). conservative endodontic therapy was performed using triple antibiotic paste as intracanal medicament. patient responded well with the treatment approach and the cutaneous lesions was healed uneventfully. in the absence of any clinical symptom complete obturation was done in mandibular right rst permanent molar. patient was kept on regular follow-up. abstract keywords : periapical lesion, extraoral sinus tract, odontogenic, non-surgical endodontic treatment. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. kapil gandhi* professor and head, department of pediatric and preventive dentistry, inderprastha dental college and hospital, ghaziabad *corresponding author dr ritika malhotra reader, department of pediatric and preventive dentistry, inderprastha dental college and hospital, ghaziabad dr. rishabh kapoor senior lecturer, department of pediatric and preventive dentistry, inderprastha dental college and hospital, ghaziabad dr. babita jangra senior lecturer, department of pediatric and preventive dentistry, inderprastha dental college and hospital, ghaziabad 6 x gjra global journal for research analysis bmp was performed with copious irrigation using 3% sodium hypochlorite (naocl) to remove the remaining necrotic pulp tissues. the canal is dried with paper points and triple antibiotic paste [figure 4] was placed within the canals. commercially prepared chemotherapeutic agents namely, ciprooxacin (cifran 500 mg, ranbaxy laboratories ltd., india), metronidazole (metrogyl 400 mg, j.b. chemicals and pharmaceuticals ltd., india) and minocycline (minoz 100 mg, ranbaxy laboratories ltd., india) were used. figure 4: radiograph showing triple antibiotic paste placed after the removal of the enteric coating and the capsule that encloses the drug products, each of the drugs was pulverized using a mortar and pestle. patient was kept on regular followup. in subsequent appointment swelling was found to be reduced. patient after 4 weeks revealed signicant healing. the excess tissues were removed using a scalpel (no.15) and the tooth was non-tender to percussion. at this appointment, the tooth was reopened, the antibiotic paste removed and the canal of permanent molar with was obturated with gp and stainless steel crown was delivered after 3 days [figure 5]. figure 5: radiograph showing obturation with gp cones and stainless steel crown clinical examinations showed no sensitivity to percussion or palpation and the soft-tissues were healthy and postoperative radiographs showed the progressive process of healing. [figure 6] figure 6: post-operative photograph lateral view discussion a periapical dental abscess may be originated by caries, periodontal disease, trauma, or thermal and chemical injuries. an intra–oral or extra–oral sinus can develop, depending on the path of the inammation, which is dictated 4,5by surrounding muscular attachment and fascial planes. the position of dental sinuses is generally anatomically adjacent to the causative tooth. sometimes, the opening of the sinus tract may be located at a far distance from the dental infection, which makes the diagnosis challenging, particularly with respect to intact teeth. the role of microorganisms in the development and spread of periapical diseases is well-documented in the literature. it is noted that appropriate sterilization of the root canals and periradicular region result in uneventful healing of periapical diseases. therefore for the successful outcome of root canal treatment, the microorganisms within the root canal system should be 2eliminated. in the present case report, a triple antibiotic paste was used as intracanal medicament. after its application, the symptoms were resolved. since the overwhelming majority of bacteria in the deep layers of the infected dentine of the root canal wall consist of obligate anaerobes, metronidazole was selected as the rst choice among antibacterial drugs. it is reported that metronidazole can penetrate the deep layers of carious lesions and disinfect the lesions in vivo and diffuse throughout 6 the dentine as the microbial ora of the root canal with a periradicular lesion is multifaceted in nature, metronidazole alone cannot eradicate all bacteria signifying that other drugs may be required to sterilize the infected root dentine. thus, ciprooxacin and minocycline were required to sterilize the infected root dentine in addition to metronidazole. a combination of antibiotics might also drop the likelihood of 7 the development of resistant bacterial strains. summary failed root canal treatments are a consequence of microleakage, inadequate cleaning and shaping and poor quality obturations. the usage of an amalgamation of antibiotic drugs in the tooth with persistent sinus tract contributes excellent clinical results. references 1. qazi ss, manzoor ma, qureshi r, arjumand b, hussain sm, afridi z. nonsurgical endodontic management of cutaneously draining odontogenic sinus. j ayub med coll abbottabad 2006;18:88-9. 2. manuel st, parolia a, kundabala m, vikram m. non-surgical endodontic therapy using triple-antibiotic paste. kaen dent j 2010;33:2 3. bose r, nummikoski p, hargreaves k. a retrospective evaluation of radiographic outcomes in immature teeth with necrotic root canal systems treated with regenerative endodontic procedures. j endod 2009;35:1343-9 4. mittal n, gupta p. management of extra oral sinus cases: a clinical dilemma. j endod. 2004;30(7):541–7. 5. sheehan dj, potter bj, davis ls. cutaneous draining sinus tract of odontogenic origin: unusual presentation of a challenge diagnosis. south med j. 2005;98(2):250–2. 6. sato i, ando-kurihara n, kota k, iwaku m, hoshino e. sterilization of infected root-canal dentine by topical application of a mixture of ciprooxacin, metronidazole and minocycline in situ. int endod j 1996;29:118-24. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: breast lump is the most common clinical presentation in most of the breast diseases. breast cancer is the second most 1, 2 common cancer among women in india. the worldwide accepted protocol for diagnosis of breast lumps is the “triple assessment” a combined approach by the triad of clinical examination, mammography and pathological diagnosis by 3 fine needle aspiration cytology. fnac is very reliable, safe, cost-effective and rapid method for diagnosis of breast lesions 1,4,5 that can be easily carried out in outpatient department. in this diagnostic era, a pathologist can perform many molecular ancillary techniques like estrogen, progesterone receptor and proliferation antigen on fna samples and so, fnac helps in deciding the proper therapeutic interventions 1 for the breast lumps specically in malignant lesions. as most of the breast lumps are benign in nature, the preoperative cytological diagnosis can decrease the unnecessary 6surgeries thus reducing the morbidity. fnac has many 1benets over breast lump biopsies. fnac has a good sensitivity, specicity and accuracy in the diagnosis of both neoplastic and non-neoplastic breast lumps thereby assist ing in early diagnosis and further 7management. the present study was conducted to study the incidence and the various cytomorphological patterns of palpable breast lesions in patients by fnac and subsequently to compare the results with those of other studies published in literature. material and methods the present study was carried out on patients presenting with palpable breast lumps in the cytopathology section over a period of one year from january 2019 to december 2019 in tertiary care hospital. a total of 432 cases were studied with detailed clinical history, clinical examination and imaging if available and consent was taken from all the patients. fnac was performed by using 5 ml plastic disposable syringe and disposable 23 guage needles. three slides were made from aspirated material, two were xed with isopropyl alcohol and stained with haematoxylene & eosin and papaniculou stains, while third slide was air dried and stained with may grunwald giemsa stain. in suspected cases of tuberculous mastitis, special stains like zn and fluorescence microscopy were also studied. fna results were obtained after correlation with clinical history and radiological ndings and then compared with ndings of other studies in the literature. results a total of 2123 cases were obtained in the department of cytology over a period of 1 year between january 2019 and december 2019 out of which 432 cases (20.4%) were fnac of breast lumps . all the 432 patients underwent a diagnostic fnac in cytopathology section. in the present study, age range of patients varied from 9 to 85 years. youngest patient (9 year old) was diagnosed with broadenoma and oldest (85 year old) was diagnosed with lobular carcinoma on fnac. majority of patients (28%) were noted in the age group of 21-30 years followed by the age group 3140 years (24.5%) as shown in table 1. table 1: age wise distribution of patients cytomorphological spectrum of breast lumps: a one year study original research paper dr. suwarna b patil associate professor, department of pathology, gmc akola, maharastra, india dr. pradeep s. umap professor and head, department of pathology, gmc akola, maharastra, india x 15gjra global journal for research analysis pathology palpable breast lump is the most common clinical presentation. breast cancer is the second most common cancer among women in india. the worldwide accepted protocol for diagnosis of breast lumps is the “triple assessment” a combined approach by the triad of clinical examination, mammography and fnac. fnac has a good sensitivity, specicity and accuracy in early diagnosis and management of breast lumps. the present study was carried out on 432 patients presenting with palpable breast lumps in the cytopathology section over a period of one year from january 2019 to december 2019 with the aim of categorizing the breast lesions among females and males, studying age incidence & laterality. fibroadenoma (44.9%), ductal carcinoma (11.8%), acute mastitis (6.4%) were the most common benign, malignant and inammatory lesions respectively in the present study. fnac for palpable breast lumps has proved to be an asset in the present study abstract keywords : breast lump, fnac, fibroadenoma, ductal carcinoma volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. shweta m. dhage* assistant professor, department of pathology, gmc akola, maharastra, india *corresponding author dr. jasleenkaur s. oberoi junior resident iii, department of pathology, gmc akola, maharastra, india dr. shobhana j. agrawal junior resident iii, department of pathology, gmc akola, maharastra, india age group number of patients percentage 0-10 01 0.2 11-20 86 19.9 21-30 121 28.0 31-40 106 24.5 41-50 48 11.1 51-60 31 7.1 61-70 32 7.4 71-80 07 1.6 total 432 100.0 16 x gjra global journal for research analysis figure 1: age and sex wise distribution of patients out of 432 cases of breast lumps, 92.1% were found in females while 7.8% were found in males. majority of female patients (27.5%) with breast lump were in the age group of 21-30 years while most of the male patients (2.7%) were in the age group of 61-70 years as shown in gure 1. figure 2: side wise distribution of breast lumps 48% cases were having right breast lump, 42% cases were with left breast lump, while 10% cases presented with bilateral breast lumps as shown in gure 2. table 3: fnac diagnosis of breast lesions out of all breast lump lesions, maximum 78.9 % cases were cytomorphologically diagnosed with benign lesions while 12.2% cases were diagnosed as malignant lesions and only 8.7% cases were diagnosed as inammatory lesions. table 4: distribution of inammatory lesions diagnosed on fnac among inammatory breast lesions, on fnac majority of cases (6.4%) were diagnosed as acute mastitis (figure 2-c) followed by granulomatous mastitis (1.1%) (figure 2-d), chronic mastitis (0.6%) and only two cases were tuberculous mastitis with positivity on both zn stain and uorescence microscopy as shown in table 4. table 5: distribution of benign lesions diagnosed on fnac among benign breast lesions, on fnac the majority (44.9%) cases were diagnosed as broadenoma (figure 3-a) followed by benign proliferative breast disease (15.5%), gynae co mastia (6.9%), brocystic disease (5.5%), galactocele (3.2%), benign phyllodes tumor (2.5%) (figure 3-e)and one female patient was having both broadenoma and phyllodes tumor with bilateral breast presentation (table 5). table 6: distribution of malignant lesions diagnosed on fnac among malignant breast lesions, on fnac 11.8% cases were diagnosed with ductal carcinoma (figure 3-b) out of which 2 patients were males. while we got only one case of each lobular carcinoma and malignant phyllodes tumor each, diagnosed on fnac. table 7: distribution of bilateral breast lesions among bilateral breast lesions, broadenoma (38%) was the most common lesion followed by proliferatibe breast disease (28.5%) and brocystic breast disease (11.9%) as shown in table 7. figure 3: cytomorphological spectrum of breast lesions (a, b, c, d, e) e) benign phyllodes tumor (he, 100x) volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra breast lesions number of cases % inammatory 38 8.7 benign 341 78.9 malignant 53 12.2 total 432 100 inammatory lesions number of cases % acute mastitis 28 6.4 chronic mastitis 03 0.6 granulomatous mastitis 05 1.1 tuberculous mastitis 02 0.4 benign lesions number of cases % fibroadenoma 194 44.9 benign phyllodes tumor 11 2.5 fibroadenoma and phyllodes tumor 01 0.2 fibrocystic disease 24 5.5 gynaecomastia 30 6.9 galactocele 14 3.2 proliferative breast disease 67 15.5 malignant lesions number of cases % ductal carcinoma 51 11.8 lobular carcinoma 01 0.2 malignant phyllodes tumor 01 0.2 breast lesions number of patients % fibroadenoma 16 38.0 proliferative breast disease 12 28.5 benign phyllodes tumor 01 2.3 galactocele 02 4.7 fibroadenoma with phyllodes tumor 01 2.3 fibrocystic breast disease 05 11.9 a) fibroadenoma (he, 100x) b) ductal carcinoma (he,400x) c) acute mastitis (he, 200x) d) granulomatous mastitis (he, 100x) majority of inammatory breast lesions (20/38) were noted in the age group of 21-30 years. among benign lesions, maximum cases of broadenoma (65/194) were noted in 21-30 years age group while majority of proliferative breast disease (22/67) were noted in 31-40 year age group. maximum cases of gynaecomastia in males were noted in older age group of 6170 years. most of the cases of brocystic disease were seen in middle age group of 41-50 years while cases of galactocele were commonly seen in younger age group of 21-30 years. patients of benign phyllodes tumor were mainly seen in 31-40 years while one case of malignant phyllodes tumor was 33 year old only. majority of ductal carcinoma cases were found in the older age group of 51-60 years while lobular carcinoma was diagnosed in 85 year old female (table 8). a total of 34/432 cases were male patients out of which 30 cases were of gynaecomastia, 2 cases were diagnosed as ductal carcinoma (one with metastasis to axillary lymph node), 1 case each of acute mastitis and proliferatibe breast disease. discussion there has been increasing use of fnac of breast lump as preoperative diagnostic tool because of awareness among the clinicians of its role. it is well tolerated and readily accepted by patients as they get report within a short span. we studied a total of 432 cases of breast lump and above results were obtained. these results were compared with various studies in the literature. in the present study, maximum patients (28%) were observed in 21-30 year age group followed by 31-40 years (24.5%) while 3 1 in the studies done by ahmad f et al (30.7%), badge s a et al (45%) the most common age group was 31-40 years. this disparity in the observation may be explained on the basis of decreasing age incidence of breast lumps over the last few decades and also on the basis of increasing awareness among females of all age groups for breast lumps. in the present study, right breast (47.9%) involvement showed slight 3predominance over left breast (42.3%) while ahmad f et al noted left breast involvement predominant. the percentage of benign lesions in the present study was 78.9%. this was similar to the ndings made by bukhari et al, rocha et al, 1,8-11feichter et al, and singh et al . while the malignant lesions in the present study were 12.2% which was similar to ndings 12of pradhan et al but slightly less as compared to the studies 1 8 9done by badge s et al , bukhari et al , rocha et al . in the present study, inammatory lesions were the least common 6similar to the ndings of dr jayanandhini m et al . in the present study, broadenoma was the most common benign lesion which was similarly noted by the study conducted by 1 6 13badge s et al , dr jayanandhini m et al , bell et al . whereas among malignant lesions, ductal carcinoma was the most common in present study similar to ndingd by badge s a et al 1 14 and mohammad et al .in this study, among inammatory lesions acute mastitis was the most common lesion which also 6observed by dr jayanandhini m et al . this observation may probably be due to poor hygiene in the low socioeconomic strata during lactation phase in this geographical area. overall, in the present study, the most common benign lesion (broadenoma) was seen in younger age group of 21-30 years 1while badge s a et al noted it in age group of 31-40 years and malignant lesions in our study were common age group of 51160 years while badge s a et al observed most malignant lesions in 41-50 years. conclusion fnac is a safe, simple, reliable and cost-effective, well tolerated preoperative procedure done in outpatient department yielding accurate diagnosis of inammatory, benign and malignant breast lesions. most of the breast lumps are benign and broadenoma is the commonest while among malignant lesions, ductal carcinoma is the prevalent breast lesion. among inammatory category, acute mastitis is the common presentation. benign lesions are predominantly seen in younger age group while malignant lesions are seen in older age group with few exceptions of young patients. suspected cases of tuberculous mastitis can also be positively diagnosed on fnac. so, this simple and time saving procedure is a boon for both clinicians and anxious patients as malignancy in suspicious cases gets ruled out within no time. as overall incidence of malignancy is rapidly increasing all over the world and hence in developing countries like india, a safe & rapid diagnostic tool like fnac for palpable breast lumps has proved to be an asset. in india, vigorous implementation of national public health programmes and mass awareness in society with affordable diagnostic procedures like fnac is being implemented on warfooting in all medical institutes. references : 1. badge sa, ovhal ag, azad k, meshram at. study of ne-needle aspiration cytology of breast lumps in rural area of bastar district,chhattisgarh. med j dy patil univ 2017;10:339-42. 2. sandhu ds, sandhu s, karwasra rk, marwah s. prole of breast cancer patients at a tertiary care hospital in north india. indian j cancer 2010;47:16 22. 3. ahmad f, mittal a, verma p, kumar a, awasthi s, dutta s. cytomorphological study of palpable breast lumps: spectrum of lesions and diagnostic utility of fnac. ann. int. med. den. res. 2016;2(4):237-41. 4. rimm dl, stastny jf, rimm eb, ayer s, frable wj. comparison of the costs of ne needle aspiration and open surgical biopsy as methods for obtaining a pathologic diagnosis. cancer 1997;81:51 6. 5. silverman jf, lannin dr, o’brien k, norris ht. the triage role of ne needle aspiration biopsy of palpable breast masses. diagnostic accuracy and cost effectiveness. acta cytol 1987;31:731 6. 6. dr.jayanandhini m "cytological spectrum of breast lesions -one year study in a tertiary care center."iosr journal of dental and medical sciences (iosr-jdms), vol. 17, no. 6, 2018, pp 05-09. 7. koss l. diagnostic cytology 4th edition. philadelphia: lippincott williams & wilkins, 1992, 6-11. 8. bukhari mh, arshad m, jamal s, niazi s, bashir s, bakhshi im, et al. use of ne needle aspiration in the evaluation of breast lumps. patholog res int 2011;2011:689521. 9. rocha pd, nadkarni ns, menezes s. fine needle aspiration biopsy of breast lesions and histopathologic correlation. an analysis of 837 cases in four years. acta cytol 1997;41:705 12. 10. feichter ge, haberthur f, gobat s, dalquen p. statistical analysis and cytohistologic correlations. acta cytol 1973;17:188 90. 11. singh k, sharma s, dubey vk, sharma pr. role of fnac in diagnosis of breast lumps. jk sci 2001;3:126 8. 12. pradhan m, dhakal hp. (2008). study of breast lumps of 2,246 cases by ne needle aspiration. j nepal med assoc, 47, 205-9. x 17gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 inammatory lesions 0 1 20 9 4 3 1 0 0 fibroadenoma 1 64 65 48 15 0 1 0 0 proliferative breast lesions 0 6 21 22 10 4 4 0 0 gynaecomastia 0 10 2 2 1 3 11 1 0 fibrocystic disease 0 0 2 8 11 2 1 0 0 galactocele 0 2 8 3 1 0 0 0 0 benign phyllodes tumor 0 1 1 6 1 1 1 0 0 fibroadenoma and phyllodes tumor 0 1 0 0 0 0 0 0 0 ductal carcinoma 0 0 2 8 5 18 12 4 2 lobular carcinoma 0 0 0 0 0 0 0 0 1 malignant phyllodes tumor 0 0 0 1 0 0 0 0 0 table 8: age wise distribution of various breast lesions 13. bell da, hajdu si, urban ja, gaston jp. role of aspiration cytology in the diagnosis and management of mammary lesions in ofce practice. cancer 1983;51:1182 9 14. mohammad q, akbar sa, ali j, mustafa s. lump in breast; role of fnac in diagnosis. prof med j 2009;16:235 8. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 18 x gjra global journal for research analysis 05.renjith final.cdr introduction regional anaesthesia effectively produces mitigation of nociception as it diminishes the intensity of afferent impulses reaching the spinal cord & brain. sciatico-popliteal and saphenous nerve block given together provide complete anaesthesia below the knee for all types of surgical procedures. this block has certain advantages over general and spinal anaesthesia for surgery of the leg, ankle and foot. prolonging surgical anaesthesia and analgesia is of signicant benet in regional anaesthesia. in order to increase the duration of local anaesthetic action and improve the quality of peripheral nerve blocks, different adjuvant medications have been added. addition of multiple adjuvants to local anaesthetic (“multimodal perineural analgesia”) may prolong analgesia after single injection peripheral nerve 1blockade. a meta-analysis found that addition of dexamethasone as an adjuvant to local anaesthetics 2 prolonged brachial plexus blockade. buprenorphine also prolongs the duration of analgesia after axillary nerve 3 4blockade , and intraoral nerve blockade. material and methods after obtaining the clearance from the institutional scientic and ethical commit tee study was undertaken at dr.jeyasekharan hospital and nursing home nagercoil, kanyakumari district, tamilnadu. the study period was 18 months from september 2017 to february 2019. after obtaining clearance from the ethical and scientic committee, the study was undertaken. written and informed consent was obtained from every patient and standard protocols were followed for anesthesia in both the group patients. pre-anesthetic checkup of the patients was done, the night before surgery and the patients were reviewed preoperatively in ot. no premedication was given. 82 patients aged above 18years were selected and they were randomly allocated by means of computer generated random table into two groups. group x: patients were given 0.5% bupivacaine 2 mg/kg with buprenorphine 2μg/kg diluted with normal saline to make 25ml block solution. group y: patients were given 0.5% bupivacaine 2 mg/kg with dexamethasone 0.1mg/kg diluted with normal saline to make 25ml block solution. random group assigned slip was enclosed in a sealed opaque envelope to ensure concealment of allocation sequence. after shifting the patient inside operation theatre, sealed envelope was opened by an anesthesiologist not involved in this study to prepare drug solution according to randomization. patient's age, sex and weight were recorded. patients were monitored with ecg, pulse oximetry (spo2), noninvasive blood pressure (nibp), and respiratory rate. all patients received sciatic nerve blockade high in the popliteal fossa, with the patient in the prone / lateral position at the junction of the tibial and common peroneal component of sciatic nerve. this was done using the linear probe of ultrasound machine and 20 ml of the block solution was administered using 22g 5cm echogenic needle. saphenous nerve was also blocked under usg guidance in the adductor canal triangle with 5ml of block solution. time of completion of block performed was noted. the time of complete sensory block was assessed every 3 minutes for 1st 30 minutes with application of cold spirit swabs and by response to atraumatic prick with a blunt needle in the areas innervated by the blocked nerves. the time when complete sensory blockade is achieved as indicated by absence of sensation to cold swabs and needle prick was noted. the onset of motor block was assessed every 3 minutes by asking the patient to move the a prospective randomised comparitive double blind study to determine the duration of analgesia of buprenorphine and dexamethasone as adjuncts to bupivacaine in sciatico-popliteal and saphenous nerve block for below knee surgeries. original research paper dr renjith i dr. jeyasekharan medical trust, nagercoil, tamilnadu, india-629003 anaesthesiology background: adjuvants to local anaesthetics improve the block properties and reduce opioid consumption. this study compared combination of local anaesthetic bupivacaine with buprenorphine and dexamethasone in ultrasound guided sciatico-popliteal and saphenous nerve block for below knee surgeries. study design: a prospective, double-blind, randomized, comparative study. material and methods: 82 patients posted for elective or emergency below knee surgeries were randomly divided into 2 groups. group x received 25ml block solution made up of 2mg/kg of 0.5% bupivacaine with 2mcg/kg buprenorphine and normal saline and group y received 25ml block solution made of 2mg/kg of 0.5% bupivacaine with 0.1mg/kg dexamethasone and normal saline. onset of sensory block, onset of motor block, duration of analgesia, hemodynamic parameters, and side effects were noted in each group. results: the mean time of onset of sensory block was earlier in group x (6.730±1.871 min) as compared to group y (11.340±3.038min). the mean time of onset of motor block was also rapid in group x (9.000±2.121 min) than in group y (13.020±2.286min). the mean total duration of analgesia was longer in group y (1098.000±169.216) as compared to group x (794.070±145.084). there was no signicant difference in the mean duration of motor block between the groups. both the groups were hemodynamically stable, and no signicant side effects were noted. conclusions: onset of sensory and motor blockade was faster in the buprenorphine group, however duration of analgesia was much longer in the dexamethasone group without any signicant side effects. abstract keywords : adjuvants, bupivacaine, buprenorphine, dexamethasone. sciatico-popliteal and saphenous nerve block. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr renu devaprasath* dr. jeyasekharan medical trust, nagercoil, tamilnadu, india-629003 *corresponding author dr geo navin jude dr. jeyasekharan medical trust, nagercoil, tamilnadu, india-629003 dr t. s. ambujam dr. jeyasekharan medical trust, nagercoil, tamilnadu, india-629003 12 x gjra global journal for research analysis ankle and / toes. when the patient could not move the ankle or toes, this was considered as the time of complete motor block and the time was noted. the surgery was allowed to proceed when complete sensory and motor block has been achieved. postoperative follow up with atraumatic needle prick was carried out in the recovery and postoperative ward every 2 hours for rst 6 hours and then every 3 hours up to total 24 hours after nerve block or at any time when the patient complained of pain. nrs score ≥ 1 or if the patient complains of pain was taken as return of sensations. the duration of analgesia was calculated from the difference between the time of return of sensation and the time of onset of sensory block. side effects if any namely nausea, vomiting, respiratory depression, hematoma at the block site; were recorded and treated accordingly. following parameters were noted: complete sensory blockade – time at which there is loss of sensation to cold spirit swabs and atraumatic needle prick. complete motor blockade – time when patient is unable to dorsiex and plantar ex the ankle and / or toes. return of sensations – nrs score ≥1 or if the patient complain of pain. motor recovery – when patient regains the ability to dorsiex and plantar ex the ankle and / or toes. duration of motor blockade – difference between the time of complete motor blockade and the time of motor recovery. total duration of analgesia – difference between the time of return of sensations and the time at which complete sensory blockade has been achieved. master chart was prepared using the available individual data from the patient proforma, following which the data was analyzed. the quantitative data is expressed in terms of mean (standard deviation) and comparison done employing “independent sample t-test.” p value is considered signicant if it is less than 0.05. statistical calculation done using statistical package of social science (spss) version 10. results and discussion the primary objective of the study was to compare the duration of analgesia of buprenorphine and dexamethasone as adjuncts to bupivacaine in sciatico-popliteal and saphenous nerve block. dexamethasone and buprenorphine have been compared in sciatic nerve block and showed prolonged block duration, reduced the intensity of worst pain, 5 6and decreased analgesic requirements. persec et al. reported a mean duration of 21 h of postoperative analgesia with 4 mg of dexamethasone with levobupivacaine in 7supraclavicular blocks. in 1997, bazin et al. showed that buprenorphine prolonged the median duration of analgesia from combination lidocaine/bupivacaine supraclavicular blocks from 11.5 to 20 hours. in this study the mean total duration of analgesia was more in dexamethasone group (1098.000 ± 169.216 minutes) compared to buprenorphine group (794.070 ± 145.084 minutes). this difference was statistically signicant and it denotes addition of dexamethasone to bupivacaine signicantly prolongs the total duration of analgesia compared to buprenorphine. the mean time of onset of sensory block was later in dexamethasone group (11.340 ± 3.038 minutes) compared to buprenorphine group (6.730 ± 1.871 minutes). this difference was statistically signicant between two groups. mean time of onset of sensory block is slightly more in this study in contrary 8to the ndings of vadhanan p et al. the mean time of onset of motor block was also later in dexamethasone group (13.020 ± 2.286 minutes) than buprenorphine (9.000 ± 2.121 minutes) group in this study. this difference was also statistically signicant between the two groups. the mean time of onset of motor block is more in this study compared to the ndings obtained by vadhanan p 8et al. in this study the mean duration of motor block for buprenorphine group and dexamethasone group is 389.290 ± 148.572 minutes and 390.630 ± 149.694 minutes respectively. this means that there is no signicant difference in the mean duration of motor block among both the groups. various adjuvants like opioids, clonidine, dexamethasone and neostigmine are added to local anaesthetic agents to improve the efcacy and safety of blocks. it also helps in prolongation of action of local anesthetics by unclear mechanisms. opioids when added as adjuvants can produce analgesia and anti-inammatory effects by activating peripheral opioid receptors thereby reducing unwanted central nervous system side effects like nausea, vomiting and respiratory depression. comparative studies of use of different opioids as adjuvants have produced conicting results which resulted in further trials and newer modications in their usage. the objective vital parameters like heart rate (hr), mean arterial pressure (map) and respiratory rate (rr) were compared among both the groups before and after giving nerve block. there is no signicant difference in heart rate or respiratory rate before and after the block in both the groups. in this study there is a signicant increase in mean arterial pressure observed in buprenorphine group compared to dexamethasone both before and after the block. this observation is different from the results of all the related studies. so the increase in mean arterial pressure with buprenorphine observed in this study may be incidental and related to the preoperative hypertension status of the patients concerned. demographic data comparing age, sex, weight, height, bmi shows no statistically signicant difference among both the groups. all patients were monitored for complications like nausea and vomiting, respiratory depression and hematoma at block site during the intra-operative period and up to 24 hours postoperatively. in my study 3 patients (7.3%) of buprenorphine volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 13gjra global journal for research analysis group developed nausea and vomiting after block within rst 24 hours monitoring period. none of the patients in the dexamethasone group had nausea and vomiting. this implies that the buprenorphine group has higher incidence of nausea and vomiting but is statistically not signicant. in this study none of the patients in both the groups had respiratory depression. none of the patients had hematoma related to block in both groups. conclusions the addition of dexamethasone as an adjuvant to bupivacaine signicantly prolonged the duration of analgesia compared to buprenorphine. this study also concluded that buprenorphine has faster onset of sensory and motor block when added to bupivacaine compared to dexamethasone. there were no signicant adverse effects with both the buprenorphine and dexamethasone as adjuvants to bupivacaine. conicting interests author declares no conict of interest. funding no funding agency ethical approval obtained informed consentobtained acknowledgements i would like to thank the patients for cooperating with us throughout the study period. i thank the department of anaesthesia for helping in conducting and publishing this study. references 1. ibinson jw, mangione mp, williams ba. local anesthetics in diabetic rats (and patients). regional anesthesia and pain medicine. 2012;37(6):574–6. 2. choi s, rodseth r, mccartney c. effects of dexamethasone as a local anaesthetic adjuvant for brachial plexus block: a systematic review and meta-analysis of randomized trials. br j anaesth. 2014;112(3):427–39. 3. candido k, winnie a, ghaleb a, fattouh m, franco c. buprenorphine added to the local anesthetic for axillary brachial plexus block prolongs postoperative analgesia. reg anesth pain med. 2002;27(2):162–7. 4. modi m, rastogi s, kumar a. buprenorphine with bupivacaine for intraoral nerve blocks to provide postoperative analgesia in outpatients after minor oral surgery. journal of oral and maxillofacial surgery. 2009;67(12):2571–6. 5. yadeau j, paroli l, fields k, kahn r, lasala v, jules-elysee k et al. addition of dexamethasone and buprenorphine to bupivacaine sciatic nerve block. regional anesthesia and pain medicine. 2015;40(4):321-329. 6. persec j, persec z, kopljar m, zupcic m, sakic l, zrinjscak i et al. low-dose dexamethasone with levobupivacaine improves analgesia after supraclavicular brachial plexus blockade. international orthopaedics. 2013;38(1):101-105. 7. bazin je, massoni c, bruelle p, fenies v, groslier d, schoefer p. the addition of opioids to local anaesthetics in brachial plexus block: the comparative effects of morphine, buprenorphine and sufentanil. anaesthesia. 1997;52(9):858–62. 8. vadhanan p, ganesh n, ahmed m. comparison of dexamethasone and buprenorphine as adjuvant in ultrasound-guided brachial plexus blocks: a randomized controlled trial. anesthesia: essays and researches. 2018;12(1):176. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 14 x gjra global journal for research analysis 14.bluetree 01.cdr globally, the prevalence of diabetes mellitus is continuously escalating. the complications of chronic diabetes mellitus i n c l u d e r e t i n o p a t h y, n e u r o p a t h y, n e p h r o p a t h y, cardiomyopathy, and vasculopathy. diabetes mellitus is the leading cause of renal failure and approximately 20-30% of all diabetic subjects develop evidence of diabetic nephropathy manifesting from microalbuminuria to macroal buminuria and renal failure. nephropathy is one of the major complications of uncontrolled diabetes mellitus. the renal pathologic alterations of diabetic nephropathy are associated with glomerular basement membrane thickening, mesangial cell expansion, glomerulosclerosis, interstitial brosis, podocyte loss, and tubular atrophy. these renal alterations during diabetic nephropathy could result in albuminuria, a decrease in glomerular ltration rate (gfr) and an increase 1in serum creatinine and urea nitrogen levels . the reninangiotensin system (ras) plays a pivotal role in the 2pathogenesis of diabetic nephropathy . the activation of the renin-angiotensin system, especially the angiotensin ii type-1 receptor (at1r) pathway, has been demonstrated to play a 3detrimental role in the progression of diabetic nephropathy . even though the etiology of diabetic nephropathy is poorly understood, chronic hyperglycemia and hypertension are 1considered major risk factors for diabetic nephropathy . although various hyperglycemia-elicited metabolic derangements such as the increased formation of advanced glycation end-products (ages), protein kinase c (pkc) activation, and enhanced production of reactive oxygen species (ros) have been proposed to contribute to the characteristic histopathological changes associated with 2diabetic nephropathy . diabetic nephropathy is characterized by glomerular and tubular basement membrane thickening, extracellular matrix (ecm) expansion, microvascular damage, and brotic changes in the tubule-interstitium. hypertension further increases the risk for onset of kidney disease and progression and cardiovascular (cv) morbidity and mortality. multiple factors contribute to increases in blood pressure and hypertension in patients with diabetes and nephropathy. the major causes of hypertension in both diabetes type i as well as type ii include volume expansion owing to increased renal sodium reabsorption and peripheral vasoconstriction as a result of dysregulation of factors that regulate peripheral vascular resistance. excess sodium retention, activation of the sympathetic nervous system (sns) and raas, endothelial cell dysfunction (ecd), and increased oxidative stress leads to hypertension in diabetic 4nephropathy . angiotensin-converting enzyme (ace) inhibitors and angiotensin-ii type 1 (at1) receptor blockers (arbs) are often employed to treat diabetic nephropathy. although new strategies for treating nephropathy are req uired as current approaches are insufcient since most of the diabetic patients continue to show progressive renal damage. new studies indicate the therapeutic potential of peroxisome proliferator-activated receptors (ppar) ligands in the treat 5,6ment of patients with diabetic nephropathy . ppars are ligand-activated transcription factors of nuclear hormone receptor superfamily, which comprises of three members such as ppar α, ppar ß and ppar γ/δ. ppar α plays an important role in the oxidation of fatty acids. studies suggest that hyperlipidemia is an independent risk factor involved in the 7–9development of diabetic nephropathy . the elevated levels of lipids are associated with the progression of renal 10dysfunction . the increase in circulating lipids induces glomerulosclerosis and tubule-interstitial injury by acceler ating the generation of reactive oxygen species (ros) and stimulating the overexpression of transforming growth factor ß (tgf-ß) in the glomeruli and tubule-interstitium. it was suggested that circulating lipids are entrapped by extracellular matrix molecules where they undergo the process of lipid peroxidation and generate ros to induce 10renal dysfunction . further evidence revealed that diabetes may mediate renal injury by increasing the expression of sterol regulatory element-binding protein-1 (srebp-1), which are responsible for increasing the synthesis of triglycerides and cholesterol in the kidney, that is associated with the upregulation of tgf-ß, vascular endothelial growth factor (vegf) and extracellular matrix proteins, resulting in glomerulosclerosis and tubule-interstitial brosis to provoke 11,12diabetic nephropathy . hence, reducing the circulating lipids in diabetic patients may provide a new therapeutic option in managing diabetic nephropathy. the agent like ppar� agonists has been suggested as a novel therapeutic 13intervention to manage diabetic nephropathy . moreover, adiponectin, an adipose tissue-derived secreted cytokine, has been found to have insulin-sensitizing, antiinammatory, and vasculoprotective actions through binding to its receptors, adipor1 and adipor2. these two adiponectin receptors have been previously shown to mediate the increase in ampk activities, as well as fatty acid oxidation and glucose uptake by adiponectin. there is a growing body of evidence demonstrating the renoprotective functions of adiponectin and its receptors, which protects against the development of 3albuminuria . thiazolidinediones, ligands for ppar�, have been employed for the treatment of type 2 diabetes mellitus, however, they have been found to increase the risk of myocardial infarction and heart failure. however, telmisartan has been suggested to be devoid of these undesirable effects. thus, telmisartan could be a novel therapeutic choice to treat co-existing diabetes mellitus and hypertension-associated role of telmisartan in diabetic nephropathy a novel treatment avenue original research paper dr manash das settlement road,ward no-1.karimganj-788712,assam medicine keywords : volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr md anfas nusrat pasha* shine speciality clinics, laxmi nagar colony, shaikpet, hyderabad *corresponding author dr mukesh gupta daksh hospital,gandhi nagar,alwar,pin301001 dr mriganka baruah vg hospital,convoy road,dibrugarh,assam,786001 dr navneet maini 5 rb duni chand road,jamun wali road amritsar 143001 punjab. 38 x gjra global journal for research analysis 1progression of diabetic nephropathy . telmisartan is a long-lasting, non-competitive/ insurmo untable, non-peptide arb with the strongest receptor binding afnity having potent anti-hypertensive action. telmisartan chemically is 2-(4-{[4-methyl-6-(1-methyl-1h-1,3-benzodiazol2-yl)-2propyl-1h-1, 3-benzodiazol-1 yl] methyl} phenyl) benzoic acid. it is orally active and possesses good oral absorption and tolerability. the oral clearance was associated with age and dose. the oral clearance was noted to be decreased with advanced age. the volume of distribution for the central compartment was noted to be related to age and dose, and the volume of distribution for the peripheral compartment was noted to be related to body weight and gender. the absolute bioavailability of telmisartan is dose-dependent, and food may slightly reduce its bioavailability. it is a lipophilic compound widely distri buted to tissue and is highly bound to plasma proteins up to 99.5%. telmisartan 1-o-acylglucuronide is the principal metabolite of telmisartan in humans. biliary fecal excretion is a primary elimination route of telmisartan and its metabolite. being an arb, telmisartan reduces high blood pressure by antagonizing the aforementioned actions of angiotensinii. because of its long half-life, a once-daily dose of telmisartan has been found to be effective in minimizing the elevated blood pressure. interestingly, telmisartan has the additional property of activating ppar� partially, which could make it a unique agent in preventing cardiovascular and renal complications. telmisartan induces ppar� activity independently to its at1 receptor blocking action. patients with uncontrolled type 2 diabetes mellitus are prone to hypertension and persistent proteinuria ranging from microalbuminuria to macroalbuminuria. raas over activ ation plays a central role in the pathogenesis of diabetic nephropathy. telmisartan has renoprotective effects that are mediated by its long-acting at1 receptor blocking action and pparγ partial agonistic action, both of which could be benecial in affording renal vasodilation, preventing renal inammation, inhibiting renal oxidative stress and halting renal injury in patients with diabetic nephropathy. the groundbreaking 'diabetics exposed to telmisartan and enalapril (detail)' trial addressed the long-term (5 years) effects of telmisartan versus enalapril on renoprotection in patients with hypertension and early type 2 diabetic nephropathy. this study suggested that telmisartan was not inferior to enalapril in reducing the decline in glomerular ltration rate. the long-term treatment with telmisartan afforded renoprotective efcacy comparable to enalapril in patients of early-type 2 diabetic nephropathies with greater 14tolerability . the incipient to overt: angiotensin ii blocker, telmisartan, investigation on type 2 diabetic nephropathy (innovation) study determined whether telmisartan could provide clinical benets in normotensive patients with diabetes mellitus and diabetic nephropathy. the patients treated with telmisartan showed a reduction in the transition rate from microalbuminuria to overt nephropathy as compared to the placebo group. moreover, a signicant number of patients in the telmisartan group was reverted to normoalbuminuria. this clinical trial strongly suggested that telmisartan could prevent the progression of microalbuminuria, and also induce remission of albuminuria in normotensive japanese patients with type 2 diabetes mellitus. a comparison of telmisartan versus losartan in hypertensive type 2 diabetic patients with overt nephropathy (amadeo) study compared the efcacy of telmisartan with losartan for reducing urinary protein-to-creatinine (upc) ratio from baseline after 52 weeks of therapy in hypertensive patients with type 2 diabetes mellitus and overt nephropathy. this clinical trial reported that telmisartan-based regimen in these patients showed a greater anti-proteinuric effect than a losartan-based regimen at similarly achieved blood pressure 1,15lowering effects . further, the long term renoprotective potential of telmisartan with effects of “standard” (80 mg once daily) versus “high” (80 mg twice daily) doses of telmisartan in hypertensive patients without diabetes with biopsy-proven chronic proteinuric nephropathies was carried out by aranda 16et al. . the study was carried out in 78 patients. at the end of the study, blood pressure control did not differ between groups. in the group administered telmisartan, 80 mg once daily, serum creatinine level increased from 1.6 ± 0.6 to 2.7±0.9 mg/dl (141 ±52 to 239±80 µmol/l), and estimated creatinine clearance declined from 68 ±30 to 50 ±34 ml/min (1.13±0.50 to 0.83 ± 0.57 ml/s), whereas in that administered 80 mg twice daily, serum creatinine (1.6±0.7 to 1.6±0.8 mg/dl [141±62 to 141± 71 µmol/l]) and estimated creatinine clearance values (67±38 to 74±38 ml/min [1.12 ±0.63 to 1.23 ± 0.63 ml/s]) did not change during the study. the decrease in proteinuria was more pronounced (p<0.01) in patients administered the high dose of telmisartan compared with those treated with the standard dose. it was concluded that long-term administration of high doses of telmisartan seems to improve the efcacy of the drug to decrease proteinuria and slow the progression to end-stage renal failure in nondiabetic 16hypertensive renal disease . attenuation of the renal damage of diabetic nephropathy through the inhibition of at1r-adipor1 heterodimerization and alleviation of downstream inammatory responses and cell apoptosis by telmisartan has also been proposed to be 3another mechanism of renoprotective action of telmisartan . simultaneously, the telmisartan versus ramipril in renal ®endothelium dysfunction (trendy ) study showed that treatment with telmisartan or ramipril for 9 weeks signicantly improved (p < 0.001) the response of the renal vasculature to nitric oxide, an indicator of basal nitric oxide activity and thereby of endothelial function of the renal vasculature. the magnitude of the effect of telmisartan appeared somewhat 17greater than that of ramipril . conclusion an essential component of the management of diabetic patients, especially those with other risk factors such as neph ropathy, is the control of blood pressure to prevent cardio v ascular events and premature death. blood pressure targets are in most cases not being met and further complicating the disease state. telmisartan seems to be an ideal drug for such a situation. telmisartan posses dual action of cardioprotection along with with underlying long term renoprotective action by virtue of inhibiting at ii and induces pparγ activity. thus, it seems logical to adopt telmisartan in therapy for the better management of diabetes complicated with hypertension and diabetic nephropathy. references 1. balakumar p, k. bishnoi h, mahadevan n. telmisartan in the management of diabetic nephropathy: a contemporary view. curr diabetes rev. 2012;8(3):183-190. doi:10.2174/157339912800563972 2. fukami k, yamagishi s. an overview on diabetic nephropathy. nutr ther interv diabetes metab syndr. 2018:125-137. doi:10.1016/b978-0-12-8120194.00010-6 3. zha d, yao t, bao l, gao p, wu x. telmisartan attenuates diabetic nephropathy progression by inhibiting the dimerization of angiotensin type-1 receptor and adiponectin receptor-1. life sci. 2019;221(august 2018):109-120. doi:10.1016/j.lfs.2019.01.044 4. van buren pn, toto r. hypertension in diabetic nephropathy: epidemiology, mechanisms, and management. adv chronic kidney dis. 2011;18(1):28-41. doi:10.1053/j.ackd.2010.10.003 5. pitrosch f, herbrig k, kinder b, passauer j, fisher s gp. rosiglitazone improves glomerular hyperlteration, renal endothelial dysfunction and microalbuminuria of incipient diabetic nephropathy in patients. diabetes. 2005;54:2206–11. 6. nagai t, tomizawa t mm. effect of bezabrate or pravastatin on serum lipid level and albuminuria in niddm patients. j atheroscler thromb. 2000;7:91–6. 7. bonnet f cm. potential inuence of lipids in diabetic nephropathy: insights volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 39gjra global journal for research analysis from experimental data and clinical studies. diab metab. 2000;26:254–64. 8. ravid m, neumann l lm. plasma lipids and progression of nephropathy in diabetes mellitus type ii: effect of ace inhibitors. kidney int. 1995;47:907–10. 9. rosario rf sp. lipids and diabetic nephropathy. curr diab rep. 2006;6:455–62. 10. munter p, coresh j, smith jc, eckfeldt j km. plasma lipids and risk of developing renal dysfunction: the atherosclerosis risk in communities study. kidney int. 2000;58:293–301. 11. wang z, jiang t, li j, proctor g, mcmanaman jl, lucia s et al. regulation of renal lipid metabolism, lipid accumulation and glomerulosclerosis in fvbdb/db mice with type 2 diabetes. diabetes. 2005;54:2328–35. 12. sun l, halaihel n, zhang w, rogers t lm. role of sterol regulatory elementbinding protein-1 in regulation of renal lipid metabolism and glomerulosclerosis in diabetes mellitus. j biol chem. 2002;277:18919–27. 13. balakumar p, arora mk, singh m. emerging role of ppar ligands in the management of diabetic nephropathy. pharmacol res. 2009;60(3):170-173. doi:10.1016/j.phrs.2009.01.010 14. rippin j, bain sc, barnett ah. rationale and design of diabetics exposed to telmisartan and enalapril (detail) study. j diabetes complications. 2002;16(3):195-200. doi:10.1016/s1056-8727(01)00165-9 15. bakris g, burgess e, weir m, davidai g, koval s. telmisartan is more effective than losartan in reducing proteinuria in patients with diabetic nephropathy. kidney int. 2008;74(3):364-369. doi:10.1038/ki.2008.204 16. aranda p, segura j, ruilope lm, et al. long-term renoprotective effects of standard versus high doses of telmisartan in hypertensive nondiabetic nephropathies. am j kidney dis. 2005;46(6):1074-1079. doi:10.105 3/j.a jkd.2005.08.034 17. schmieder re, delles c, mimran a, fauvel jp rl. impact of telmisartan versus ramipril on renal endothelial function in patients with hypertension and type 2 diabetes. diabetes care. 2007;30:1351-1356. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 40 x gjra global journal for research analysis background: fever is dened as an elevation of the body temperature above the normal circadian range, as the result of a change in the thermoregulatory centre located in the anterior hypoth alamus. a morning temperature of more than 37.2°c (98.9 °f) or evening temperature of more than 37.7°c (99.9°f) would 1dene fever. thrombocytopenia is dened as platelet count less than 150,000 /�l. thrombocytopenia classied as mild (platelet count between 50,000-1,50,000/�l), moderate ( platelet count between 20,000-50,000/�l), severe ( platelet 2count < 20,000/�l). septicaemia, infections like malaria, dengue, leptospirosis, typhoid, human immunodeciency virus (hiv) and miliary tuberculosis are some of the common 3causes of fever with thrombocytopenia. this is due to decreased production, increased destruction (immunogenic and nonimmunogenic) and increased sequestration in spleen.4 the present study was intended to know the underlying etiology of febrile thrombocytopenia in our community, various presentations and relationship between platelet count and severity of disease and outcome. aims and objective: 1. to study the clinical presentation of patients with febrile thrombocytopenia. 2. to study etiological prole of patients with febrile thrombocytopenia. 3. to study severity of thrombocytopenia of patients with febrile thrombocytopenia. 4. to study the disease outcome of patients with febrile thrombocytopenia. material and method: this study was conducted from july 2018 to december 2018 in the department of medicine in geetanjali medical college and hospital, udaipur. patients of >21 years of age admitted 0to the hospital with documented fever of >99.9 f and platelet count < 1,50,000 cells/cumm who gave written consent were included in study. a detailed clinical history and clinical examination was done. scrub typhus was diagnosed by rapid immunochromatographic assay. all these patients were investigated for routine blood tests like complete blood count, erythrocyte sedimentation rate, peripheral smear for malaria parasite, qbc for malaria parasite, bleeding time and clotting time, urine routine and microscopy, blood culture, urine culture, renal function tests, liver function tests, widal test, dengue ns1 , brucella standard agglutination test, leptospira elisa, bone marrow examination etc.) were done as and when indicated. patient with known hematological disorder, chronic intake of drugs causing thrombocytopenia , presence of chronic liver disease, chronic renal disease, chronic alcohol intake, hiv positive individual and pregnant female were excluded. results: a total 100 patient admitted over a period of 6 months in this hospital were studied. among the total 100 patients admitted, 56 patients were male and 44 patients were female. fever with thrombocytopenia affected all age group but it was found that younger age group as 21-30 years of age group (48%) and 3140 years(22%) was predominant than the older age group (more than 40 years of age). the mean age of the study was 34.7+15.37 years (table 1). in the present study 92% of the patient presented with complaints of fever with chills & rigors followed by 80% body pain,72% with headache and 65% with nausea and vomiting.19% patients had jaundice and 16% had oliguria. bleeding manifestation were present in 13% clinical profile, etiological profile, severity and outcome of febrile thrombocytopenia patients: a hospital-based cross-sectional study. original research paper shah arth resident, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india x 23gjra global journal for research analysis general medicine background: fever with thrombocytopenia is commonly caused by infection like malaria, dengue fever, enteric fever, leptospirosis and septicemia. the present study was intended to know the underlying etiology of febrile thrombocytopenia in our community, various presentations and relationship between platelet count and severity of disease and outcome. aims and objective: to study the clinical presentation, etiological prole and severity of thrombocytopenia and the disease outcome of patients with febrile thrombocytopenia. material and method: this study was conducted in the department of general medicine of geetanjali medical college and hospital, udaipur from july 2018 to december 2018. 100 patients of >18 years of age admitted to the hospital with documented fever of >99.90 f and platelet count < 1,50,000 cells/cumm were included in study. results: among the total 100 patients admitted, 56 patients were male and 44 patients were female. fever with chills and rigors (92%) and body pain (80%) were commonly observed symptoms. hepatomegaly (33%) and splenomegaly (32%) were commonly observed signs. 47% cases presented with moderate thrombocytopenia in which maximum cases were due to malaria (36%) and 43% cases presented with severe thrombocytopenia in which maximum cases were from dengue fever. most common etiology of febrile thrombocytopenia was found to be dengue fever (36%) followed by malaria (29%). it was found that 8 patients expired out of which 2 had scrub typhus, 3 had malaria, 3 had dengue fever respectively. most likely cause was multiorgan dysfunction (mods). conclusion: fever with thrombocytopenia is an important clinical condition commonly caused by infections, particularly dengue, malaria and septicaemia. mortality in febrile thrombocytopenia is not directly associated with degree of thrombocytopenia but with concomitant involvement of other organs leading to multiorgan dysfunction. abstract keywords : fever, thrombocytopenia, malaria, dengue fever. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra basu abhijit* professor and head, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india *corresponding author dudhatra ashutosh resident, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india 24 x gjra global journal for research analysis patients (table 2). in the present study 19% of the patients presented with sign of icterus and 17% with tachypnea followed by 14% of pedal oedema. hepatomegaly was found in 33% and splenomegaly in 32%. ascites in 8% and purpura in 3% (table 3). in this study most common etiology was found to be dengue fever which was 36% followed by malaria in 29%. scrub typhus was seen in 5%, enteric fever in 8%, septicaemia in 12%, leptospirosis in 2% patients. 8% cases were diagnosed as puo (table 4). in the present study 10% cases presented with mild thrombocytopenia (platelet count between 50,000 cells/cumm to 1,50,000 cells/cumm), 47% cases presented with moderate thrombocytopenia (platelet count between 20,000 cells/cumm to 50,000 cells/cumm) and 43% cases presented with severe thrombocytopenia (platelet count less than 20,000 cells/cumm). in the present study, it was found that out of 100 patients, 8 patients expired as 2 from scrub typhus, 3 from malaria, 3 from dengue fever. table 1: age wise distribution: table 2: clinical symptoms wise distribution table 3:clinical sign wise distribution table 4: etiology of fever with thrombocytopenia discussion: in our study, male population (56%) were more affected then female (44%). the most common age group affected in our study was 21-30 years of age. study conducted by raikar et al observed the clinical picture associated with febrile thrombocytopenia. they enrolled a total of 100 patients in the study who were suffering from fever and investigations found thrombocytopenia. they found males are more commonly .5selected than females in a study done by suresh et al, showed male preponderance with males 54% and females 646%. in another study conducted by nair p s et al 76% were 9male and 24% were female patients. in our study dengue was commonest infection seen in (36%) cases of fever with thrombocytopenia and other causes of fever with thrombocytopenia were malaria in 29 patients [p.f15, p.v-12, both-2], scrub typhus in 5 patients, enteric fever in 8patients, septicaemia in 12 patients, leptospirosis in 2 patients, and 8 patients cause could not be detected. a study conducted by gondhali mp et al observed 100 subjects of more than 12 years of age with fever and thrombocytopenia. they found the most common cause of febrile thrombo 7 cytopenia was dengue (infection) similar to our study. in the study of prithviraj patil et al septicaemia accounted for 60%, dengue accounted for 20% and other causes accounted for 820% of mortality. in the study of srinivas et al septicaemia accounted for 78% and dengue accounted for 22% of 10mortality. another study conducted by geetha et al 41.86% patients had malaria, 32.55% of patients had dengue, 4.65% had chikungunya and in 20.94% cases, no etiology was found. there was a highly signicant association found between 11thrombocytopenia with dengue and malaria. in our study, we found fever, headache, myalgia, chills, and rigor were the commonest signs and symptoms (table 2). a study conducted by fah et al comparatively observed that myalgia and headache were common ndings among all subjects. however, young patients present with thromb ocytopenia had nausea and vomiting more often and 12signicantly than in patients with normal platelet count. in our study 8 patients expired due to multiorgan dysfunction (mods) out of which 2 had scrub typhus, 3 septicaemia and 3 dengue fever. conclusion: fever with thrombocytopenia is an important clinical condition commonly caused by infections, particularly dengue, malaria and septicaemia. mortality in febrile thrombocytopenia is not directly associated with degree of thrombocytopenia but with concomitant involvement of other organs leading to multiorgan dysfunction. references: 1. charles a. dinorello, reuven porat. fever.in : kasper dl, fauci as, hauser sl,longo dl, jameson jl, loscalzo j, et al.(eds.). harrison’s principles of internal medicine, 19th edition. mcgraw hill education; 2015.p. 123-26. 2. the hemorrhagic disorders: capillary and platelet defects. in : firkin f, chesterman c, penington d, rush b, et al.(eds.) de gruchy’s clinical hematology in medical practice, 5th edition. blackwell science; 1996 .p. 360405. 3. george m. rodgers. thrombocytopenia: pathophysiology and classication. in : greer j, foerster j, rodgers g, paraskevas f, glader b, arber d, means rt jr., et al.(eds.) wintrobe’s clinical hematology; 12th edition.wolter kluwer health/lippincott williams and wilkins; 2009. volume 2 .p. 1289-91. 4. douglas b. cines. approach to the patient with thrombocytopenia. in : william n. kelley, herbert l. dupont, et al.(eds.).textbook of internal medicine, 3rd edition. lippincott-raven; 1997 .p. 1305-11. 5. raikar sr, kamdar pk. clinical and laboratory evaluation of patients with fever with thrombocytopenia. intern med 360 indian j clin pract [internet]. 2013;24(4). 6. putta suresh, c. yamini devi, c. ramesh kumar, y. jalaja. evaluation of the cause in fever with thrombocytopenia cases. journal of evidence based medicine and healthcare; 2015;2:2134-2137. 7. gondhali m., vethekar m, bhangale d, choudhary k, chaudhary m, patrike g, et al. international journal of medical research &amp; health sciences. [internet]. vol. 5, international journal of medical research & health sciences. international journal of medical research & health sciences. 258volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra age (years) no of patients 21-30 48 (48%) 31-40 22 (22%) 41-50 14 (14%) 51-60 7 (7%) 61-70 6 (6%) >70 3 (3%) total 100 (100%) mean age 34.7+15.37 clinical symptoms no of patients rigors and chills 92 (92%) body pain 80 (80%) headache 72 (72%) nausea and vomiting 65 (65%) abdominal pain 46 (46%) diarrhea and loose stools 27 (27%) jaundice 19 (19%) oliguria 16 (16%) bleeding manifestation 41 (41%) cough 10 (10%) arthralgia 9 (9%) altered sensorium 9 (9%) clinical signs no of patients hepatomegaly 33 (33%) splenomegaly 32 (32%) hepatosplenomegaly 22 (22%) purpura/petechia 33 (33%) icterus 19 (19%) tachypnoea 17 (17%) pedal edema 14 (14%) ascitis 8 (8%) etiology no of patients dengue fever 36 (36%) malaria p.f p.v both 29 (29%) 15 12 02 scrub typhus 05 (5%) enteric fever 08 (8%) septicaemia 12 (12%) leptospirosis 02 (2%) undiagnosed 08 (8%) 277 8. prithviraj patil, pranita solanke, gayatri harshe. to study clinical evaluation and outcome of patients with febrile thrombocytopenia. international journal of scientic and research publications 2014; 4:1-3. 9. nair ps, jain a, khanduri u, kumar v. a study of fever associated with thrombocytopenia. j assoc physicians of india 2003; 51:1151-73. 10. srinivas, gutthi lp, vegesna s, et al. clinical and lab prole of fever with thrombocytopenia. international journal of contemporary medical research 2017; 4:1057-2016. 11. geetha j. p.; rashmi m. v.; murthy n. acute febrile illness with thrombocytopenia--a common scenario. indian j public heal res dev [internet]. 2015;6(4):163–7. 12. fah ts, mmed naa, liew cg, omar k. clinical features of acute febrile thrombocytopaenia among patients attending primary care clinics. malaysian fam physician off j acad fam physicians malaysia [internet]. 2006;1(1):15–8 x 25gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: employment now-a-days become a big challenge for every country. every country tries to nd new sources to generate employment towards their country people. the nature itself contributed much more resources such as hills, rock, river, lake, forest, sea, ora-fauna, wild-life, culture, food and last but not least the people itself. the totality of these natural resources can be use as way to create employment. these resources form the very core of the term tourism. the concept of tourism is old; it was found that the word was thrst appeared in 14 century. and it was drived from latin word 'tornare' which means return, go back or come and the word tourist was used 1772. in ancient period it was basically happened for the purpose of trade and searching for food and devoting. generally the concept tourism is about movement of people for various purposes from a common geographical area to another. it includes activities, service and industries which is associated with accommodation, fooding, recreation, entertainment, shopping, and relaxation, refreshing of human being with experience. at different time the various author gives many denition regarding tourism. the rst denition of tourism was given by guyer and feuler(1905) “as phenomenon unique to modern time which dependent on the people's increasing need for a change and relaxation, the wise of recognizing the beauties of nature and art and the belief that nature gives happiness to human beings and which helps nations and communities approach each other thanks to the developments in commerce and industry and the communication and transportation tools becoming excellent” unwto dene tourism as “tourism comprises the activities of persons travelling to and staying in places outside their usual environment for not more than one consecutive year for leisure, business and other purpose.'' one of the notable thinks that there is difference between tourism and travel .whenever we say about tourism it must be displacement of people for various purpose. commercialized tourism started almost 261 years ago when richard cox became ofcial travel agent for royal armed force during the british era and cox & king became rst travel agency in the early 1758. from that period till the date these sections become one of large industry in the world platform and generate income through various ways of its services. according to record of world tourism ranking during the year 2017, 1.323 billion people become as tourist across the world with the increase rate of 6.8% compare to 2016. in these regards asia-pacic region recorded 323 million international tourists and india had received 15.5 million tourists during the year. in case of india the country have one of specic region in the foot hill of himalayan range; this region is known as northeast region which consist of 8 states such as assam, manipur, meghalaya, mizoram, nagaland, tripura and sikkim. geographically this part of the country is sharing international border with several countries. the region is rich by its virgin beauty and epic culture which have a vast scope for tourism, many part of this region still untouched by the world. in this case one of state of this region meghalaya popularly called 'scotland of the east' have eye catching nature beauty and history of some of popular tribe of northeast known as khasi, jaintia and garo. objectives: the study has been done with the following objectives1. to study the role of social media in attracting tourists in selected unexplored tourist spot of meghalaya; 2. to examine the increase in income generation of local people in the selected spots. research queries: the following research queries have been framed for this study1. whether social media has played a role in attracting tourists in selected unexplored tourist spot of meghalaya? 2. whether tourism has assisted the local people in their income generation? methodology: the study is based on primary and secondary data. four unexplored tourist spots in meghalaya have been chosen. these spots are ialong village and nartian durga temple selected from west jaintia hills and pynursula, kongthong village are selected from east khasi hills part of the meghalaya. 10 local people residing in each of these destinations have been selected. moreover 10 tourists visiting these spots have also been selected for interview for the purpose of this study. thus a total of 40 local people and 10 tourists have been selected on the basis of simple random sampling. the secondary sources of data include research papers, websites and face book pages of these selected spots. the study has been undertaken for a time period of three months. the study is limited to the availability of data. unexplored tourist spots of meghalaya: meghalaya have 3 divisions with 11 district such as khasi hills division, jaintia hills division and garo hills division. this 3 division have too many unexplored place which preserve lot of eye catching natural beauty along with lot of scope for tourism activities. some of place specied in the paper by the researcher which is mainly located east khasi hill and jaintia hill division. name of the place are ilong village, mawlyngbna , mawphanlur ,umden, nonglang, kongthong , pynursla, sohra (river camyoing), mawphlang sacred grave, mawkhong view point, langkawet, phe phe water falls, tyrshi falls, moopun water falls, syntu ksiar, borghat temple, narting durga temple, narting monoliths, kyrdemkhla, sua ludong water falls, thadlaskein lake, lawmusiang, mawphlang, mairang, nonkhnum island etc. some of them are discussed in details below: 1. ilong village: this is the typical village of east jaintia hills. the village have 400 household and one of the specic character of the village tourism, employment and social media-a study on unexplored tourist spots of meghalaya original research paper alpana baruah assistant professor darrang college,tezpur x 39gjra global journal for research analysis commerce keywords : dr. bonosree bhuyan* assistant professor gauhati university,guwahati *corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 40 x gjra global journal for research analysis is that majority of population is belong to a single clean .the place is famous for its cultural richness; some of specic festival celebrating in the village such as chad chukra and noh sceriat which is celebrating during the month of april relating to sowing and harvesting activities. another festival behdeinkhlam and manic celebrating at the time of august for the purpose of good health, property and bumper festival .the village is sourding by pynthorwah vallye, myntdu river and ilong eco park which are truly breath taking. and the village is also rich for organizing archery contests and local theatre. 2.nartiang durga temple: this is one of the shakti peethas of hindu mythology among the 51 which located west jaintia hills. it is one of the best examples of hindu and ancient khasi tradition. the temple have more than 500 years old history where it have mention that the temple was constructed by the jaintia king dhan manik to converted into hinduism . presently the temple is well maintain by the local people and even today during the period of navaratri (sep or oct month) the local people organized durga puja and workshop the devi. the local chieftain or syiem is considered the chief patron of the temple. the temple is famous for sacricing rites from the ancient period; earlier human also sacrices for rites and even today goats and duck are sacriced for the devi. 3. kongthong village: this village is located east khasi hills part of the state which is located 56 km from the main shillong city and which is also part of khatar shnong group of a 12 village . the village has one of the unique character i.e no villager called each other's by their name instead sing out names that are given to individual of the village at childhood .it is quaint village with a distinction in organic honey production which is brought by the village into international and national level. the village has traveler nest facilities which known as kongthong travelers' nest and it is manage by indigenous agro tourism cooperative society ltd, khatar-shnong .the place is famous for trekking, shing & angling, camping and its valley. 4.pynursula: it is one of the offbeat parts of meghalaya. it is one of the last part of east khasi hill and nearest to bangladesh. the place is located 51 km from the shillong city. the place is famous for providing home stay service in rural setting environment along with adventurous activities. pynursla have 133 villages through which offerde rural village tourism. the place has trek road from cherrapunjee to pynursula and krang to pynursula and pynursula root bridge . 5. umden traveller's nest (umiaphati village): it is a small hamlet ideal gateway which is located 75km from shillong city under the ri-bhoi district, nongpoh .the place is famous for sericulture activities which mainly produce eri silk . the village also related with traditional handloom activities and also famous for age old traditional production process of eri silk where they does not killed the silk worms. all these activities carried by the villager under the corporation of diwon handloom cotton and khadi village industrial cooperative society ltd. along with eri silk production process the place is also attracted by kayaking, mountain biking, heritage walk. 6. mawphanlur: it is one of the hill top village of west khasi hill. the village is witness of glorious setting of the sun and quite dark beauty of night with great himalaya range. it is a place for truly nature lover along with trekking, camping activities. the village has mawphanlur integrated multipule cooperative society ltd who manage or own mawphanlur traveler nest and engaged every individual of the village towards traveling activities. 7. nartiang monoliths: this place is haven for those who are interested in archaeological study. it is the collection of monoliths which are constructed during 1500ad and 1835 ad by jaintia king which is located 65 km from the capital of the state. there are lot of believe regarding construction of these monoliths like on the memory of legendry of king and women, for particular events and some of believe there was stable for royal horses. it was thsummer resort of jaintia king during 17 century according to local believe. it also believed that the place have longest monoliths of the world which is 8 meter long. 8. tyrshi falls: one of the water falls of jaintia hills which is located 8 km away from jowai. 9. syndai: it is one of important village of west jaintia hills which is famous for several caves and limestone-borne area. role of social media: in the present times, social media has become all pervasive in the lives of people throughout the world. an internet connection and a device get people connected across the globe through social networking. social media means and includes forms of electronic communication (websites and applications) through which users share information, ideas, videos and such other contents quickly. social networking is a powerful tool in the hands of people. in this section the role of social media in attractinng tourists in the select destinations has been studied. it has been found by tafveez (2017) that social media has evolved as an important platform and it plays a prominent role in tourism. unexplored tourist destinations are those which have potentialities for tourism but they have remained unknown mostly due to lack of promotion. social networking sites provide a platform for people to post pictures, videos and share the contents with others connected through the sites. it also enables other users to comment on such contents or post queries. when a person visits an unexplored destination, shares posts in social media, then such posts attracts the attention of other like-minded individuals and intrigues him/her to know more about the destination which nally results in travelling to that spot. it needs to be mentioned that the local people in all the selected spots have pointed out that there has been an increase in the tourist inow to these spots. they have also mentioned that many of the tourists include people outside meghalaya. however, the number of tourist inow could not be gathered and is a limitation of this study. the selected tourists are non locals and they have come outside the state of meghalaya to visit the destinations. the tourists, when interviewed, pointed out that posts and recommendations in social media forms the foremost reason for their visit to such unexplored spots. a close observation on how social media has attracted tourists and also led to the increase in tourists for the four unexplored destinations reveals the following: ÿ except nartian durga temple, ialong village, pynursula, and kongthong village have their respective face book page and youtube channel in which people can share pictures, videos and recommend the place. ÿ when asked about the source of information of these spots, all the selected tourists have said that their major source of information about these spots is social media. they have pointed out towards face book. ÿ all the tourists have agreed that that they will surely share posts or have already shared posts containing pictures or videos accompanied by their experiences (in words) and recommend these places in social media. ÿ the tourists have also mentioned that reviews put forward by other travellers in social media is very helpful in planning their visit as they can know beforehand what to volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra expect from these unexplored destination and how to reach the spots. thus, social media has played a role in attracting tourists towards the four selected unexplored tourist spots of meghalaya. employment of local people: there is a scope of generating employment for any tourist destination. most of place of the selected division of meghalaya are surrounded by hills and semi forest area. the main activity of the state is agriculture; 80% of total population is engaged into it by seasonally but rest of time they are unemployed. earlier coal mine and rock mine were some of the essential income source for the local people but due to various legal issues now it is stopped and as result a number of local people lost their way of earning. now many of rural people selected their inherited beauty as source of income and created self-employments. while visit ing the destinations, observation of their activities was done by the researchers. further interview of the selected local people has also been done. the following has been revealed: ÿ in kongthong village the villagers have adopted organic bee farming in the near forest area and constructed 2 tourist cottages at valley top which is maintained by the local villager under the guidance of headman of the village. the total income drive from the tourist cottage and honey selling is distributed among the villagers and also each individual from the village got the chance to work there as tracking guide or caretaker or service person. tourists are their one of main buyer of their organic honey. ÿ the ilong place is locally known as ilong recreation cum tourist centre which is created 1997. based on it there is constructed eco lodge with 3 cottage facilities. due to this cottage services, many of local people open small retail shop which basically serve the people who visit there and also being local toll gate service for the tourist cars where mainly engaged local villagers. ÿ in the content of nartian durga temple, as it is one of notable shakti peethas of the country ; devotes come from various part of the country who are aware about it whole of the year but during the period of navaratri (durga puja) the number of visitor increase. and is also one of recreation place for other part of state meghalaya. the local people also organized various fairs in their time by time of the year and it is also near of nartiang monoliths as a result visitor of monoliths visit their too as targeting the visitor and devote the villager sold their locally produce fruits and various decorative items which is made from bamboo and pine trees at very minimum cost. ÿ pynursula one of place for tracking, hiking and cycling with this feature the local people stated loading services along with facility of food with minimum variability. basically home stay services provided by them those go too visited secrete forest and buttery park, root bridge. around 133 villages of pynursula division in most villages, home stays are one of the major sources of income and also provide the guide services to explore the area by the tourist at reasonable fees. now some of resorts are also opened who only appoint local people to serve the tourist with local khasi tradition. all the selected spots are lesser known by the world and lesser connected by the all means and also have language problem still the local people can nd a way of live hood due promotion of visitor or tourists through various social networking sites. conclusion: northeastern part of the country yet not has any big business house or industrial unit as a result it is very difcult to create employment of this region in organised way. and the government of all state is also not capable to full the demand of employment. in this regard the tourism might become one of the large ways to create and fulll the demand of income and employment of people in this region because the region has epic beauty and can become tourism hot-spot of the country. the present world is information edge as a result social media play an important role to give information to the entire world especially about those places which is not easily reachable by everyone. from the ancient period northeast india always be unexplored for the world. though tourism has developed, however, the researchers express that the serenity and beauty of these spots need to be protected. it has been found that social media has contributed towards attracting more and more tourists to those places which were less popular; thus it helps local people to get employment at their own places. hence tourism in lesser known or unexplored spots has become a source of income for the local people in the study area. references: 1. annual final report of tourism survey for state of meghalaya (april 2014 march 2015) by datamation consultants pvt. ltd., 2016 2. bonarou christina, heritage tourism and museum management, 2011-12 3. lange-faria, wendy & elliot, statia (2012). understanding the role of social media in destination marketing, tourismos: an international multidisciplinary journal of tourism, vol. 7, pp. 193-211 4. praveenkumar, s. (2014) role of media in the promotion of tourism industry in india, global review of research in tourism, hospitality and leisure management (grrthlm), vol. 1, issue 3, pp. 187-192 5. saha saibal kimar, babal, t.c. and saha sangita (2018). adventure tourism of meghalaya, journal of tourism and hospitality 6. tafveez, mir (2017). role of social media in tourism: a literature review, international journal for research in applied science & engineering technology (ijraset), vol. 5, issue 9, pp. 633-635 7. tower, john (1995). what is tourism’s history? tourism management, vol. 16, no. 5, pp.339-345, butterworth heinmann 8. www.census2011.co.in, village & tourism of pynursula 9. http://en.m wikipedia.org>wikilist of districts of meghalaya x 41gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction surgery is a medical specialty associated with greater risks and challenges to its practitioner yet can be highly rewarding as the prudence and dexterity of a surgeon can save the lives of many patients who otherwise may seemed to have lost all hopes of surviving. wounds are believed to be affecting approximately 1% of the population worldwide. whereas an indian perspective of hospital based study shows leprosy (40%), diabetes (23%), venous disease (11%), and trauma (13%) were among important causes of lower extremity wounds. in that study, 13% of wounds were directly linked to any known cause2.wound is a discontinuity or break in the surface epithelium3. wound healing is a mechanism whereby the body attempts to restore the integrity of the injured part4. active promotion of wound healing is a continuing challenge in current surgical practice. routine antiseptic dressings though reduce the microbial colony have a deleterious effect on growing epithelium5. antibiotic ointments will irritate the skin, slow down healing and greatly increase risk of contact dermatitis and antibiotic resistance. because of this, they should be used when a person shows signs of infection and not as a preventive measure6. mitigation of pain, discharge and discoloration after healing are the other important factors. the proper initial care of the fresh wound will denitely prevent the inadvertent use of the oral and systemic antibiotics. management of wound has always been a difcult proposition in the evolution of medical practice. only recently the medical professional and researchers have realized that spending time in search of newer antimicrobial is of no use. thus relentless emergence of antibiotic-resistant strains of pathogens, together with the retarded discovery of novel antibiotics has led to the need to nd alternative treatments7. now the scenario is changing and the whole world is looking towards the traditional and herbal medicine for the management of infection.as the science is advanced newer remedies are tried out for speedy recovery of wounds, but the older remedies still contribute high. ayurvedic treatises especially sushruta samhita describes wounds elaborately, in terms of denition, etiology, classication, clinical features and also a detail management is described, in the form of shashtiupkramas8 (60 therapeutic procedures). these principles of management are valid even today. among these shashtiupakrama, 7 types of healants (ropana) are listed using decoction( kashaya),pack (varti),paste( kalka), medicated ghee (sarpi), oil (taila),linctus(rasakriya) and dusting of drugs(avachoornana)9. in shalyatantra, ropana denotes active promotion of wound healing in a shuddha vrana10 (uncomplicated clean ulcer or wound). durvadi oil11 is a formulation mentioned in bhaishajya ratnavali containing durva svarasa, kampillaka, daruharidra bark powder and tila oil as ingredients, having ropana property. this is an experimental study with an affort to evaluate the effect of healing property of durvadi oil on clean excision wounds induced in wistar albino rats, compared to standard (povidone iodine) & control (no intervention). the objective parameters are period of epithelialisation, hydroxyproline estimation, histopathology study and percentage wound area contraction. therefore, this study seeks to identify the active wound healing potential of an ayurvedic formulation which is simple, reliable, easily available, economical and easy to use that promotes wound healing without any complications. methods a. test drugs: mallotus philippinensis(kampillak phalraj12) f a m i l y e u p h o r b i a c e a e , 1 0 0 g m b e r b e r i s aristata(daruharidra bark13)family-berberidaceae, 100 gm,cynodon dactylon(durva juice14 )family-graminae ,6 l sesamum indicum(tila oil15) family-pidaliceae 1.5 l b. standard drug: povidone iodine ointment c. experimental animals: healthy 18 albino rats of either sex with average body weight of 180-255g d. route of drug administration: external application experimental evaluation of wound healing property of durvadi oil in wister albino rats original research paper sharma sukrant* dr. sukrant sharma m.s (ayu) assistant professor, jammu institute of ayurveda and research nardini, jammu, india corresponding author ayurveda wound (vrana) means break /destruction / rupture / discontinuity of body tissue / part of body. sushruta samhita describes vrana as the sign of the disease (lesion) which never disappears even after complete healing and as its imprint persist lifelong1. these descriptions match the description of a wound. wound is a discontinuity or break in the surface epithelium. wound healing is a mechanism whereby the body attempts to restore the integrity of the injured part. durvadi oil is a formulation mentioned in bhaishajya ratnavali having healing property. this is an experimental study on wistar albino rats to nd out the healing effect of durvadi oil.there were 3 groupsnormal control, standard and test, each group containing 6 rats. in control group no intervention was done. in standard and test group were treated with povidone iodine ointment and durvadi oil as an external medication respectively. study was carried out for 24 days. observational parameters included period of epithelialisation, percentage of wound contraction periodically, hydroxyproline estimation and histopathology assessed on 24th day. period of epithelialisation was considerably reduced in test and standard group as compared to normal control group. hydroxylproline estimation in the test group has shown signicant decrease in the concentration as compared to normal control group. histological examination showed better wound healing prole in reference standard and test drug applied group than normal control group. wound area contraction rate was higher in test and standard group in comparison to normal control group. abstract keywords : wound, vrana, durvadi oil, hydroxyproline, epithelialisation, wistar albino rats bhardwaj ashanka ashanka bhardwaj mds(oral pathologist),jammu yadav rajesh assistant professor, sgm p.g ayurvedic medical college and hospital saheri ghazipur u.p. kour sarabjeet kour pg scholar, jammu institute of ayurveda and research nardini, jammu, india volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 64 x gjra global journal for research analysis e. total duration of the study : 24 days the animals were anesthetized by using diethyl ether as an anesthetic agent. an impression was made on the dorsal thoracic region 1 cm away from vertebral column and 5 cm away from ear on the anaesthetized rat. the particular skin area was shaved one day prior to the experiment. the skin of impressed area was excised to the full thickness to obtain a wound area of about 2x2cm2. haemostasis was achieved by blotting the wound with cotton swab soaked in normal saline. the animals were then grouped and treated as follows: group i: (normal control): no intervention group ii: (reference standard): povidone iodine ointment group iii: (test drug): durvadi oil parameters estimated 1. period of epithelialisation falling of scab, leaving no raw wound behind has been taken as end point of complete epithelisation and the days required for this were taken as period of epithelialisation. 2. hydroxyproline estimation of the wound bed, after the 24 days of the study. 3. histopathological study of the wound bed, after 24 days of the study. 4. wound area contraction observed on 4th, 8th, 12th, 16th, 20th & 24th day of post wounding. the percentage wound contraction was assessed by noting the progressive changes in wound area plan metrically, excluding the day of the wounding. the sizes of the wounds were traced on a transparent paper every 2 days, throughout the monitoring period. the tracing was then superimposed on a 1 mm 2 graph sheet, from which the wound surface area was evaluated. the evaluated surface area was then employed to calculate the percentage of wound contraction, taking the initial size of the wound, as 100%, by using the following formula. % of wound contraction = initial wound size specic day wound size ÷ initial wound size x 100 result data was statistically analyzed as mean±sem using one way anova followed by tukey's multiple comparison test the data shows there was decrease in number of days taken for epithelialisation in standard group and as compared to normal control. the observed decrease was found to be statistically non-signicant. the data shows there was decrease in number of days taken for epithelialisation in test group when compared to control group. the observed decrease was found to be statistically non-signicant. there was 1.78 % decrease in the number of days taken for epithelial formation in test group comparison to normal control. from the data it can be observed that there was statistically non-signicant decrease in the hydroxylproline concentration in standard group in comparison to normal control. the test drug administered group has shown statistically very signicant decrease in the hydroxylproline concentration in comparison to normal control. there was 68.33 % decrease in test group compared to control group. the data related to the % changes in wound contraction on 2nd day.the data shows there was increase in % wound contraction in 2nd day of standard group when compared to the normal control group, the observed increase was found to be statistically non-signicant. the data shows there was increase in % wound contraction in 2nd day of test group when compared to the normal control group, the observed increase was found to be statistically non-signicant. there was 126.41% increase in test group compared to control group. while compared with standard drug % wound contraction was increased. the observed increase was found to be statistically non-signicant. overall p value is 0.0986 considered not quit signicant. the data related to the % changes in wound area on 8th days. the data shows there was increase in % wound contraction on 8thday in standard group when compared to the normal control group, the observed increase was found to be statistically non-signicant. the data shows there was decrease in % wound contraction in 8th day of test group when compared to the normal control group, the observed decrease was found to be statistically non-signicant. there was 13.65 % decrease was noted in test group compared to control group. while compared with standard drug % wound contraction was decreased. the observed decrease was found to be statistically non-signicant. overall p value is 0.091 considered very signicant. the data related to the % wound contraction measured on 16th days.the data shows there was increase in % wound contraction on 16th day in standard group when compared to the normal control group, the observed increase was found to be statistically non-signicant. the data shows there was increase in % wound contraction on 16th day of test group when compared to the normal control group, the observed increase was found to be statistically non-signicant. there was 4% increase in test group compared to control group. the data related to the % changes in wound area on 24th days has been expressed in the table 45.12. the data shows there was increase in % wound contraction in on 24th day of standard group when compared to the normal control group, the observed increase was found to be statistically nonsignicant. the data shows there was increase in % wound contraction in 24th day of test group when compared to the normal control group, the observed increase was found to be statistically non-signicant. there was 0.47% increase in test group compared to control group. while compared with standard drug % wound contraction was increased. the observed increase was found to be statistically nonsignicant. overall p value is 0. 198 considered nonsignicant. conclusion period of epithelialisation was considerably reduced in test and standard group as compared to normal control group.the estimated hydroxyproline level was less in durvadi oil group than standard povidone iodine and normal control group histological examination showed better wound healing prole in reference standard and test drug applied group than normal control group.the percentage wound contraction was comparatively high in the test and reference standard group in the initial and at the end of the observational period as compared with normal control group. no adverse effects were detected in experimental study. overall, experimentally durvadi oil is a safe and effective healing oil and better compared to normal control group. references 1. sushruta, sushruta samhita, nibandhasamgraha commentary of dalhanacharya and nyayachandrika panchika commentary of gayadasa, editor yadavji trikamji acharya, 2. ed.2014, sutra stana 21th chapter, sloka-40, chaukhamba sanskrit sansthan,varanasi, pp -824, page no.107. g u p t a s k , s h u k l a v k . epidemiological study of wounds: an indian perspective, 1st ed. new delhi: jaypee brothers medical publishers (p) ltd; 2007, p. 1. 3. manipal manual of surgery chief edited by dr. k rajgopal shenoy and coedited by dr.anita nileshwar, 3rd edition 2010, kmc manipal,pp969,page no.1. 4. michael j.earley “wounds, tissue repair and scars” chapter 3 in bailey and love’s short practice of surgery 25th edition 2008, edited by norman s.williams, christopher j.k.bulstrode and p.ronan o’connell, publice by hodder arnold, hachette, uk, pp -1513, page no.24. 5. gregory w.thomas, bs leonard t. rael, ms ,raphael bar-or, bs richard shimonkevitz, charles w, mains, denetta sue slone michael l, craun, david bar, the journal of trauma® injury, infection, and critical care, j traum. january2009; volume 66: page no.8291. 6. american academy of dermatology (february 2013),”five things physicians and patients should question” choosing wisely: abim foundation, retrieved volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 65gjra global journal for research analysis 5 december 2013, sheth, v.m; weitzul, s (2008), post-operative topical antimicrobial use” dermatitis:contact atopic occupational, drug 19(4):181189. 7. rose cooper bsc, phd, pgce, c biol, mi biol, principal lecturer in microbiology, article, a review of the evidence for the use of topical antimicrobial agents in wound care. 8. sushruta, sushruta samhita, nibandhasamgraha commentary of dalhanacharya and nyayachandrika panchika commentary of gayadasa, editor yadavji trikamji acharya, ed.2012, sutrastana 1st chapter, sloka-3, chaukhamba sanskrit sansthan varanasi, pp -824,page no.2. 9. sushruta, sushruta samhita, nibandhasamgraha commentary of dalhanacharya and nyayachandrika panchika commentary of gayadasa, editor yadavji trikamji acharya, ed.2012, chikitsastana 1st chapter, sloka-8, chaukhamba sanskrit sansthan varanasi, pp -824, page no.397. 10. sushruta, sushruta samhita, nibandhasamgraha commentary of dalhanacharya and nyayachandrika panchika commentary of gayadasa, editor yadavji trikamji acharya, sutrastana, 5th chapter, ed.2012, chaukhamba sanskrit sansthan varanasi, pp-824, p. no.-22. 11. bhaisajya ratnavali of kaviraj govind das sen edited with “siddhiprada” hindi commentary by prof. siddhi nandan misra edition 2009, vranashothadhikar 47th chapter, sloka -77,chaukhambha sanskrit sansthan varanasi, pp-1196, page no.827. 12. dravyaguna vijnana, dr.j.l.n. shastry, volume 2, reprint edition 2012, chaukhambha orientalia varanasi, pp-1114 , page no-523. 13. dr.j.l.n. shastry, dravyagunavijnana, volume 2, reprint edition 2012, chaukhambha orientalia varanasi, pp-1114, page no-537. 14. dr.j.l.n. shastry, dravyagunavijnana, volume 2, reprint edition 2012, chaukhambha orientalia, varanasi , pp-1114 page no-79. 15. dr.j.l.n. shastry, dravyagunavijnana, volume 2, reprint edition 2012, chaukhambha orientalia, varanasi, pp-1114, page no882. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 66 x gjra global journal for research analysis introduction dyslipidemia is highly prevalent in patients on maintenance hemodialysis (mhd), with predominance of the atherogenic triad, i.e. hypertriglyceridemia, elevated very low density lipoprotein (vldl) and reduced high-density lipoprotein (hdl). the risk factors for coronary heart disease (chd) in the general population remain predictive of chd among patients with chronic kidney disease (ckd) as well. cardiovascular disease is the leading cause of death in patients on mhd, accounting for almost 50% of the deaths. the incidence of cardiac death in dialysis and transplant patients has been estimated to be fourto 20folds higher than in the general population. hyperlipidemia has been incriminated as a risk factor for atherosclerotic vascular disease in dialyzed patients, and is characterized by hypertriglyceridemia without cholesterol accumulation. other dyslipidemias consist of decreased hdl cholesterol and elevated serum lipoprotein (lp-a); the low-density lipoprotein (ldl) cholesterol is usually not elevated. lp-a is an independent risk factor for cardiovascular disease. a number of investigators have shown an increase in lpa in hd patients. cressman et al have suggested that elevated levels of lipoprotein also correlate with cardiovascular mortality. elevated serum magnesium (mg) can be a problem in patients on mhd. because kidneys are the major route of excretion of mg from the body, increased serum mg would be expected in patients with renal insufciency. mg may be normal or decreased in dialysis patients, which is probably due to decreased dietary intake combined with impaired intestinal absorption. in patients on chronic hd, the major determinant of mg balance is concentration of mg in the dialysate. thus, in patients with ckd, there may be reduced intake, impaired absorption from the intestine, use of diuretics and acidosis, which may result in decreased serum mg, wher as reduced renal excretion may cause accumulation of mg resulting in increased serum mg levels in ckd patients. bone concentration and total body mg also appear to be increased. data have shown a correlation between dyslipidemia and serum mg concentration in patients on hd. therefore, we designed this study to assess the association between serum mg and dyslipidemia in patients on endstage renal disease patients and methods: fifty patients with diagnosis of chronic kidney disease who are on routine dialysis for more than 3 months admitted to medicine department of sree balaji medical college , chennai were taken for the study. the patient excluded were patient having acute renal failure, history of carotid surgery, malignancy; signicant illness and patients on magnesium therapy. information was collected through prepared proforma for each patient and informed consent was obtained from each participant. history of smoking, dm, hypertension. cardiovascular event, hyperlipidemia and use of statin and magnesium therapy were evaluated. a complete clinical examination was done with special reference to signs of ckd like pallor, pufness of face etc. blood pressure was measured with standard mercury sphygmomanometer and cuff, after the subject had rested in supine position for 15 minutes.. hypertension was dened as blood pressure >140/90 mm hg or if patient is already on antihypertensive drug. the morning urine sample and blood samples were collected after 8 hours of overnight fasting for complete hemogram, blood urea levels, serum creatinine levels, serum elecrolytes and lipid prole (total cholesterol, triglycerides and hdl) and serum magnesium. all the biochemical parameters were measured by standard laboratory technique.. glomerular ltration rate (gfr) was calculated by cockcroft gault equation. dialysis was performed using dialog + dialysis machine with ultraltration rate from 500 to 800 mt/hr and temperature of diasylate to he maintained at 36.5 0 c. the diasylate solution used was as follows: sodium 7900 mmol/l, pottasium 2.00 mmol/l, calcium 1.7smrnol/l, magnesium 0.75 mmol/l, acetate 4.0 mmol/l and chloride 86.0 mmol/l. a study on correlation of serum magnesium with lipid profile in ckd patients on maintenance hemodialysis original research paper dr. venkat sai. gangapatnam* junior resident department of general medicine , sree balaji medical college , chennai,tamil nadu *corresponding author general medicine objective: the objective this study was performed to determine the correlation between serum magnesium (mg) and lipid prole in patients on maintenance hemodialysis (mhd). material &method: this hospital-based crosssectional observational study was conducted at the department of medicine, sree balaji medical college , chennai . fifty patients with end-stage kidney disease on mhd treatment (29 males and 21 females) were studied. the mean frequency being two to three sessions /week of hemodialysis and each session lasted for four hours. after obtaining informed written consent, the general information of each patient was recorded on a proforma. after overnight fasting, blood samples was drawn for complete hemogram, blood urea , serum creatinine, lipid prole and serum mg. results: the serum magnesium was signicantly correlated with diabetes in the study. ( p < 0.001) the mean bmi in ckd patients was 18.37 ± 1.82 kg/m2 in the present study most of the ckd patients was in stage 5. i.e. 43 cases. total serum cholesterol levels (>200 mg/dl) was found higher than normal in 15 cases and the mean was 174.1 ± 44.62. the mean serum triglyceride levels was 144.54 ± 58.09 mg/ dl in ckd patients and it correlated signicantly with serum magnesium. the mean hdl-c levels was 39.26 ± 6.40 mg/dl were lower in ckd patients found. in 30 patients among 50 cases. serum magnesium in ckd patients signicantly correlated with age (p< 0.001), systolic blood pressure( p<0.001), serum triglyceride levels (p=0.02), the mean age of the studied ckd patients was 45.46 ± 15.60 years (range 1876). conclusion: magnesium may affect the metabolism of tg and hdl in liver and kidneys. the association of dyslipidemia with serum mg levels is not clearly understood, and further large clinical studies are needed to understand this association better. abstract keywords : esrd,hemodialysis,mg,hdl volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. n. n. anand professor department of general medicine , sree balaji medical college , chennai,tamil nadu 112 x gjra global journal for research analysis statistical methods: for different parameters, mean and standard deviation were calculated.. the values of p which are < 0.05 were treated as signicant. the qualitative variables (like sex, diabetes) were compared using x2 test. the statistical software spss ver. 20 was used for statistical analysis. univariate correlation analysis was used to conrm the signicance of variables with serum magnesium levels. results: the study included 50 cases of ckd patients on dialysis ; 29 male and 21 females. the mean age of the studied ckd patients was 45.46 ± 15.60 years (range 18-76). maximum patient in the study were in age group of 50 to 60 years. the mean haemoglobin was 8.86 ± 1.71gm/dl, mean blood urea was 149.9± 60.81 and mean creatinine was 6.88 ± 3.24 mg/dl. diabetes mellitus was the etiology of ckd in 28% patients. the serum magnesium was signicantly correlated with diabetes in the study. ( p < 0.001) the mean bmi in ckd patients was 18.37 ± 1.82 kg/m2 in the present study most of the ckd patients was in stage 5. i.e. 43 cases. total serum cholesterol levels (>200 mg/dl) was found higher than normal in 15 cases and the mean was 174.1 ± 44.62. the mean serum triglyceride levels was 144.54 ± 58.09 mg/ dl in ckd patients and it correlated signicantly with serum magnesium. the mean hdl-c levels was 39.26 ± 6.40 mg/dl were lower in ckd patients found. in 30 patients among 50 cases. serum magnesium in ckd patients signicantly correlated with age (p< 0.001), systolic blood pressure ( p<0.001),serum triglyceride levels (p=0.02), fbs ( p= 0.04). table-1genderwise distribution of patients[total-50] table-2agewise distribution of patients[total-50] table-3 value of s. magnesium in patients[total-50] table-4 basic clinical and laboratory characteristic of study table 5 correlation with respect to serum magnesium: discussion: in our study,the lipid prole was derranged in relation to serum magnesium. magnesium showed positive correlation with hdl. ie (p= 0.14) but was not signicant. the magnesium was signicantly negatively correlated with serum triglycerides, with p value ( p < 0.001). magnesium was negatively correlated with total cholesterol levels p value (p = 0.096) which is not signicant. thus the lower serum magnesium level may be associated with dyslipidemia in patients on maintance hemodialysis the pattern of dyslipidemia in our study showed hypertriglyceridemia , increases cholesterol and decreased hdl. these lipid abnormalities are well recognised risk factors for atherosclerotic vascular disease in hd patients and thus there is strong need to focus on underlying causes and treatment of hyperlipidemia. in j. elementol, no statistically signicant effect of magnesium concentration on the content of lipids analysed in blood serum was found.. magnesium content in blood serum was also positively correlated with hdl cholesterol in men of both groups. a positive effect on ldl-cholesterol was observed in the group of older women and that of younger men. however, also small negative correlation between mg and ldlcholesterol contents was obtained in older men. similarly we found positive correlation of serum magnesium with hdl and negative correlation of magnesium with cholesterol and triglycerides. in nasri, baradaran et al 2004. meaningful positive correlation (hut statistically non-signicant) was obtained between mg and total cholesterol. in feng liu et al, 98 chronic hd patients were recruited, ), high-density lipoprotein cholesterol (hdl-c) levels, carotid artery plaque (cap), and carotid intima-media thickness (cimt)' (all p<0.05, respectively) were higher in patients with low serum magnesium there was no signicant correlation between mg and low-density lipoprotein cholesterol (ldl-c), lipoprotein-a (lp-a), cholesterol (tc), serum triglycerides (tg) (p>0.05, respectively)in contrast we found signicant correlation with triglycerides and non signicant with cholesterol and hdl.in ansari mr et al, studied 50 patients and concludes that there was a signicant positive correlation between serum mg and serum lipoprotein-a (r = ((p-a) 0.40. p c 0.007), serum hdl (r = 0.31, p < 0.01) and serum tg (r = 0.35, p < 0.005). there was no signicant correlation between serum mg and serum ldl-c and serum tc. the serum tg and lp-a levels were signicantly increased while hdl-c was signicantly lower in mhd patients. the serum tc, ldl-c and very lowdensity lipoprotein-c were not signicantly elevated. in robles nit et al , twenty-ve hemodialysis patients volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra gender total no of pts % male 29 58% female 21 42% age[yr] <20 21-30 31-40 41-50 51-60 >60 no of pts 2 10 10 8 12 8 total hypomagne saemia normal magnesium hypomagne saemia 50 13 13 24 parameters mean ± sd age 45.46 ± 15.60 sex(m/f) 29 / 21 height 158.94 = 8.37 weight 46.46 ± 5.07 bmi 18.37± 1.82 diabetes ( y / n ) 14 / 36 pulse 74.5±14.80 systolic blood pressure 162.24 ± 20.40 diastolic blood pressure 98.08 + 12.45 haemoglobin 8.861 1.71fasting blood sugar 126.8 ± 74.24 blood urea 149.9 ± 60.81 serum creatinine 6.88 ± 3.24 gfr 10.95 ± 714 number of dialysis 20.98 ±14.48 serum albumin 3.01 ± 0.56 hdl 39.26 ± 6.40 triglycerides 144.54 ±58.09 total cholesterol 174.1 ± 44.62 magnesium 2.35 ± 0.98 parameters p r age 0.001 [s] -0.523 height 0.551 -0.086 weight 0.363 -0.131 bmi 0.692 -0.057 pulse 0:288 -0.153 systolic blood pressure 0.001 [s] -0.459 diastolic blood pressure 0.166 -0.199 haemoglobin 0.157 -0.203 fasting blood sugar 0.040 [s] -0.397 blood urea 0.366 0.131 serum cretinine 0.749 -0.046 gfr 0.904 0.018 number of dialysis 0.394 -0.122 serum albumin 0.908 0.017 hdl 0.245 0.167 triglycerides 0.029 [s] -0.310 total cholesterol 0.079 -0.250 mean cimt 0.001 [s] -0.536 x 113gjra global journal for research analysis reported a positive signicant correlation between serum magnesium levels and serum total cholesterol, and serum triglycerides. conclusion: magnesium may affect the metabolism of tg and hdl in liver and kidneys, and it may be involved in enzymes responsible for lipoprotein synthesis, but these factors are not clearly understood and further large studies are needed in this regard. our results indicate that patients with ckd undergoing mhd show signicant dyslipidemia. as a rst means of controlling hyperlipidemia, body weight normalization, dietary modication, regular exercise and education about diet should be applied. the association of dyslipidemia with serum mg levels is not clearly understood, and further large clinical studies are needed to understand this association better. references: 1. pennell p, leclercq b, delahunty mi, walton ba. the utility of non-hdl in managing dyslipidemia of stage 5 chronic kidney diseases. clin nephrol 2006;66(5):336.47. 2. soubassi lp, papadakis ed, theodoropoutos ix, et al. incidence and risk factors of coronary artery disease in patients on chronic hemodialysis. int artif organs 2007;30(3):253-7. 3. al wake&15, mitvralli ah, al mohaya 5, et al. morbidity and mortality in esrd patients on dialysis. saudi j kidney dis i ramp' 2002;13 (4):473-7. 4. manske ci.. icasiske bt. lipid abnormalities after renal transplantation. in: keane wi, stein 111, eds. lipids and renal disease. contemporary issues in nephrology, churchill livingstone, new york, 1991;3/-61. 5. keane wp, oda h. lipid abnormalities in end stage renal disease nephrol dial transplant 1998;13(suppl 1):4s-9. 6. kronenherg f, kathrein h, ko-nig p, et al. apolipoprotein(a) • phenotypes predict the risk for carotid a inerostierosis in patients with end-stage renal disease. arteriosder thromb 1994; 14: 1405-11 . 7. mountokalakis rd. magnesium metabolism in chronic renal failure. magnessres 1990;3(2): 121-7. 8. lindeman rd. chronic renal failure and magnesium metabolism. magnesium 1986;5(5-6): 293-300. 9. j. elementol.,et al evaluation of the correlations between magnesium concentration and selected serum lipid components in women and men of different age with chronic kidney failure2030,15(2): 321-329. 10. nasir h, baradaran a. correlation of swum magnesium with dyslipidemia in maintenance hrunodialysis patients. acta medics 2004; 47: 263-265. 11. feng lill, xintian zhanng et al. corelataion of serum magnesium with cardiovascular risk factors in maintenance hernodialysis patients. a cross sectional study. magnes res 2013 july-sep ; 26(3); 100-8 12. anson mr., tvlaheshwad net al : correlation or serum magnesium with dyslipidemia in patients on maintenance iie•odiaiys;s saudi j kidney dis transplant. 2012 jan;23(1):21-5. 13. rebles escola 1m, aibarran 1, espada r, cruz a. correlation of serum magnesium and serum lipid levels in hemodialysis patients. dialysis & transplantation 1998, volum 27,10 : 644.648 oct. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 114 x gjra global journal for research analysis introduction increased age of the population has led to rising incidence of 1,2intertrochanteric femoral fractures in past few years. the aim of treatment remains strong xation which permits rapid & early post-op mobilisation. the quest for satisfying this aim has led to developments of many intramedullary nails. the status of dynamic hip screw as gold standard has been challenged due to these nails.the pros and cons of the 3gamma nail have been analysed in prior studies. literature concerning comparison of pfn versus dhs are few and 4,5scare. also, the primary aim of these studies was targeted towards technique and results or the overall patient 6rehabilitation. the pertinent question remains that does there exist a difference in the outcomes of patients treated with these 2 implants. hence, we planned he study to evaluate the patients ' post-operative recovery in patients with intertrochanteric femoral fracture after use of either dhs or pfn in a retrospective study of 148 patients. patients and methods between august 2016 and may 2019, 148 patients with extracapsular intertrochanteric femoral fractures who were treated with the dynamic hip screw or the proximal femoral nail were analysed. patients were included only after signed informed consent and ethics clearance. inclusion criteria was all patients with extracapsular intertrochanteric femoral fractures and only those with pathological fracture or multiple injuries were excluded. routine protocol included radiographs of pelvis with bop hips ap and lateral view. since it was a retrospective study there was no way to determine which implant was used for which patient. capability to walk was divided into 3 categories: capable of walking independently without any external aids, capable of walking independently but with the help of crutches or frame and capable of walking only when being supported by atleast one more person. all the patients who utilised a walking stick were still considered as independent walkers. standard operative protocol was followed for all patients. technique and precautions mentioned in the instruction manual supplied by the manufacturer were properly followed. all patients were injected with prophylactic and post-op intravenous antibiotic. plain anteroposterior (ap) and lateral radiographs were done post-operatively, and evaluated for quality of reduction and implant positioning. reduction qualied to be good if the medial continuity at the calcar was reinstated. the perfect position for the richart screw for the dhs and was considered as being centro-central on the ap and lateral radiographs (figs 1 and 2). fig. 1a: post-operative antero-posterior radiograph of right sided intertrochanteric femur fracture treated with proximal femoral nail figure 1b – post-operative lateral radiograph of right sided intertrochanteric femur fracture treated with proximal femoral nail comparison of outcome of intertrochanteric fractures treated with dynamic hip screw versus proximal femoral nail original research paper tushar rathod associate professor, department of orthopedics, seth gs medical college and kem hospital, mumbai. x 79gjra global journal for research analysis orthopaedics we retrospectively analysed 148 patients with intertrochanteric femoral fracture treated using either the dynamic hip screw or the proximal femoral nail & compared functional and radiological out come. patients with pfn(n = 74) had recovered their pre-operative walking ability signicantly(p < 0.05) more frequently at the sixmonth analysis than those with dhs(n = 74).peri-operative or immediate post-operative parameters did not vary between groups. functional outcome was analysed using harris hip score and radiological ndings were compared at 3, 6, and 12 months postoperatively. the dhs permitted a signicantly larger compression at the fracture site during the follow-up evaluations, but union at the fracture site was comparable between the two groups.3 major failure of reduction were reported in each group, resulting in a total of 6 revision operations. we can conclude from our study that the pfn results in sooner postoperative recovery of walking ability as compared to dhs in short-term. abstract keywords : intertrochanteric fractures, dynamic hip screw, proximal femoral nail abhinav jogani* senior registrar, department of orthopedics, seth gs medical college and kem hospital, mumbai. *corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 80 x gjra global journal for research analysis figure 2a: post-operative antero-posterior radiograph of left sided intertrochanteric femur fracture treated with dynamic hip screw fig 2b: post-operative lateral radiograph of left sided intertrochanteric femur fracture treated with dynamic hip screw weight-bearing as per pain tolerance was allowed from the rst post-operative day. the same post-op rehabilitation protocol was followed regardless of mode of xation/type of implant. the patients were discharged from hospital after dose of intravenous antibiotics and mobile painlessly. follow-up analysis was done at 3,6 and 12 months post-operatively. routine ap and lateral radiographs of the hip were done as part of standard routine protocol. all alterations in the implant position and fracture alignment, on comparison with the immediate post-operative radiographs were noted. capability to walk was noted at each visit. the statistical analysis was performed using graphpad software for windows. the odds ratios was calculated with condence intervals (ci) set at 95%. p values were calculated with independent samples t-test and fisher's exact test; values of p < 0.05 were considered to be signicant. results as per records, the mean blood loss for the surgeries was 289 ml (70 to 1100ml), and the mean number of transfused blood units (350 cc/unit) during the stay was 1.6 (0 to 5). most commonly (140 out of 148, 95%) spinal anaesthesia was used. fracture reduction was classied as good in 101/148 patients (68.24%), and the implant position was considered ideal in 119 (80.4%) of the radiographs. the patients were discharged at a mean of 7 days (3 to 18) post-operatively. one death was noted during the hospital stay from aspiration. nine complications were noted at the follow-up visit. there were 3 cases of displacement of the fracture in both groups. all six patients needed revision surgery. one post-op pfn patient was diagnosed with heterotopic ossication. yet this anomaly had no impact on the post-op rehab and capability of walking was recovered at six months. there was no incidence of supercial or deep wound infections, or deep vein thromboses. at follow-up of six months, 131 (88.5%) of the original 148 patients were evaluated. of the 17 ineligible patients, one died during hospital stay and another six died during follow-up period. 10 patients were lost to follow-up. the six patients who required revisions were excluded, and hence the eventual analysis was performed for 121 patients. the mean compression at the fracture site, evidenced by femoral neck shortening, was 3.1 mm (0.5 to 26), with a statistically signicant difference between the groups. the mean femoral shaft shortening was 2.9 mm (0.7 to 21), when measured from the ap radiographs. at 6 months follow-up, 42 (28.37%) patients were capable of walking independently, 62(41.9%) required external aid in the form of crutches, and 27 (18.2%) were incapable of independent walk. we found out that the recovery of walking capability was attained more frequently in those patients who were operated with a pfn (79.7%) compared with those operated with a dhs (57.2%) this difference was statistically signicant (p = 0.040). at 3 months follow up, it was noted that the functional outcome calculated by utilising the harris hip score in patients operated with dhs implant scored an average of 34.41 in comparison to those operated with pfn implant who fared better with a score of 54.51 and this nding had statistical signicance (p=0.001). scores increased to 63.2 and 88.1 for patients with dhs and pfn implants respectively at 6 months follow up (p=0.001). but at 12 months follow-up, the average harris hip score for the patients in the dhs group increased to a value of 88.67 in comparison to the patients with pfn implant which in turn increased to 91.07. there was no statistically signicant difference between the two groups (p=0.31). discussion the principle of dhs is backed by its biomechanical 11properties which are supposed to enhance fracture healing. currently, the gamma nail (stryker howmedica, freiburg, germany) reports the lengthiest follow-up studies. the intial design of the nail had reported risk of both intraoperative and post-operative complications in several 13,14studies despite the fact that satisfactory healing rates have 1 2been reported. some recent meta-analyses have recommended the use of dhs for the treatment of 15,16intertrochanteric fractures. the pfn which was developed as a viable alternative to the gamma nail appears to have 17lesser associated complications. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra one randomised controlled trial of the pfn involved 168 patients, wherein several intra-operative, radiographic and clinical parameters were analysed and compared between 18the dhs and pfn after a one-year follow-up. comparable to our results, 87 (51.8%) of patients were capable of walking independently. although there was no statistically signicant difference between mean preand post-operative scores of function and mobility between the two treatment groups, it was found that there was an increase by 1.5 times in the score for social function during follow-up in the pfn group compared with the dhs group. also, there was greater reduction in the score for mobility in the patients treated with pfn. but the statistical signicance of this nding, as well as the power of the study, 18were not found. the conclusions from that study that can be drawn state that the use of dhs implant may allow more 18patients to return to their previous level of activity. in contradistinction, patients in our study operated with a pfn recovered their pre-operative walking capability at six months signicantly more frequently than those treated with a dhs. it proposes that the use of a pfn may lead to early restoration of function in the elderly population in comparison to a dhs. possible justication maybe that the signicantly larger impaction of the fracture in the dhs group causes shortening of the femoral neck. it is plausible that substantial compression at the fracture site may alter the hip biomechanics and inhibit the recovery of the capability to walk. post-op mobilisation was similarly successful for both groups eventually, which suggests that the differences between the implants are not signicant in the long term. furthermore, the lack in the pfn group of the kind of compression seen in the dhs group did not appear to limit the fracture healing. irrespective of the implant which was used around 90% of patients had good functional scores at 12month follow-up. this nding of our study is in agreement with the results from 19 20retrospective studies done by banan et al, al-yassari et al 8and simmermacher et al who also observed recovery of preoperative mobility in approximately 40% to 50% of the patients operated with pfn. similarly, studies report comparable 14,21results in the use of dhs and a gamma nail. it therefore seems rational to expect around half the patients with an intertrochanteric fracture to recover their pre-operative functional status at the time of fracture healing, regardless of 4the implant used. still, some studies quote superior results. with regards to other parameters, failure of xation of the fracture occurred in similar number of patients in both groups. the femoral shaft fracture at nail tip is a known complication linked with the intramedullary nails in the treatment of proximal femoral fractures. we had no such complication in our patients but a shorter follow-up may account for it. a common issue in previous studies, similar to ours, is the attrition rate due to withdrawal. this could in part be attributed to the geriatric population under study. in our study, 17 patients lost to follow-up had expired or were too ill to return to hospital. even though the attrition rate may introduce some amount of bias in the analysis, when the overall recovery is evaluated, the results analysis is not changed. conclusion: we can safely conclude that utilising the pfn implant in the treatment of intertrochanteric femoral fractures tends to have a positive impact on the speed of recovery of walking, on comparison with patients operated with dhs implant. the explanation for this lies in the well reinstated anatomy of the hip. the basis for future larger sample size studies lies in determining the superlative implant for the management of these fractures. conict of interest: none acknowledgements: none references 1. kannus p, oarkkari j, sievänen h, et al. epidemiology of hip fractures. bone 1996;18 (suppl 1):57-63. 2. gullberg b, duppe h, nilsson b, et al. incidence of hip fractures in malmö, sweden (1950-1991). bone 1993;14 (suppl 1):23-9. 3. ahrengart l, törnqvist h, fornander p, et al. a randomised study of the compression hip screw and gamma nail in 426 fractures. clin orthop 2002;401:209-22. 4. domingo lj, cecilia d, herrera a, resines c. trochanteric fractures treated with a proximal femoral nail. int orthop 2001;25:298-301. 5. boldin c, seibert fj, frankhauser f, et al. the proximal femoral nail (pfn): a minimal invasive treatment of unstable proximal femoral fractures: a prospective study of 55 patients with a follow-up of 15 months. acta orthop scand 2003;74:53-8. 6. huusko t, karppi p, avikainen v, kautiainen h, sulkava r. intensive geriatric rehabilitation of hip fracture patients. acta orthop scand 2002;73:425-31. 7. hoffman r, haas np. femur: proximal. in: ruedi tp, murphy wm, eds. ao principles of fracture management. stuttgart, etc: thieme, 2000:441-54. 8. simmermacher rkj, bosch am, ven der werken c. the ao/asif proximal femoral nail (pfn): a new device for the treatment of unstable proximal femoral fractures. injury 1999;30:327-32. 9. wu c-c, shih c-h, lee m-y, tai c-l. biomechanical analysis of location of lag screw of a dynamic hip screw in treatment of unstable intertrochanteric fractures. j trauma 1996;41:699-702. 10. brooker a, bowerman j, robinson r, riley lh jr. ectopic ossication following total hip replacement: incidence and a method of classication. j bone joint surg [am] 1973;55-a:1629-32. 11. rosenblum sf, zuckerman jd, kummer fj, ram bs. a biomechanical evaluation of the gamma nail. j bone joint surg [br] 1992;74-b:352-7. 12. valverde j, alonso m, porro j, et al. use of gamma nail in the treatment of fractures of the proximal femur. clin orthop 1998;350:56-61. 13. aune ak, ekeland a, grongaard b, odegaard b, alho a. gamma nail vs compression screw for trochanteric femoral fractures: 15 reoperations in a prospective, randomised study of 378 patients. acta orthop scand 1994;65:127-30. 14. butt ms, krikler sj, nae s, ali ms. comparison of dynamic hip screw and gamma nail: a prospective, randomized, controlled trial. injury 1995;26:61518. 15. parker mj, handoll hhg. gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures. cochrane musculoskeletal injuries group cochrane database of systematic reviews. 3, 2003. 16. parker mj, pryor ga. gamma nailing versus dhs for extracapsular femoral fractures: a meta-analysis of 10 randomised trials. int orthop 1996;20:163-8. 17. herrera a, domingo lj, calvo a, martinez a. a comparative study of trochanteric fractures treated with the gamma nail of the proximal femoral nail. int orthop 2002; 26:365-9. 18. saudan m, lübbeke a, sadowski c, et al. pertrochanteric fractures: is there an advantage to an intramedullary nail? j orthop trauma 2002;16:386-93. 19. banan h, al-sabti a, jimulia t, hart aj. the treatment of unstable, extracapsular hip fractures with the ao/asif proximal femoral nail (pfn): our rst 60 cases. injury 2002;33:401-5. 20. al-yassari g, langstaff rj, jones jwm, al-lami m. the ao/asif proximal femoral nail (pfn) for the treatment of unstable trochanteric femoral fracture. injury 2002; 33:395-9. 21. madsen j, næss l, aune a, et al. dynamic hip screw with trochanteric stabilising plate in the treatment of unstable proximal femoral fractures: a comparative study with the gamma nail and compression hip screw. j orthop trauma 1998;12:241-8. 22. owens wd, felts ja, spitznagel el. asa physical status classications: a study of consistency ratings. anesthesiology 1978;49:239-43. x 81gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: enuresis as a childhood developmental issue has drawn much attention from researchers in the paediatric and child health services especially in the last two decades. iccs denes nocturnal enuresis as any discreet amount of wetting at night in a child aged ve years or over. it is considered to be primary enuresis if the child has been previously dry for less than six months, and secondary if the child has been dry for a 1period of at least six months . nocturnal enuresis is considered as a common problem with its description deeply embedded in paediatric practice of all times; ancient and 2modern, traditional and contemporary medicine. material & methods: an exploratory survey to identify the prevalence of nocturnal enuresis among children aged 5 to 12 years was undertaken in the villages of 4 phcs in a district in bangalore, karnataka. door-to-door survey was done and oral report of mother was elicited. after two weeks, mothers were visited to conrm the frequency of ne for accuracy. screening was performed based on iccs guidelines for conrming primary nocturnal enuresis among children. expert validated structured interview schedule nocturnal enuresis diary was used for recording frequency of bedwetting; determining background factors of children and parents. weekly nocturnal enuresis diary was used to conrm the frequency of nocturnal enuresis. results: from the villages in four primary health centre areas, 161 children were identied and nally, 134 children were accurately recording. the distribution of children was according to their age. majority of them were in the age group of 5-10 years 85.82%, while 35.07% of them were boys and more than half of them 64.93% were females. most of them 97.01% had completed immunisation according to age on records and only 2.99% presently reported as incomplete immunisation. most of them did not report any allergy 94.03% and only 5.97% had reported allergies to cold weather and dust etc. majority 78.36% of their bmi were < 18.5 while only 21.64% had bmi ranging18.6-24.9. regarding their relevant history: birth weights -none reported low birth weight; 5.22% reported as < 2.5kg, while 30.60% reported 2.53 kg and most of them reported >3 kg 64.18%. majority of them had 68.66% ftnd normal delivery and 31.34% had lscs. most of the children were born full term 96.27% and only small number reported pre term 3.73%. order st ndof birth -half of them 49.25% 1 child, 41.04% 2 child. only rd thvery small number of children were 3 child 8.96% and 4 child 0.75% respectively. with regards to duration of breastfeeding half of them 50% reported having breastfed their children for over 12-17 months. nearly half 42.54% more than 18 months, and only 6.97% had breastfed children for less than 11 months. children who were toilet trained at age 1 year was 0.75%; by 2 years, majority of them 91.80% and only 7.40% toilet trained at 3 years of age. most children were not reported as any delayed milestones 92.54% and only a small number were having minor or negligible delay in speech and walking 7.46%. majority of the children 79.10% did sleep with their parents or siblings while only 20.90% slept alone. most children 91.05% did not have a sibling with history of nocturnal enuresis and only a small percentage of them 8.95% had on siblings with nocturnal enuresis. most of them seem to be deep sleep 78.36% and only 21.64% were not deep sleepers. most children 91.05% did not have any sleep disturbances while a small percentage of them 8.95% had apparent sleep disturbance as reported. most of the children did not seem to have snoring 92.54% and a small number of them 7.46% had snoring while asleep. nightmares were not present in majority rdof the children 70.15%; and 1/3 of them 29.85% seemed to have nightmares. majority of them 82.09% did not have fear of darkness and small number of children 17.91% reported having fear of darkness. figure 1 distribution of children according to severity of nocturnal enuresis figure 1 depicts that most children had severe form of nocturnal enuresis. among them, 10.4% of the children had 4 nights per week of bedwetting, while 12.7% had ve nights, and 6% had 6 nights. majority of the children included for the study had reported all night's bedwetting. the mean ne 6.37 ± 1.06. table 1. distribution of parents' background factors and nocturnal enuresis related parameters children with primary nocturnal enuresis, their background factors and parenting factors in an urban district original research paper sequeira s j phd scholar, national consortium for phd in nursing, rguhs karnataka, faculty of community health nursing. x 39gjra global journal for research analysis nursing an exploratory survey to identify the prevalence of nocturnal enuresis among children aged 5 to 12 years was undertaken in the villages of 4 phcs in a district in bangalore, karnataka. door-to-door survey was done and oral report of mother was elicited. majority of children with nocturnal enuresis were in the age group of 5-10 years 85.82%. while 35.07% were males, more than half (64.93%) were females. among them, 10.4% of the children had 4 wet nights per week, 12.7% had 5 wet nights and 6% had 6 wet nights and majority of the children reported all 7 nights as wet nights. the mean nocturnal enuresis among children in this study is 6.37 ± 1.06. parents report permissive style, yet there is reporting of resorting to punitive methods and shaming as well as criticising the child. abstract keywords : enuresis, primary nocturnal enuresis, parenting volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra background factors mother n=134 frequency (%) father n=127 frequency (%) 40 x gjra global journal for research analysis regarding the parents' background factors, majority of the mothers 73.88% were aged between 25-34 years, while most fathers 70.08% were aged between 30-39 years. among parents, slightly more than half of them among mothers 59.70% and fathers 60.63% were educated up to middle and high school. nearly one-third of the parents 65.67% were not of consanguineous marriage and only 1/3 of the parents were consanguineous 34.33%. most of the parents were presently married and cohabiting 92.54% and 5.22% were widowed and 2.24% divorced. father's parenting role was considered either negligible 43.31% or supportive 54.33% by most mothers. most of the fathers were engaged in playing 78.74%, while only 21.26% of fathers were engaged with all other parenting tasks. most parents considered themselves permissive or liberal and do not punish children. when specic questions were asked, over 1/3 and over half of them reported as resorting to punitive methods. however, only a small percent of parents' shame 12.69% or criticize 7.09% the child for bedwetting. discussion it was found that majority of the children were found to be in the age group of 5-10 years which is consistent with other 2,3,4 studies. present study found more female children which is different from institution and community based studies which may be attributed to natural preference of male children for treatment. factors of children such as birth weight, type of birth, term at birth, birth order, bmi as well as parenting attitude and negative parenting behaviour including punishment for wetting behaviour have been found to be 3,5,6signicantly associated in other studies. in this study, parents reported readily punishing their children which is also 6,7 found to be similar in other studies. this study found parent strategy and positive approach were signicantly associated with nocturnal enuresis frequency. rao, in a study combining medication with parenting behaviour modication, found 8positive practices as helpful and desirable conclusion majority of children with nocturnal enuresis wet the bed on all days, and as held before in this region, it is not predominantly seen among boys. a small fraction of parents' report family history of nocturnal enuresis for self or their own siblings. despite parents' common belief that primary nocturnal enuresis is a simple developmental issue, parents still experience stigma and often resort to punishment. references 1. neveus t et al. the standardization of terminology of lower urinary tract function in children and adolescents: report from the standardization committee of the international children’s continence society. the journal of urology. 2006 vol.176,314-324. 2. srinath s, girimaji sc, gururaj g, et al. epidemiological study of child and adolescent psychiatric disorders in urban and rural areas of bangalore, india. indian j med res 2005; 122:67-79. 3. nakate dp, vaidya ss, gaikwad sy, patil rs, ghogare ms. prevalence and determinants of nocturnal enuresis in school going children in southern maharashtra, india. int j contemp pediatr 2019; 6:564-8. doi: http://dx.doi.org/10.18203/2349-3291.ijcp20190427 4. sripada r, ragiri v r, gamini s l, bonam j, datla d b &kodamanchili v b. a study on prevalence of nocturnal enuresis among rural paediatric and adolescent population. int j of pharmaceutical and clinical research 2015; 7(1):92-95 5. suri j. c., sen m. k., adhikaritulsi, epidemiology of sleep disorders in school children of delhi: a questionnaire based study, the indian journal of sleep medicine, 2008, volume: 3, issue: 2 6. de sousa. a, kapoor. h, jagtap. j, sen. m, prevalence and factors affecting enresis amongst primary school children,in mumbai india, indian journal of urology, vol 23, issue 4, p 354-7, 2007 7. immanuel thomas &radhika s, parental attitudes and practices in relation to enuresis in children nimhans journal, 19(1&2), january & april 2001, pp 23-38 8. govindrao s a 2011 rguhs clinical study avathkari pushpavati in the management of shayyammothra md ayurveda dissertation rguhs karnataka 101,104-105 volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra age 20-24 25-29 30-34 35-39 40-44 >45 15 (11.19) 60 (44.78) 39 (29.10) 20 (14.93) 16 (12.60) 42 (33.07) 47 (37.01) 18 (14.17) 4 (3.15) education no formal education primary school 1-4 class middle school 57 class high school 8-10 class puc diploma degree post graduate 30 (23.39) 15 (11.19) 64 (47.76) 16 (11.94) 1 (0.75) 6 (4.48) 2 (1.22) 23 (18.11) 3 (2.36) 23 (18.11) 54 (42.52) 10 (7.87) 4 (3.15) 7 (5.52) 3 (2.36) employed not employed self-employed/ employed 88 (65.67) 46 (34.33) 6 (4.72) 121(95.28) history of nocturnal enuresis positive for self positive for siblings 8 (5.97) 8 (5.97) 1 (0.79) 5 (3.94) parenting style permissive moderate strict very strict 111 (82.84) 6 (4.48) 11 (8.21) 6 (4.48) 104 (81.89) 11 (8.66) 5 (3.94) punishment does indulge often uses hand to beat uses cane to strike 31 (23.13) 93 (69.40) 41 (30.60) 5 (3.94) 77 (60.63) 50 (39.37) response to bedwetting criticise shames 11 (8.21) 17 (12.69) 9 (7.09) 9 (7.09) inroduction: regional anaesthesia has been the preferred technique in majority of patients coming for abdominal hysterectomy. its advantage revolved around its simplicity of administration, its reliability of action and its minimal side effects. subarachnoid block offers rapid onset of action and good surgical anaesthesia. hypotension occurs usually due to autonomic blockade which is two segments higher than the sensory block after administration of spinal anaesthesia. hence volume preloading has been recommended for prevention of spinal – induced hypotension in this situation. need for study : this study was conducted to compare the efcacy of crystalloid to colloid preloading in reducing the incidence and severity of spinal induced hypotension aim: the aim of my study was to assess the safety and efcacy of colloid (hydroxyethyl starch) over crystalloid (ringer's lactate) preloading in preventing hypotension following spinal anaesthesia. objectives: 1. to assess if the preloading is benecial in preventing the adverse haemodynamic changes in abdominal hysterectomy under spinal anaesthesia. 2. to nd out the better preloading uid between colloids and crystalloids. 3. to assess the requirement of vasopressors. methods : type and design of study : randomized prospective study study population : the study population included 60 patients undergoing elective abdominal hysterectomy under spinal anesthesia during november 2018 – august 2019 . study location : mvj medical college and research hospital ethical clearance : obtained inclusion criteria: 1. patients undergoing abdominal hystrectomy. 2. patients belonging to asa i &ii. 3. patients belonging to age group 18-60years. exclusive criteria: 1. patients refusing spinal anaesthesia. 2. patients with cardiac disorders. 3. patients with skin or soft tissue infection at the site of needle entry and coagulopathy. 4. any contraindications to spinal anaesthesia . sample size : with a condence interval of 90% , and p value of <0.l, the sample size for the current study was calculated to be 60 , with a population of 30 in each group. methodology : 60 patients of asa i and ii posted for abdominal hysterectomy are considered for the study after permission from hospital ethical committee and written informed consent is obtained from every patient. patients with cardiac disorders, skin or soft tissue infection at the site of needle entry ,coagulopathy and refusing spinal anaesthesia or with any other contraind ications for spinal anaesthesia were excluded from the study . routine pre-anaesthetic evaluation was done. relevant investigations were done. on arrival into operation theatre patients were placed in supine position. baseline hemodynamic parameters will be noted in both groups.iv line is secured using iv cannula 18g and xed. patients were randomly divided into 2 groups of 30 each. group a – will receive ringer lactate 10ml/kg in 20 minutes before giving sab. group b – will receive hydroxyethyl starch, 5ml/kg in 20 minutes, before giving sab. immediately after preloading ,under aseptic precautions patients in both groups received 0.5% bupivacaine (heavy) 3 ml in lateral position at l2-l3 / l3-l4 space for subarachnoid block. patients were turned supine and ringers lactate infusion is started .oxygen was given by facemask at the rate of 4-5l/min. following spinal anaesthesia mean arterial pressure were recorded at following intervals 1, 5, 10, 15, 30, 45, 60, 90 minutes and 3 hours after spinal anaesthesia. rescue medications were recorded if used. if the systolic blood pressure goes below 30% of the baseline it is taken as hypotension hypotension was treated with rapid iv uid infusion and inj. ephedrine, 6 mg iv. blood loss was replaced with crystalloids and blood transfusion as required. patients were observed for nausea, vomiting, rigors, and allergic reaction. urine output, total uid requirement and blood loss were recorded at the end of surgery and patients were observed for 1 hour in recovery room postoperatively and pr, nibp, spo2 were recorded. a comparative study of ringer lactate and hydroxyethyl starch as a preloading fluid for prevention of hypotension following subarachnoid block in abdominal hysterectomy. original research paper dr kaveti vihitha reddy pg , mvj mc&rh medical college and research hospital dr tahir s hatturkar pg , mvj mc& rh medical college and research hospital anaesthesiology keywords : volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr somasekharam p* prof , mvj mc&rh medical college and research hospital *corresponding author dr jawabulla vazhayil pg , mvj medical college and research hospital 30 x gjra global journal for research analysis statistical analysis was performed using anova and chi square test results: table 1 : demographic characteristics (mean) there was no signicant difference between two groups before the surgery in regards to mean age and weight. level of sensory block attained in the both the groups was ≥ t6 and hence was comparable. at the end of surgery level of block was ≤ t8 and was comparable. both groups pre-induction blood pressure is noted and is almost similar. however the incidence of hypotension was higher in group a (rl) compared to group b (hes) (60 % vs 30% ). (table 3) table 2: hypotensive episodes and their management table : mean blood pressure (mm of hg) the mean arterial pressure was compared among the two groups at the pre-set time intervals for this study. the differences among the two groups were statistically signicant at 0 min ( p =0.005) , 1 min ( p =0.047), 5 min ( p = 0.042), & 15 min ( p =0.037). discussion : sympathetic denervation occurs during spinal anaesthesia. in spinal anaesthesia the severity of hypotension depends on the degree of sympathetic blockade. in spinal anesthesia, hypotension is dened as a fall in systolic blood pressure by 30% of the baseline. various measures have been tried for prevention of hypotension induced by spinal anesthesia. 1) preloading 2) leg compression by inatable splint 3) prophylactic use of vasopressors. all measures have their own limitations. volume preloading is an effective technique to prevent hypotension induced by spinal anesthesia. different crystalloid and colloid have been used as preloading uid for prevention of hypotension induced by spinal anesthesia. in this study this character has been studied by giving ringer lactate and hes as preloading uid before giving spinal anesthesia. we had selected ringer's lactate as preloading uid because it is most physiological uid, its osmolality is similar to plasma and most of the authors have selected it in their studies as preloading uid . hydroxyethyl starch (hes) is extensively during resuscitation in polytrauma, critically ill patients in intensive care settings, vascular and orthopedic surgery and in burns and sepsis patients. its use is contraindicated in patient's with renal failure and in those with known sensitivity to the drug. the incidence of anaphylactic reactions to hydroxyethyl starch is much less than with gelatins and 7dextrans (0.006%, 0.038% and 0.008% respectively). in terms of cost, performance and low incidence of side effects 6% hes is an adequate alternative to 5% albumin. for the above reasons, we chose 6% hes as our study uid. severe hypotension is dened as mean arterial pressure 1 (map) below 30% of base line value. we dened hypotension as a decrease in mean blood pressure of 30% or more from the baseline value. we were not able to completely prevent spinal block induced hypotension by preloading with either 6% hes or ringer lactate. but patients who received 6% hes had a much lower incidence of hypotension (12%) as compared to those who received ringer lactate (68%). the incidence of hypotension in both the group is less than that reported by other authors' who have shown similar results. patients who received 6% hes had signicantly less number of hypotensive episodes requiring treatment with ephedrine as compared to the patients who had received ringer lactate. the rst episode of hypotension occurred as early as 5 min after the subarachnoid block in the ringer lactate group whereas the earliest hypotensive episode in the 6% hes group occurred 10 min after the subarachnoid block. but in our study the incidence of hypotension between group a and group b were 60% vs 30%. moreover the ephedrine requirements were more in group a than group b which was also statistically signicant (p value <0.01). in the study by sheikh imran et al 36.4% of patients in hes group and 63.6% patients in rl group needed rescue doses of inj.mephentermine.(4)hydroxyethyl starch remains longer in the intravascular compartment than any crystalloid solution and is also able to maintain greater colloid osmotic pressure in the maternal circulation. about 75% of any crystalloid given diffuses into the interstitial space and 2.5 to 3 times the volume of crystalloid is needed to achieve the same degree of plasma expansion. extravascular redistribution of crysta volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra variables group a (rl) group b (hes) age in yrs 40.8 39.7 weight in kg 59.8 57.3 group a (rl) group b (hes) p value incidence of hypotension 18(60%) 9 (30%) not signicant hypotension corrected by additional rapid infusion of ringer's lactate 13(43%) 7 (23%) not signicant hypotension corrected by injection ephedrine 5(17%) 2 (7%) p< 0.01 time group r group h p value pre op 82.57±10.88 88.97 ± 6.80 0.194 0 77.90 ± 8.85 86.05 ±9.38 0.005 1 mins 64.47±13.26 76.32±12.39 0.047 5 mins 63.20±10.97 74.82±10.15 0.042 10 mins 62.70±10.54 73.30±10.53 0.059 15 mins 60.62 ±11.07 72.85±10.97 0.037 30 mins 68.97 ±9.90 72.32 ±9.19 0.186 45 mins 69.35 ±8.99 72.12 ±8.42 0.735 60 mins 70.77 ±7.36 74.82 ±8.69 0.759 90 mins 71.90 ±6.68 74.17 ±7.80 0.525 180 mins 72.12 ±6.80 76.02 ±7.43 0.549 x 31gjra global journal for research analysis lloids may be so rapid that it may be impossible to infuse them fast enough to maintain the intravascular volume and avoid hypotension during spinal anaesthesia. we may have been able to reduce the incidence of hypotension by giving larger volumes of crystalloid solutions. but this would have required more time to preload and would have placed both parturient and foetus at a greater risk of uid overload. the patients in the 6% hes group required less intravenous uid intraoperatively as compared to the ringer lactate group. there was no signicant difference in the amount of uids received postoperatively between the two groups. the study by singh et al concluded that administering preload uid had no benecial effect in preventing hypotension after spinal anaesthesia. but from the observations in our study, it is clear that preloading with 6% hydroxyethyl starch is superior to the standard preload to ringer lactate in preventing post spinal hypotension. conclusion: from the observations in present study, it is concluded that : 1. 6% hes (colloid) is better in volume preloadingwith minimal haemodynamic changes compared to the ringer lactate (crystalloids). 2. there was increased requirement of vasopressors when ringer lactate (crystalloid) was used and requirement of vasopressors was more when preloading with rl compared to preloading with 6% hes. references : 1. verma rk. mishra ld. nath ss.efcacy of polygenic preloading in prevention of hypotension following csea.indian j. anaesthesia 2005;49(2):105-108. 2. mercier f. diemunsch.j.p. bouthors asd.et.al6% hydroxyethyl starch (130/0.4) vs ringer’s lactate preloading before spinal anaesthesia for caesarean delivery:the randomized, double-blind, multicentre caesar trial.british journal of anaesthesia 2014;113 (3): 459–67 . 3. singh b, singh ap,bhardwaj a, singh i. c comparative study of preloading with ringer lactate v/s 6% hexa starch solutions to prevent hypotension following spinal anaesthesia in elective surgery. int j med and dent sci 2016;5(2):1178-1183. 4. imran s .padmanabha s. rehman h . sahoo a. a comparative study of preloading efcacy of ringers lactate v/s 6% heta starch solutions in preventing hypotension following spinal anaesthesia.iosrjdms 2014;13(3):43-48. 5. jalandhara b.makwana jc .a comparative study of crystalloids and colloids as preloading in spinal anaesthesia for ptrevention of hypotension .gcsmc j med sci 2014;iii(1) :48-52. 6. yatish bevinaguddaiah, vinayak seenappa pujari, tejesh ca, manjunath ac. “volume preloading prior to subarachnoid block: comparison between hetastarch (6%), polygelatin, ringer`s lactate solution”. journal of evolution of medical and dental sciences 2013; 2(47): 9220-9227. 7. lund n. anaphylactoid reactions to infusion of polygelatin. a study in pregnant women. anaesth 1980;35(7):655-9. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 32 x gjra global journal for research analysis 1.literature review thermoelectric coolers (tec), also known as peltier coolers are solid state heat pumps that utilize the peltier effect to move heat. the principle of thermoelectric cooling dates back to the discovery of the peltier effect by jean peltier in 1834. peltier observed that when electric current passes across the two junctions of two dissimilar conductors (a thermocouple) there was a heating effect that could not be explained by joule heating alone. infect, the direction of current decides the cooling effect or heating effect. this effect can be harnessed to transfer heat, creating a heater or cooler. peltier could not realize the importance of this phenomenon and the other thscientists also could not utilize this phenomenon till late 20 century. thermoelectric technology, as one entirely solid state energy conversion way, can directly transform thermal energy in to electricity and vice-versa by using thermoelectric transformation materials. a thermoelectric tec has no moving parts, and is compact, quiet, highly reliable and environment friendly. due to these merits, this technology is presently becoming a noticeable research direction. bell (2008); heremans et al. (2008); poudel et al. (2008); hochbaum et al. (2008); boukai et al. (2008); lyeo et al. (2004); hsu et al. (2004) 2.working of tec when the two ends of two dissimilar conductors are connected to a battery, electrons ow out of one in which the electrons are loosely bound to the one in which the electrons are tightly bound. this occurs due to the deference in the fermi level between the conductors. the fermi level represents the demarcation in energy with in the conduction band of a metal, between the energy level occupied and unoccupied energy levels. when the two different conductors are joined which have different fermi levels, electron start owing from the conductor with higher level to the other one. this ow continues till the electrostatic potential bridges this gap and the two fermi levels come at the same value. current passing across the junction results in either a forward or a reverse bias, resulting in temperature gradient. if the temperature of the hotter junction is kept low by removing the heat, the temperature of the cold plate can be cooled by tens of degrees. 2.1tec construction tec are constructed using two dissimilar semi-conductors, ntype and p-type (in order to have different electron densities needed for better effect) fig 2.1. the two semi-conductors are positioned thermally in parallel and joined at one end by a conducting cooling plate (typically of copper or aluminum). a voltage is applied to the free ends of the two different conducting materials, resulting in a ow of electricity through the two semi conductors in series. the ow of dc across the junction of the two semiconductors creates a temperature difference. giving rise to peltier cooling and hence absorption of heat from the vicinity of the cooling plate. if the direction of current is changed by changing the polarity of the battery, the cold side becomes hot side and the hot side becomes cold side in tec. fig 2.1: tec construction thermoelectric based all weather cooler original research paper saswat kumar das department of mechanical engineering,iimt college of engineering, greater noida x 113gjra global journal for research analysis mechanical engineering in this automation scenario when everyone is serious about glaciers melting & ozone layer depletion so it's important to do which helps in overcoming this problem. many type of refrigerator are made using refrigerant which to extent affect our environment. then it strikes to make a cooling & heating system in which there is no use of refrigerant so there is an option of vapour absorption system. now the problem occurs about its shape (heating & cooling system) is heavy & bulky. but our system is not very heavier shape and weight. the idea generation for the project had come in order to face and tackle the harmful for the environment. that's where the principle of internal heat generation and manipulation comes to save the day. if the room is heated or cooled just before the required time, it will subsequently decrease the energy losses and produce the required temperature at the right time. but despite using high energy consuming resistance coils to produce heat and refrigeration system to produce cooling. we use peltier effect to produce either heating/cooling as per the user's requirement. the jit (just in time) philosophy of our product increases accountability to meet the user's needs efciently while reducing the heat loss/gain incurred during the process of pre-heating/pre-cooling of room. there have been a lot of advancements made to all weather coller over the years, but no one's made anything for the "modern man,". without any harm to our environment. abstract keywords : peltier, thermoelectric heating/cooling, environment atul kr yadav* department of mechanical engineering,iimt college of engineering, greater noida *corresponding author bablu department of mechanical engineering,iimt college of engineering, greater noida volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra deepak department of mechanical engineering,iimt college of engineering, greater noida deepak kumar department of mechanical engineering,iimt college of engineering, greater noida 114 x gjra global journal for research analysis 2.2 benets of tec while refrigerators and air-conditioners utilize compressors, condensers and refrigerants to lower temperature; solid state cooling utilizes dc power, heat sinks and semiconductors. venkatasubramanain et al. (2001); chen et al. (2010); yamashita (2009); yamashita (2008). this fundamental difference gives solid state thermoelectric coolers the following advantages over conventional devices. environment friendly (as no refrigerants are used). therefore leaking problem of refrigerants can also be avoided. as cfc's have high ozone depletion potential and hcfc's have comparatively low ozone depletion level, they are being phased out. it this situation tec's can be the best alternate as it has zero harmful effect. it can be manufactured in compact sizes using less space. light weight, which can be advantageous where light weight is more imporatant feature than cop.(e.g. in aircrafts). rate of refrigeration and cop can be easily controlled by varying voltage and current. 3.thermoeconomics thermoeconomics, as an exergy-aided cost reduction method, provides important information for the design of cost effective energy conversion systems. the exergy costing principle is used to assign monitory values to all material and energy streams within a system as well as tho the exergy destruction within the system. the design evaluation and optimization is based upon the trade-off between exergy destruction (exegetic efciency) and investment cost. it is observed that in most of the studies (adnan, 2001; aprea et al, 2002; adnan et al., 2003; aprea et al., 2004; adnan et al., 2007; kabul et al;, 2008; ozkaymak et al., 2008; bayrakci et al., 2009; kizilkan et al., 2010; variyelni et al., 2011), performance comparison and performance analysis of refrigeration system is performed using energy approach based on rst law and exergy analysis based on second law. energy and exergy approaches are generally well known approaches, used to analyze thermal processes. there are various terminologies and names given to various exergoeconomic approaches presented in the past by researchers in previous years. these names include the following: 3.1 economic approach (eea) 3.2 first exergoeconomic approach (fea) 3.3 thermoeconomic functional analysis (tea) 3.4 exergetic cost theory (ect) 3.5 e ngineering functional analysis (efa) 3.6 last-in-first out approach (lifoa) 3.7 structural analysis approach (saa) 3.8 speco method (specom) 4.recent developments in thermoelectrics a multi-objective and multi-parameter optimization was implemented by meng et al. (2014) to design the optimal structure of bismuth-telluride-based teg (thermoelectric generator) module. a multi-physics teg model combining the scg (simplied conjugate-gradient) algorithm was used as the optimization tool. a thermoelectric generator must be designed keeping all geometric features in to account to enhance the performance such as efciency and power output. a study has been done in which three the-state-of-theart multi-objective evolutionary algorithms, namely, nsga-ii (non-dominated sorting genetic algorithm-ii), gde3 (generalized differential evolution generation 3), and smpso (speedconstrained multi-objective particle swarm optimization) are used to optimize the geometric features of a thermoelectric generator to improve its efciency and power output when it is operating in different conditions. geometric parameters may be dened shape factor and size of pin length and the operating parameters may be dened as temperature ratio and load on thermoelectric cooler. 5.gaps and opportunities 5.1second law analysis of thermoelectric devices is required to understand their potential to serve the desired purposes. 5.2optimized operating condition should be evaluated to improve the performance. optimized design should be developed to enhance the application of thermoelectric devices where size, weight and shape are more important than efciency or cop. 6.conclusion ÿ as per the calculation and heat transfer rate required, peltier module tec-12706 is selected for cooling and heat generation. design : 7. advantages 1. environmentally friendly 2. recycles wasted heat energy 3. reliable source of energy 4. lowers production cost 5. scability, meaning that the device can be applied to any size heat source from a water heater to a manufactures equipment. 8. disadvantages 1.te material is expensive 2. structural failure of te at high temperatures 3.electrical resistivity increases. 9.applications 1. stir coolers 2. electrophoresis cell coolers 3. environmental analyzers references volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 85.dr monali rewatkar online.cdr introduction thyroid diseases are among the commonest endocrine disorders worldwide, it has been estimated that about 42 million people in india suffer from thyroid diseases. hypothyroidism is the common thyroid disorder with the prevalence of 3.9% in india [3]. thyroid hormones are essential for normal organ growth and development.thyroid hormones regulate the basal metabolic rate of all cells, so alteration in there level can affects the entire metabolism. thyroid hormones regulate hepatocytes and thereby modulate hepatic function. the liver in turn metabolizes the thyroid hormones and regulates their systemic endocrine effect.[4,5] thyroid dysfunction may perturb liver function. knowledge of the association between hypothyroidism and deranged biochemical markers of liver function is important for the clinician, to consider an evaluation of thyroid function in the work up of the patient with altered liver function tests.[6,14] this may emphasize the need for monitoring liver function in hypothyroid patients and vice versa. the present study was undertaken to study the inuence of thyroid hormones on liver function (transaminases) in hypothyroidism.present study was done to evaluate the biochemical parameters of thyroid function test (t3, t4, tsh) and liver function test (ast,alt and alp) and to nd out any possible correlation among the measured parameters. objectives of the study 1) to evaluate the effect of thyroid dysfunction on liver function tests 2) to study pearsons correlation between liver enzymes & thyroid prole method of collection of data & selection of subjects: this study include about 100 patients attending the clinical biochemistry opd, iggmc, nagpur for routine thyroid test. history was taken as per designed proforma and consent form was obtained. we collect 5 ml blood sample in plain bulb. collected sample was analysed for liver enzymes as well as thyroid test ie t3,t4 & tsh. thyroid tests was run on elisa ( reader & washer). serum values of thyroid stimulating hormone (tsh), thyroxine (t4) and tri-iodo thyronine (t3) were assayed by elisa tests and values were compared & correlated with liver enzymes ( ast,alt,alp). liver function tests – normal range alanine transaminases implications of thyroid dysfunction on liver enzymes original research paper dr monali rewatkar assistant professor, biochemistry department indira gandhi government medical college, nagpur, maharashtra, india x 39gjra global journal for research analysis biochemistry background: the liver has an important role in thyroid hormone metabolism. normal level of thyroid hormones also important for normal hepatic function [1].thyroid disorders often accompany abnormal serum enzyme levels and disturbances in liver functions. thyroid diseases may be associated with elevation of alanine aminotransferase (alt), aspartate aminotransferase (ast) and alkaline phosphatase(alp).[2] thyroid hormones regulate the basal metabolic rate of all cells including hepatocytes, and hence, modulate hepatic function; the liver in turn metabolizes the thyroid hormones and regulates their systemic endocrine effects .[3] thyroid dysfunction may perturb liver function .so, the objective of this study is to evaluate the changes in liver function in thyroid dysfunction. aims: aim of the present study is to determine the biochemical markers of liver function test ie aspartate transaminase (ast), alanine transaminase (alt) and alkaline phosphatase (alp) in patients with thyroid dysfunction and to evaluate the effect of altered thyroid hormones on liver function tests . also to nd their possible correlation ie pearsons correlation between liver specic enzymes & thyroid hormones in patients attending clinical biochemistry opd at tertiary care unit, iggmc,nagpur. materials & methods – this study include about 100 patients attending clinical biochemistry opd, iggmc, nagpur for routine thyroid test. estimations of thyroxine (t4), triiodothyronine (t3), thyroid stimulating hormone (tsh) done & liver specic enzymes like activities of aspartate transaminase (ast), alanine transaminase (alt), alkaline phosphatase (alp) estimated in all patients..collected sample was analysed for liver enzymes, run on autoanalyser em 460 in clinical biochemistry laboratory,iggmc,nagpur. thyroid tests was run on elisa reader & washer . serum values of thyroid stimulating hormone (tsh), thyroxine (t4) and tri-iodo thyronine (t3) were assayed by elisa tests and values were compared & correlated with liver enzymes level .the data was analysed & pearsons correlation was obtained, p value <0.05 considered as signicant. results: results of our study shows positive pearsons correlation between tsh & liver enzymes in thyroid dysfunction while there is negative pearsons correlation between t3,t4 with liver enzymes. p value is found to be statistically signicant ie <0.05 . conclusions: thyroid dysfunction patients should be regularly checked for biochemical parameters of liver enzymes. it can be concluded that thyroid hormones altered liver function tests. it is thus recommended that liver function tests interpretation in thyroid dysfunction must be advised to prevent progression of disease. abstract keywords : liver function test, thyroid dysfunction , t3, t4, tsh, ast, alt and alp volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr arun tadas * professor & head, biochemistry department indira gandhi government medical college, nagpur, maharashtra, india *corresponding author sanjay agrawal statistitian psm department, indira gandhi government medical college, nagpur, maharashtra, india prayas nimbarte intern, biochemistry department, indira gandhi government medical college, nagpur, maharashtra, india 40 x gjra global journal for research analysis (alt)10 to 40 iu/l, aspartate transaminases (ast) -10 to 40 iu/l , alkaline phosphatase (alp) – 44 to 147 iu/l, were estimated on fully analyzer em 460 for t3, t4, tsh – immunoassay elisa kit method on elisa reader & washer normal range –t3 0.52 to 1.85 ng/ml, t4 5 to 15 ug/dl, tsh – 0.39 to 6.16 uiu/ml analysis was carried on autoanalyser em – 460 in clinical biochemistry lab, iggmc for serum ast,alt & alp . all estimations was done & their values were compared & correlated. the data was analysed & pearsons correlation was obtained, & . p value <0.05 was considered statistically signicant. results table no 1 : mean values of t3, t4, tsh ( thyroid test) & ast , alt, alp ( liver enzymes) table no 2 : pearsons correlation between thyroid horm ones & liver specic enzymes **. correlation is signicant at the 0.01 level (2-tailed). discussion result of our study shows tsh level (mean 5 .63) shows positive correlation with serum enzymes specic for liver ie ast,alt & alp by pearsons correlation (table 2) similarly vice versa with t3 ,t4 shows negative pearsons correlation with liver specic enzymes. the ndings of our study is in corroboration with ndings of the study by kalita n et al,[6] yadav a. et al.[7], p.d grifths et al [8] and pandey r. et al.[9] malik and hodgson[10] mentioned that thyroid hormones t3 and t4 are essential for the growth, development and function of all organs of the body. they regulate bmr of all cells of the body including the hepatocytes and thereby modulate hepatic function. the liver in turn metabolises thyroid hormones and regulates their systemic endocrine effects. therefore thyroid dysfunction may disturb liver function and liver disease affects thyroid hormone metabolism and a variety of systemic diseases affect both organs. it highlights a close relationship between thyroid and liver in health and disease. in our study tsh level showed signicant positive correlation with ast, alt and alp levels in thyroid dysfunction. (table 2 ). our study may be explained by the observations made by targhar g. et al [11], khan t. et al [12] and prakash a. et al[13]. that thyroid alteration effects the liver enzymes like alp,ast and alt. the pearsons positive correlation of tsh levels with ast and alt levels is statistically signicant ( p <0.05) conclusion – to conclude, the present study indicates that thyroid disorder might cause signicant effect on metabolism of various cells like hepatocytes reected by increase in biochemical param eters of liver function test ie activity of ast, alt and alp . this suggests that hypothyroid patients should be regularly checked for biochemical parameters of liver function tests. early detection and treatment can prevent the further complications related to the disorder and will be helpful during the management of thyroid patients. references 1. klion f.m., segal r., schaffner f. the effect of altered thyroid function on the ultrastructure of the human liver.1971; 50: p.317-24. 2. mane a, bhagwat v. serum enzymes and liver function tests in thyroid disorders. biomedicine 2011; 31: 517– 522 3. huang mj, liaw yf. clinical associations between thyroid and liver diseases. j gastroenterol hepatol 1995; 10:344–50. 4. manjula k. s, priyadarshini k. s, h. v. shetty, usha s.m.r, reena. r. study of serum transaminases in hypothyroidism. journal of evolution of medical and dental sciences 2013;2:230-234 5. hasan b, ibrahim n. estimation of thyroid hormones and liver enzymes levels in hypo and hyperthyroidism in iraqi women. int j pharm bio sci 2016;7: 707 – 713 6. kalita n, devi r, ahmed s. inuence of hypothyroidism on biochemical markers of liver function test: a cross sectional study. indian journal of basic and applied medical research 2016; 5:478-490 7. yadav a., arora s., saini v., arora mk., singh r., bhattacharjee j. inuence of thyroid hormones on biochemical parameters of liver function: a casecontrol study in north indian population. internet journal of medical update. 2013;8: p.4-8 8. p. d. grifths. serum enzymes in diseases of thyroid gland. j clini path 1965; 18:660. 9. pandey r, jaiswal s, sah j, bastola k, dulal s. assessment of serum enzymes level in patients with thyroid alteration attending manipal teaching hospital, pokhara. a journal of life sciences 2014;3: 2249-8656 10 malik r, hodgson h. the relationship between the thyroid gland and the liver. q j med. 2002;95:p.559-69. 11. targher g., montagnana m., salvagno g. et al.association between serum tsh, free t4 and serum liver enzyme activities in a large cohort of unselected outpatients. clin endocrinol 2008; 68: p.481–484. 12. khan t.m., malik s, diju i.u. correlation betweenplasma thyroid hormones and liver enzymes level inthyrotoxic cases and controls in hazara division. j ayub med coll abbottabad. 2010; 22: p.176–179 13. prakash a., lal a.k., negi k.s. serum creatine kinase activity in thyroid disorders. j med edu research. 2007;9: p.25–26. 14. bandebuche s, jagtap s.study of liver and kidney function tests in patients of hypothyroidism.international journal of biochemistry. 2017;4:66-69 volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra mean std. deviation n t3 1.0427 .34098 100 t4 6.55 2.650 100 tsh 5.634 4.7064 100 ast 48.020 39.7865 100 alt 49.890 42.0221 100 alp 167.440 79.7502 100 correlation ast alt alp t3 pearson correlation sig. (2-tailed) n -.734** 0.000 100 -.783** 0.000 100 -.664** 0.00 100 t4 pearson correlation sig. (2-tailed) n -.723** 0.000 100 -.778** 0.000 100 -.727** 0.000 100 tsh pearson correlation sig. (2-tailed) n .696** 0.000 100 .736** 0.000 100 .695** 0.000 100 introduction: vital aim of any educational system is to initiate desired behavioral changes among the students and also to sustain such behavior throughout their life. however, educational institutions are not the lone agency of bringing out of such desired behavior, as person's intelligence as well as study habits also plays an important role in such endeavors. this could be accomplished only when readiness of learner and congenial environment work in coordination to develop and sustain such behavior in tune with the social contexts. generally, the quality of education is estimated in terms of achieving learning outcomes, which is, academic achievement. agarwal mamta, jain,v.k and chandrashekher,k.,(2004) reports that physical facilities, regular evaluation practices, teacher's positive attitude and high expectations from students, congenial institution climate and good leadership had positive effect on learning of students. agarwal mamta, jain,v.k and chandrashekher, k., (2004) collaborate that student's reading habits and hours spent in studies turned out to be important variables which affected learning. this is also con�rmed by tiwari, g.n (1982). he observed that study habits scores positively and signi�cantly correlated with annual examination marks. sen, bharat kalpana (1992) also observed that study habits scores positively and signi�cantly are correlated with annual marks. emotional intelligence is one of the potential factors of individual that in�uence all round development of a student. the rapid development of the era is challenging the adolescents to face the wave of globalization. thus, the ability to control the emotions has become important for not carried away by the �ow of negative and evil elements. a high emotional intelligence helps to maintain a state of harmony in oneself and �nally be more self-con�dent in dealing with the challenges of living and learning in educational institutions. emotional intelligence is a cross-section of interrelated emotional and social competencies, skills and facilitators that determine how effectively we understand and express ourselves, understand others and relate with them, and cope with daily demands and pressures (bar-on, 2006). it is that part of the human spirit which motivates us to perform, which gives us energy to demonstrate behaviors such as intentionality, persistence, creativity, impulse control, social deftness, compassion, intuition and integrity (kapp, 2002). lam and kirby (2002) are of the opinion that emotional intelligence involves perceiving, understanding, and regulating emotions. high emotional intelligence can contribute to a student in the learning process (goleman, 1996; elias, ubriaco, reese et.al., 1992, svetlana, 2007). students who are low on emotional intelligence may �nd failure more difficult to dealt with, which undermines their academic motivation (drago, 2004). the researcher examined the emotional intelligence (ei) and study habits (sh) of physically challenged and normal secondary students. objectives of the study: the following were the major objectives of the study: ÿ to study the signi�cant difference of emotional intelligence and study habits of physically challenged and normal secondary school students. ÿ to study the relationship of emotional intelligence with study habits of physically challenged and normal secondary school students. hypothesis of the study: the following were the major hypothesis of the study: ÿ there is no signi�cant difference of emotional intelligence between physically challenged and normal secondary school students. ÿ there is no signi�cant difference of study habits between physically challenged and normal secondary school students. ÿ there is no signi�cant relationship of emotional intelligence with study habits of physically challenged students. ÿ there is no signi�cant relationship of emotional intelligence with study habits of normal secondary school students. method of research: descriptive survey was conducted in bhopal district colleges of madhya pradesh state. in order to test the hypothesis, the investigation is planned and carried out in three phases. in �rst phase the researcher reviewed the related literature and previous research studies. in order to measure emotional intelligence and study habits the tools developed by the s.k mangal and shubra mangal and patel, b.v have been selected respectively. in the second phase researcher has collected data by administrating the tools on a sample of 200 secondary school students (100 physically challenged and normal secondary school students) drawn from bhopal district of madhya pradesh state. in the third phase, the collected data are analyzed by using appropriate statistical techniques. reporting the results of the study is also carried out in this phase. sample was selected through purposive and random sampling method. purposive for physically challenged students and random sampling technique used for normal secondary school students analysis and interpretation of data table no. 1 signi�cant difference of emotional intelligence between physically challenged and normal secondary school students. the value of 't' is found to be not signi�cant and the hypothesis is accepted. thus, it is concluded that there is no signi�cant difference of emotional intelligence between physically challenged and normal secondary school students. this indicates that there is no difference in their emotional intelligence of both categories of students. this shows that, emotional intelligence of secondary students of normal category and physically challenged students are of same type. it indicates the students who's physical or mental condition signi�cantly limits their motors, sensory organs or cognitive abilities doesn't affect the obtained scores in emotional intelligence test. it is clear that, environment of school and home are similar for the emotional growth of children whether they are normal students or differently able children. table no. 2 showing signi�cant difference of study habits between physically challenged and normal secondary school students. a study of emotional intelligence and study habits of physically challenged and normal secondary school students. original research paper kusum bhadouriya research scholar, barkatullah university, bhopal. x 35gjra global journal for research analysis education keywords : category mean sd n df 't' sig. physically challenged 59.84 7.2 100 198 1.47 ns normal students 61.26 6.5 100 category mean sd n df 't' sig. physically challenged 168.84 16.8 100 198 3.49 sig. normal students 161.18 14.2 100 volume-7, issue-12, december-2018 • print issn no 2277 8160 36 x gjra global journal for research analysis the value of 't' is found to be signi�cant and the hypothesis is not accepted. thus, it is concluded that there is signi�cant difference of study habits between physically challenged and normal secondary school students. this indicates that there is difference in their study habits. this shows that study habits of physically challenged students are better than the study habits of normal secondary school students. the value of 't' is found to be signi�cant hence the hypothesis is not accepted. thus, it is concluded that there is signi�cant difference of study habits between physically challenged and normal secondary school students. table no. 3 showing relationship between emotional intelligence with study habits of physically challenged secondary students. from table no.3 it is clear that, the coefficient of correlation obtained between emotional intelligence with study habits of physically challenged students is 0.72. hence hypothesis third is rejected. it means positive signi�cant relationship found between the emotional intelligence with study habits of physically challenged students. it indicates that the study habits of physically challenged students is in�uenced by the emotional intelligence . it can be say that those students have better emotional intelligence they possess good study habits also. the 4th,hypothesis of study states that there is no signi�cant relationship of emotional intelligence and study habits of normal secondary school students. this hypothesis is veri�ed by t test and presented in table no 4. table no. 4 showing relationship between emotional intelligence with study habits of normal secondary students. from table no.4 it is clear that, the coefficient of correlation obtained between emotional intelligence with study habits of normal secondary students is 0.68. hence hypothesis third is rejected. it means positive signi�cant relationship found between the emotional intelligence with study habits of normal secondary students. it indicates that the study habits of normal secondary students is in�uenced by the emotional intelligence . it can be say that those students have better emotional intelligence they possess good study habits also. findings, conclusion and suggestions: ÿ there is no signi�cant difference of emotional intelligence between physically challenged and normal secondary school students. ÿ there is signi�cant difference of study habits between physically challenged and normal secondary school students. ÿ there is signi�cant relationship of emotional intelligence with study habits of physically challenged students. ÿ there is signi�cant relationship of emotional intelligence with study habits of normal secondary school students.. conclusion: the conclusions on the basis of �ndings of the study are there is positive signi�cant relationship found between emotional intelligence with study habits among physically challenged as well as in normal category secondary school students. emotional intelligence is an important factor which can play important role in determining the good study habits i.e. planning, time management and concentration. similarly those students are able to deal intelligently where emotions have the last laugh; they can adopt better strategies to adopt good study habits. those student’s have the ability to monitor one’s own and others feelings and emotions to discriminate among them and to use this information to guide one’s thinking, they have an ability to achieve better marks in their exams. similarly the systematic ways of studying also affects the achievement of students in subjects. this study also concludes that study habits, is positively correlated to emotional intelligence. if classroom teachers, teach students good study habits and self management’s skills together with appropriate strategies and planning, de�nitely they will move towards the right direction for achieving the real goal of education. references 1. alon and higgins (2005) global leadership success through emotional and cultural intelligences”, business horizons, vol 48 (6), pp 501-512. 2. aurora, saroj singh and anju. (1997). the back ground of mothering in high caste families. indian journal of psychometry & education, vol. 28(2) 119-123. 3. bal subramanian & et al(2008) the role of emotional intelligence in organisational leadership, sixth aims international conference on management. 4. clark. (1937). habits. encyclopedia of religion and ethics. 5. gole & hall. (2003). psychology of adolescence pg. no. 523-643. 6. goleman &etal 1996 http://en.wikipedia.org/wiki/emotional intelligence 7. mangal, s.k . (2007). essentials of educational psychology, printice – hall of india, new delhi. 90-111. 8. patel, b.v. (1980). manual of study habits inventory, aprc, agra 9. patel, g.n. (1979). a study of anxiety among secondary school students of sabarkantha district of gujrat. third survey of educational research, vol-i 10. patel, m.r. (1996). study habits of pupils and its impact upon their academic achievement. the progress of education, vol.xxi (4), 74-76. 11. varshney, s.r. (2007). the effect of parental encouragement on emotional intelligence of adolescent.psycholingua 37 (2) 152-53. s.no variable n df 'r' 1. emotional intelligence 100 98 0.72 2. study habits 100 s.no variable n df 'r' 1. emotional intelligence 100 98 0.68 2. study habits 100 volume-7, issue-12, december-2018 • print issn no 2277 8160 introduction the prevalence of neck pain is generally higher in women than men and usually increases with age; there is evidence that the younger population has a better prognosis for improvement. people with neck pain may have associated psychological factors, including anxiety, depression, [1]catastrophizing, and fear of movement the who denes quality of life (qol) as an individual purpose-aligned cultural and value system by which a person lives, relative to their aims, hopes, living standards and interests. this is a detailed concept which incorporates individuals' physical and psychological health, their degree of independence, their social liaisons and how they relate to their surroundings. quality of life is an area of study that has attracted an ever increasing amount of interest (mccall, 2005; ruzevicius, 2012). the long term, lower intensity stress and strain and improper posture are believed to be the most important causative factor [13]for neck pain material and method ÿ study design: comparative study ÿ sample size: 100 ÿ source of data collection: community ÿ sampling design: convenient participation criteria inclusion criteria: ÿ undergraduate students between the ages of 18-25 years. ÿ both male and female suffering from non-specic neck pain since 6 months. exclusion criteria: ÿ person who have traumatic injury in past 6 months. ÿ history of cervical fracture. ÿ any other clinical pathology in last 6 months. result table 1: comparison of pain intensity scores between male and female subjects. **signicant at .01 level inference: the mean value for the score of pain intensity (pi) of male is 0.84 with standard deviation of 0.817. the mean value for the score of pain intensity (pi) of female is 1.46 with standard deviation of 1.073. the t-value is 3.250 suggesting results to be signicant at .01 levels, which means that the pain intensity component of quality of life in females with non-specic neck pain is higher than males with non-specic neck pain. table 2: comparison of reading scores between male and female subjects. **signicant at .01 level inference: the mean value for the score of reading (rg) of male is 0.88 with standard deviation of 0.824. the mean value for the score of reading (rg) of female is 1.54 with standard deviation 0.973. the t-value is 3.659 suggesting results to be signicant at .01 levels, which means that the reading component of quality of life in females with non-specic neck pain is higher than males with non-specic neck pain a comparative study between quality of life of male and female and its association with non-specific neck pain original research paper sana ansari intern (b.o.th), department of rehabilitation sciences, jamia hamdard, new delhi, india x 11gjra global journal for research analysis rehabilitation science background: the prevalence of neck pain is generally higher in women than men and usually increases with age. qol is an area of study that has attracted an ever increasing amount of interest. the who denes quality of life (qol) as an individual purpose-aligned cultural and value system by which a person lives, relative to their aims, hopes, living standards and interests. hrqol has become increasingly important, as it combines the evaluation and treatment of the patient's perception of the diseases impact. objective: to nd out the association of non-specic neck pain with quality of life. to nd out the difference in quality of life of male and female due to non-specic neck pain. method: 50 males and 50 females between the ages of 18-25 years with non-specic neck pain were taken. data was collected by using neck disability index questionnaire and lled by the participants. result: higher the non-specic neck pain more will be the quality of life affected. conclusion: the nding of the study suggests that qol of females is more affected than males and it is associated with non-specic neck pain. abstract keywords : non-specic neck pain, hrqol, chronic pain. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. deepshikha gupta* assistant professor (occupational therapy), department of rehabilitation sciences, jamia hamdard, new delhi, india *corresponding author male 50 0.84 0.817 3.250** female 50 1.46 1.073 gender n mean s.d t-value gender n mean s.d t-value male 50 0.88 0.824 3.659** female 50 1.54 0.973 12 x gjra global journal for research analysis table 3: comparison of headache scores between male and female subjects. *signicant at .05 level inference: the mean value for the score of headache (ha) of male is 1.00 with standard deviation of 0.833.the mean value for the score of headache (ha) of female is 1.44 with standard deviation 1.146. the t-value is 2.196 suggesting result to be signicant at .05 level, which means that the headache component of quality of life in females with non-specic neck pain is higher than males with non-specic neck pain. table 4: comparison of concentration scores between male and female subjects *signicant at .05 level inference: the mean value for the score of concentration (cc) of male is 0.78 with standard deviation 0.864. the mean value for the score of concentration (cc) of female is 1.30 with standard deviation 1.233. the t-value is 2.442 suggesting results to be signicant at .05 levels, which means that the concentration component of quality of life in females with non-specic neck pain is higher than males with non-specic neck pain. table 5: comparison of total score between male and female subjects. *signicant at .05 level inference: the mean value for the total score (ts) of male is 17.64 with standard deviation 11.302. the mean value for the total score (ts) of female is 23.08 with standard deviation 10.581. the t-value is 2.485 suggesting results to be signicant at .05 levels, which means that total score of female with nonspecic neck pain is higher than males with non-specic neck pain. discussion the purpose of the study was to compare the quality of life of male and female and its association with non-specic neck pain in general population from age range 18 to 25 years. the result of the study suggested that, higher the non-specic neck pain more will be the quality of life affected. total 100 subjects were taken in the study with non-specic neck pain after considering the inclusion and exclusion criteria. the age group of the subjects taken was 18-25 years. the participants were divided into male and female, 50 each. the purpose of study was explained to all eligible participants in their local language. consent was obtained from all who were willing to participate in the survey. after taking the demographic data, research data was collected. questio nnaire was lled by the participants. the questionnaire used was the neck disability index (ndi) developed by vernon, h. & mior, s. (1991). ndi is 10 items scale.-pain intensity, personal care, lifting, reading, headache, concentration, work, driving, sleeping, and recreation. each of the 10 item scores from 0 to 5.the maximum score is 50. scoring was calculated by the investigator and was statically analyzed using t-test. the scoring of the questionnaire was calculated by the investigator and was statistically analyzed using t test. the result of the study for n=100, the mean of pain intensity for male is 0.84 with s.d 0.817 and mean for female is 1.46 with s.d 1.073. the t-value is 3.250**, which is signicant at .01 levels. this result suggested that the pain intensity of females with non-specic neck pain is higher than males. for n=99, 50 were male 49 were female, the mean of personal care for male is 0.58 with s.d 0.883 and for female is 0.53 with s.d ns,0.844. the t-value is 0.284 which is not signicant. this result suggests that the personal care component of quality of life is not affected by non-specic neck pain in males and females. for n=100, the mean of lifting for male is 0.98 with s.d 1.152 and mean for female is 1.18 with s.d 1.173. the tnsvalue was 0.860 , which is not signicant. this result suggests that lifting component of quality of life is not affected by nonspecic neck pain in males and females. for n= 100, the mean of reading component for male is 0.88 with s.d 0.824 and mean for female is 1.54 with s.d 0.973. the t-value was 3.659** which is signicant at .01 levels. the result suggests that the reading component of quality of life in females with non-specic neck pain is higher than males with non-specic neck pain. for n=100, the mean of headache for male is 1.00 with s.d 0.833 and mean for female is 1.44with s.d 1.146. the volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra gender n mean s.d t-value male 50 1.00 0.833 2.196* female 50 1.44 1.146 gender n mean s.d t-value male 50 0.78 0.864 2.442* female 50 1.30 1.233 gender n mean s.d t-value male 50 17.64 11.302 2.485* female 50 23.08 10.581 t-value was 2.196*. which are signicant at .05 level. the headache component of quality of life in females with nonspecic neck pain is higher than males with non-specic neck pain. for n=100, the mean of concentration male is 0.78 with s.d 0.864 and mean for female is 1.30 with s.d 1.233. the tvalue was 2.442*, which is signicant at .05 level. this result suggests that, the concentration component of quality of life in females with non-specic neck pain is higher than males with non-specic neck pain. for n=100, the mean of work for male is 1.00 with s.d 1.143 and mean for female is 0.78 with nss.d 0.840. the t-value is 1.097 , which is not signicant. hence this result suggests that the work component of quality of life is not affected by non-specic neck pain in males and females. for n=80, 39 were male 41 were female, the mean of driving for male is 1.38 with s.d 1.549 and mean for female is ns1.37 with s.d 1.729. the t-value was 0.51 , which is not signicant. this result suggests that the driving component of quality of life is not affected by non-specic neck pain in males and females. for n=100, the mean of sleeping score for male 0.76 with s.d 1.098 and mean for female 1.00 with nss.d 0.990. the t-value is 1.148 , which is not signicant. this result suggests that, the sleeping component of quality of life is not affected by non-specic neck pain in males and females. for n=99, 50 were male, 49 were female, the mean of recreation component of quality of life for male is 0.76 with s.d 0.797 and mean for female is 1.00 with s.d 0.677. the tnsvalue was 1.613 , which is not signicant. this result suggests that recreation component of quality of life is not affected by non-specic neck pain in males and females. for n=100, the mean of total score for male is 17.64 with s.d 11.302 and mean for female is 23.08 with s.d 10.581.the tvalue was 2.485*. which is signicant at .05 level. this result suggests that the total score of female with non-specic neck pain is higher than males with neck pain. which suggest that higher the neck pain more will be the quality of life affected. the result of the present study suggests that, there is a comparison between quality of life of male and female and its association with non-specic neck pain. this research is supported by the research conducted in 2018 prachita walankar et al department of musculoskeletal sciences, mgm college of physiotherapy, navi mumbai on pain and quality of life in non-specic neck pain patients. signicant difference was observed quality of life scores among males and females, hence these component should included during assessment which will provide a holistic and multimodal approach towards the understanding, planning and enhancement of management of these patients. according to filiz altug et al that chronic neck pain negatively impacts on overall health status and the causes of dysfunctions due to an increase in intensity of pain and decreasing of level quality of life. we recommended that improving quality of life and preventing disability in chronic neck pain patients must be motivated for regular exercise. begum saripinarli,et al department of physiotherapy and rehabilitation, faculty of health science, okan university on relationship between sleep quality and chronic neck pain in adults. negative ndings in individuals with non-specic chronic neck pain can affect the individual's sleep quality. although medium correlation found between neck pain and sleep quality in response, patients may face many of the traditional compensatory strategies in an effort to improve sleep quantity and quality. conclusion the study showed that there is signicant difference in quality of life of males and females with non-specic neck pain. the pain intensity, personal care, lifting, reading, headache, concentration, and recreation is higher in females, but work, sleeping and driving is higher in males, so the quality of life of females is more affected than males. it showed there is a negative correlation between pain and quality of life which indicates that increase in the intensity of pain the quality of life reduces. acknowledgement it is my esteemed to present the research survey and whole hearted thanks to each and everyone who helped me in this research survey. firstly, i would like to thank almighty god for giving me the courage to complete my research survey. i thank dr. manju chhugani dean of snsah and dr. ona p. desai, h.o.d of department of rehabilitation, who provided a conductive atmosphere to pursue this research survey. it is a great pleasure to express my deep sense of respect to my guide dr. deepshikha gupta. i took up this project and could see myself through the completion of it only because of her friendly suggestion, abundant affection and high degree of knowledge, excellent research temperament and zeal. i express my sincere thanks to dr. nazia ali, dr. saba aziz, dr. aditya kasotia, dr. kaaynat khan who always enriched me with experiences, high degree of knowledge, and valuable advices, wherever i required. i am also thankful to prof. b.s nagi, who played a key role in analyzing my data. i would like to show my gratitude towards him for helping me whenever and wherever i needed. i am grateful to my family and friends who are the ultimate source of strength, their love and sacrice over the years who have opened countless opportunities for me. i want to thanks my mother mrs. nasra ansari; father dr. ruknuddin ansari, brother mr. momin ansari, sisters mrs. tamhid ansari, mrs. nahid ansari, ms. hina ansari, sister in law mrs. khushhal sahiba. i am very thankful to my friends sidra farooqui, waize naqui, jagriti yadav, and namira hasan. finally yet importantly, i would like to thanks all the subjects who have participated in the study. to these people and many others-thank you once again for your help and encouragement. i regret if i have forgotten anyone's name. may god bless them all. references 1. prachita walankar, disha gandhi pain and quality of life in non-specic neck pain patients. ierj 2018, issn no: 24549916 2. hectorbeltronalacreu, ibai lapez-de-uralde-villanueva, cesar calvo labo, roy la touche, roberto cano-de la-curda, alfonso gil-martinez, david fernandez-ayuso, josue fernandez-carnero. prediction models of health related quality of life in different neck pain conditions: a cross sectional study. dove press 2018; 12:657-666. 3. was –aal hadid prevalence and factors inuencing neck pain among health worker in dentistry in jordan. jojnhcms.id.555706 (2018). 4. fatemeh ehsani, zahra mosallanezhad and ghazaleh vohedi the prevalence, risk factor and consequences of neck pain in ofce employees.mejrh.42031 (2017). 5. hectorbeltronalacreu, ibai lapez-de-uralde-villanueva, cesar calvo labo, josue fernandez-carnero, roy la touche. clinical features of patients with chronic nonspecic neck pain per disability level: a novel observational study. rev assoc med bras 64(8):700-709 (2017). 6. mohammad hr, samena ak, ehsanur r,shazal kd,obaidul h.charac teristics of pain and disability among patient with chronic neck pain attended at centre for the rehabilitation of the paralyzed (crp) int. phys med rehab j.2017,1(2):38-40. 7. dr. reshma s. gurav, dr.vrushali p. panhale. the association between neck pain and upper limb disability in patients with non-specic neck pain.ijhsr2017; vol.7. 8. andrade-ortega ja, ceron-fernandez, ribeiro-gonzalez m, garcia-liorent r, almecija-ruiz r and delgado-martinez ad. pain disability and quality of life in chronic non-specic neck pain. phys med rehabil int 3(4):id1094 (2016)0104. 9. sumaiyah o and mirza ob. disability due to neck pain. j yoga phys ther, an open access journal issn: 21577595(2017). 10. mustafa ozer, lale altan, canan celik and burcu metin okmen prevalence of neck pain in hospital secretaries and impact of disability on psychological state and quality of life. austin med scivolume 1 issue 2-2016. x 13gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction present day lifestyle especially of a hardworking teacher is difcult with respect to his diet habits. the maintenance of the food regulation and life style are difcult and leads to the indigestion, a chief cause of udara roga. i.e. ascites and organomegaly. even though many infectious conditions are placed before to get a “hepatomegaly” in medical practice. in ayurveda according to sign and symptoms and the pathology of the disease we can consider this clinical entity as yakritdalyudar. there is no detailed description of yakritdalyudar but acharyas correlate its symptoms with pleehodar as “evameva yakridapi dakshinparshvastham kuryat.” clinical features of yakritdalyudar are dorba ly a (weakness), aruchi(anorexia), avipaka (indigestion), varcha graha(retention of stool), trishnadhikya(excessive thirst), mandagni(indigestion), udarshool(abdominal pain), tamapravesh(anxiety). main causative factor of this disease is mandagni, altered food habits etc. the presented case has no history or evidence of generating the hepatomegaly other then his altered food habits and life style. case presentation a 33 yrs old hindu married male patient residing udaipur presented to the opd of kayachikitsa ayurvedic college, udaipur on 14/3/19 (opd no. 3265) with complain of anxiety, constipation, tenderness in rt. hypochondrium, gaseous abdomen, coated tongue, excessive thirst, polyurea, abdominal pain and burning after taking food. the pain was aggrevated by oily, spicy and heavy foods. patient's life style was disturbed, irregular food habits and sleep was also disturbed. there was no signicant family history. the ayurvedic diagnosis on these condition is yakritdalyudar can be correlated with hepatomegaly. on physical examination, vitals were normal and was fatty built. his pulse rate was 80/min, bp140/80 mmofhg and repiratory rate 20/min with normal body tempreture. the skin, mucous membrane were normal. on systemic examination, git examination showed the tenderness in r ight hypochondrium and mild liver enlargement was observed. there was no any abdominal mass was reported. before coming here patient look out another physician and he has suggested some essential investigations like complete blood count, liver function tests, urine complete and usg whole abdomen. first time he diagnosed hepatomegaly in 6/12/18. usg suggested showed hepatomegaly with fatty inltration of liver grade – �. after that patient took allopathy and other treatment but didn't get satised. then patient came in anusandhan hospital opd. table no. 1 showing blood investigation report before and after treatment management and treatment the treatment planned according to patients condition. first of all patient is advised his life style and dietary changes (pathya and apathya) and some medicines for 10 days. after 10 days patient came for follow up and reported relief in his complaints and patient's reports showed remarkable improvement in his reports in sgot,sgpt, hb% etc. then same treatment was continued till his for next 10 days due some mild symptoms present. some medication added according to patient's complaint. after next 10 days follow up, patient visited to hospital, there was complete relief in symptoms. af ter t reatment repor ts were showed encourageous results with improvement in liver echotexture.( table no.1) table no. 2 showing given treatment and follow up. in this preparation triphala churna works as rechan dravya because yakritdalyudar is one type of udara roga and rechan is specially mentioned in udara roga by acharyas and triphala also have rasayana, agni pradipak and kaphapitta shamak properties. mandoor bhasma also have hepatoprotective properties and it also helps to increase blood cells in our body. discussion in present case triphala churna and mandoor bhasma is advised to the patient. triphala contain haritaki, amalaki and bibhitak. haritaki is a good liver tonic, promote overall body health and for the support of digestive system and functioning and have vatanulaman property. bibhitak is luxative in nature, cure loss of appetite and enhance immunity. amalaki also ayurvedic management of hepatomegaly w.s.r. of yakrit dalyodar – a case study original research paper dr. jyoti jangid p.g. scholar, p.g. dept. of kayachikitsa madan mohan malviyagovt. ayurveda college, udaipur (raj) x 9gjra global journal for research analysis ayurveda hepatomegaly is a enlargement of the liver. it is caused by inadequate life style and food habits, infection (like viral hepatitis), toxins (such as alcohol), genetic disease or autoimmune disease. benign and cancerous tumors may also cause liver enlargement. in ayurveda hepatomegaly (yakritdalyodar) is described as one of the type of udara roga. in ayurveda there are many herbs and natural remedies available for treatment of liver disorder. in this case study a 33 yrs old married patient was reported in kayachikitsa opd, govt. ayurved hospital and research centre associated with m.m.m. govt. ayurvedic college, udaipur with complain of anxiety, abdominal pain, constipation, tenderness in rt. hypochondrium, gaseous abdomen, coated tongue, excessive thirst. the condition is well managed with ayurvedic medicines viz. triphala churna, mandur bhasma in short time effectively. the patient recovered in 10 days prescription of these medicines and the lft is expressive as normal. abstract keywords : hepatomegaly, yakritdalyudar, udara roga. dr. ravi sharma* prof. & h.o.d., p.g. dept. of kayachikitsa madan mohan malviyagovt. ayurveda college, udaipur (raj) *corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra particulars b.t. (13/10/18) a.t. (24/3/019) sgot 55.2 u/l 27.80 u/l sgpt 52.3 u/l 37.10 u/l date s.no. given treatment anupana 14/3/19 1. triphala churma 3gm madoor bhasma 500mg bd madhu 22/3/19 2. same repeated madhu 03/4/19 3. repeated same t/t madhu 10 x gjra global journal for research analysis balance agni. in ayurveda all udara roga caused by mainly due to agni mandhya and all the drugs contents have property of increase the agni. mandoor bhasma is a iron formulation. it contains iron dust, triphala decoction, cow's urine and aloe vera juice. in ayurveda it is used for anemia, jaundice, hepatomegaly( yakritdalyudar) and also in spleenomegaly (pleehodara). in this formulation triphala and cow's urine works as a virechana dravya which helps in detoxication of liver and whole body and yakritdalyudara is one type of udara roga and virechana is rst line of treatment in udara roga so it is helpful in yakritdalyudara. conclusion results of this study indicates that the ayurvedic drugs has the effect in hepatomegaly by improving the health of liver. it is concluded that ayurveda is useful for treating yakritdal yudara as an alternative to purgative drugs. in present case we get remarkable improvement in clinical and objective parameters with ayurvedic treatment. this is quite safe and no any adverse effect. ayurvedic treatment is proved to be an effective, cheapest and safe in management of hepatome galy(yakritdalyudar). references 1. davidson, principle and practice of medicine, edited by haslett chilvers edwin r.etal. ninteenth edition, 2002, 866. 2. pandit kashinaath shastri, dr. gorakhnath chaturvedi charak samhita of maharshi charak, chukambhaprakashan, varanasi, chikitsasthan, chapter 13, shlok 38 page no.387. 3. pandit kashinaath shastri, dr. gorakhnath chaturvedi charak samhita of maharshi charak, chukambhaprakashan, varanasi, chikitsasthan, chapter 13, shlok 61 page no.392. 4. dr. brhmanand tripathi, sharandhar samhita of acharya sharangdhar, chukambha surbharati prakashan varanasi, madhyam khanda, churna kalpana, shlok 9-10 page no.117 5. vaidhya yadav ji trikam ji, siddha yaga sangraha, chaturtha sanskaran, page 145 volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra background a poison is any substance that is harmful to your body when ingested (eaten), inhaled (breathed), injected, or absorbed through the skin. poisons have been used for many purposes across the span of human existence, most commonly as [1, 2]weapons, anti-venoms, and medicines . over the last few decades agricultural pesticides have become a common household item in rural areas of the developing world. due to their easy availability, pesticides have also become commonly used for intentional self[3, 4]poisoning . poisoning is an acute presentation and demands a need for early and aggressive management in emergency. early identication and triage helps to guide the needed resuscitation efforts and other management priorities like use of antidotes, supportive measures and psychiatric (5, 6)care if needed . the incidence of poisoning in india is among the highest in the world. it is estimated that more than 50,000 people die every year from toxic exposure. according to the national poisons information centre, new delhi, analysis of poisoning calls showed that the highest incidence of poisoning was due to household agents (44.1%) followed by drugs (18.8%), agricultural pesticides (12.8%), industrial chemicals (8.9%), animals bites and stings (4.7%), plants (1.7%), unknown (2.9%) and miscellaneous groups (5.6%)(7). poisoning patients with the evidence of organ failure require admission to the intensive care unit (icu) for organ support and specic management. there are various clinical entities that can determine the clinical course and outcome in the icu. besides the type of poison, delayed presentation and multiorgan failure that require immediately advanced life support . (8, 9)organ can lead to high mortality aim and objectives: 1. to study sociodemographic prole of patients with poisoning. 2. to study the relationship between sociodemographic variables by nature of poisoning. 3. to determine nature and frequency of poisoning. materials and method: this is a cross sectional, descriptive, observational, analytical study which was conducted on 60 patients admitted in medicine ward and intensive care unit with poison case in geetanjali medical college and hospital, udaipur. the study was conducted from june 2018 to december 2018.data of patients were collected by detailed case history from patient or the attendant regarding nature of poison ,circumstances of poisoning and time of consumption. all routine investigations was done. follow-up of the enrolled cases was done to know about the clinical course, complications, treatment received and the outcome and data regarding age, sex, time elapsed after intake; circumstances of poisoning, name of the poisonous substance, chemical type, and duration of hospitalization, severity and outcome were collected in the pre-structured proforma. informed consent was obtained from all subjects to participate in the study. patient condentiality was maintained. inclusion criteria: 1) inpatients having organophosphorus poisoning, aluminium phosphide, zinc phosphide, chemicals and drugs. 2) inpatients age more than 18 years. exclusion criteria: all cases with food poisoning and allergic reactions to drugs. results: with 60 cases study most common poison is organopho sphorus 31.7% with intentional ingestion 95.0% highest among age group 31-40 years with female predominance 75.0% and most commonly seen in married 78.3% and are housewives 43.3%.majority of patients were educated less ththan 12 class 65% and those who belong to upper middle class 31.7% were highest. table 1: age group table 2: sex study of socio-demographic and clinical profile of various poisoning cases in adults at tertiary centre original research paper dr. rootik patel resident, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india general medicine background – in this study, we determined data of all poisoning cases admitted in medicine ward and intensive care unit with detailed history about nature of poison, time of consumption and circumstances of poisoning. methodthis is a cross-sectional, descriptive, observational, analytical study on the sociodemographic and clinical prole of various poisoning cases in geetanjali medical college and hospital, and udaipur.60 cases were included in the study. . resultsthe patients between ages 31-40 are highly 36.7% exposed to poisonous substance with 75.0% female predominance thwhile 25% male, 78.3% were married, 65% patients had education less than 12 class, 43.3% were housewife, organophosphorus is most common 31.7% and upper middle class patients were highest 31.7%. conclusionthis study found that organophosphorus was the leading cause of acute poisoning .most common mode was intentional. majority patients belong to upper middle socioeconomic class with predominance in age 31-40years more common in females who are married and are housewives abstract keywords : organophosphorus, poison volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. j. s. jhala* associate professor, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india *corresponding author frequency percent age group (years) 31-40 22 36.7 21-30 17 28.3 <20 10 16.7 41-50 10 16.7 51-60 1 1.7 total 60 100.0 frequency percent sex female 45 75.0 male 15 25.0 total 60 100.0 38 x gjra global journal for research analysis table 3: marital status table 5: occupation table 6: socioeconomic status table 7: poisonous substance discussion: in the current study, it was found that the majority of the patients belonged to 31-40 years age group. however, in contrast to the current study vaiday et al., (2012) found that majority of the patients were aged in 21-30 years of age group. the study showed female predominance. contrastingly, in the study of vaidya et al., (2012) the male patients outnumbered the female patients. in the current study majority of the patients were married. however, according to the study of reddy et al., (2018) there was not much difference between the married and unmarried patients. in the current study, it was found that the majority of patients belonged to upper middle socio-economic class. in contrast to the current results, reddy et al. (2018) found that the majority of patients belonged to upper lower socio-economic the current, it was found that the most common poisoning substance was organophosphorus. similarly, the study of vaidya et al., (2012) found the organophosphorus was the most common type of poisoning substance. conclusion it was found in the current study that organophosphorus was the leading cause of acute poisoning. the most common mode of poisoning was intentional. majority of the patients in the current study belonged to upper middle socio-economic class which claried the reason of suicidal tendencies among the study population. the study also depicted that more number of married females consumed poisonous substances. the study also depicted that more number of married females consumed poisonous substances. increasing incidence of mortality due to poisoning (either suicidal or accidental) makes it necessary to take some measures, to reduce the same. references: 1. muhammad ni, nasimul i. retrospective study of 273 deaths due to poisoning at sir salimullah medical college from 1988 to 1997. leg med. 2003; 5:s12931. 2. ahuja h, mathai as, pannu a, arora r. acute poisonings admitted to a tertiary level intensive care unit in northern india: patient prole and outcomes. j clin diagn res 2015; 9:uc01-4. 3. jeyaratnam j (1990) acute pesticide poisoning: a major global health problem. world health stat q 43: 139-144. 4. eddleston m, phillips mr (2004) self-poisoning with pesticides. bmj 328: 4244. 5. bhandari r. bhandari r. gupta pr. trend and outcome of acute poisoning case: an experience from emergency department of eastern nepal. int j community med public health. 2018; 5(1):66-71. 6. cairans fj, koelmeyer td, smeeton wm. deaths from drugs and poisons. n z med j. 1982; 96:1045–8. 7. asawari r. pawar a. kakane b. dave p. shaj k. gulam aj. toxicological pattern of poisoning in urban hospitals of western india. j young pharm, 2017; 9(3):315-320. 8. rajbanshi lk. ariyal b. mandal r. clinical prole and outcome of patients with acute poisoning admitted in intensive care unit of tertiary care center in eastern nepal. indian j crit care med. 2018; 22(10): 691–696. 9. gagandeepa s, dheeraj k. neurology of acute organophosphate poisoning. neurol india. 2009; 57:119–25. 10. vaidya yp, hulke sm. study of trends of poisoning in the cases reported to government hospital, yavatmal. chron young sci. 2012; 3:63-7 11. kanchan t, menezes rg. suicidal poisoning in southern india: gender differences. j forensic leg med. 2008; 15:7-14. 12. harish d, chavali kh, singh a, kumar a. recent advances in the management of poisoning cases. j indian acad forensic med 2011; 33:74-9. 13. srinivasa k. yadukul s. madyastha m. study of prole of poisoning cases reported to district hospital, chamarajanagar, karnataka, india. international journal of basic & clinical pharmacology. 2016; 5(4):1215-19. 14. kanchan t, menezes rg. suicidal poisoning in southern india: gender differences. j forensic leg med. 2008; 15:7-14. 15. prakruti pk. bengaluru records second-highest rate of suicide in the country. bangalore mirror bureau; 2015. 16. prajapati t, prajapati k, tandon r, merchant s. acute chemical and pharmaceutical poisoning cases treated in civil hospital, ahmedabad: one year study. asia pac j med toxicol 2013; 2:63-7. 17. reddy s. revathi d. prassanna lv. ramesh ac. sociodemographic prole of patients with acute poisoning in the 10(6):50-56. 18. nimal s, laxman k. pattern of acute poisoning in a medical unit in central srilanka. forensic sci int. 1988; 36:101-4. 19. maheswari e, abraham l, chacko cs, saraswathy gr, ramesh ac. assessment of pattern, severity and outcome of poisoning in the emergency care unit. j appl pharm sci 2016; 6:178-83. 20. singh o, javeri y, juneja d, gupta m, singh g, dang r. prole and outcome of patients with acute toxicity admitted in intensive care unit: experiences from a major corporate hospital in urban india. indian j anaesth 2011; 55:370-4. 21. tendon sk, qureshi gu, pandey dn, aggarwal a. a prole of poisoning cases admitted in s.n. medical college and hospital, agra. j forensic med toxicol. 1996; 13:10-2. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra frequency percent marital status married 47 78.3 unmarried 13 21.7 total 60 100.0 frequency percent occupation housewife 26 43.3 student 16 26.7 farmer 11 18.3 worker 7 11.7 total 60 100.0 frequency percent socioeconomic status upper middle 19 31.7 lower 18 30.0 upper lower 16 26.7 lower middle 7 11.7 total 60 100.0 frequency percent name of poisonous substance celphos poison 18 30.0 organophosphorus 19 31.7 phenyl 6 10.0 dolo 3 5.0 insecticide 3 5.0 laxman rekha 3 5.0 alprax 2 3.3 clonotril 2 3.3 crocin 1 1.7 lobivon 1 1.7 metocard xl 1 1.7 prolomet xl 1 1.7 total 60 100.0 x 39gjra global journal for research analysis introduction introduction of composite restorative materials in the 1960s marked the beginning of modern cosmetic dentistry by combining the principles of esthetics and tooth conservation. smooth, highly polished restorations are more esthetically appealing and less susceptible to plaque accumulation and extrinsic discoloration and they also exhibit improved mechanical properties.1 early studies have shown that the smoothest surface of a resin restoration is attained when the resin is polymerized against an appropriate matrix strip. when a matrix is not used, polymerization of outer layer is inhibited, resulting in a surface layer rich in organic binder with stick and soft consistency. in either case, removal of that outermost resin by trimming and nishing procedures would lead to producing a harder, more wear resistant, and, hence, a more aesthetically stable surface.2 the primary goal of nishing is to obtain a restoration with good contour, occlusion, healthy embrasure forms and a smooth surface. tight margins of the restorations should blend aesthetically into the tooth's natural contours.2 the resin matrix and the ller particles of composite resins do not abrade to the same degree due to different hardnesses. for instance, craters are often formed around hard quartz particles of conventional composite resins after polishing. as consequence, irregularities appear on the surface of the restorations. the ller content of the composite resin also affects roughness, as microlled composite resins show smoother surfaces than hybrid composite resins. similarly, the resin matrix composition may also play a role in the nal smoothness of the restoration.3the nishing and polishing procedure involves some fundamental principles that allow us to better understand its application in dentistry.4 a variety of instruments are commonly used for nishing and polishing tooth-colored restorative materials including; carbide and diamond nishing burs, abrasive impregnated rigid points, impregnated rubber cups and points, aluminium oxide coated abrasive discs, abrasive strips, and polishing pastes.5 each of these instruments or devices remove the oxygen inhibited layer of resin but leave the surface of restorative materials with varying degrees of surface roughness. thus it is important to understand which type of surface-nishing treatments would signicantly affect the surface irregularities of different composite resin restorations. the present study evaluated the effect of various nishing and polishing procedures on the surface roughness of nanolled composite and the effectiveness of surface sealant application after nishing and polishing procedure of tested composite. material and method the resin composites used in this study were z 350(nanolled) of shade a3,60 cylindrical blocks of lightcured resin composite, 6mm in diameter and 3mm in depth, were prepared in a stainless steel mould. the stainless steel mould was placed on a glass slab and the composite was inserted in each cavity in a single increment using a resin packing plastic instrument. flash was removed and material was nished ush with the top of the mold surface. a mylar strip & glass slide was placed on the mould and the specimen discs were light cured from both the sides for 40seconds as instructed using a quartz-tungsten-halogen (qth) unit. the tip of the curing light was placed on the glass slide perpendicular to the specimen surface to standardize the distance between the light source and the specimen. all specimens were stored in distilled water at 370c for 24 hours in an incubator (incubator (dbk bod, model dtc 96, innovative bacteriological incubator). the 60 samples of composite resin were then randomly divided into 3 subgroups, as listed in . a mylar strip group of 20 specimens of both the materials received no polishing treatment after being cured. the remaining 40 specimens were surfaced with a diamond nishing bur in a rotary motion, for 15 seconds with water coolant, to simulate initial nishing of the restorative material. the three nishing and polishing system used in this study were shofu nishing and polishing kit, sof-lex composite nishing and polishing kit (3m), mylar strips (unident). shows the complete description of these systems. 20 samples of each of the two composite resins were nished and polished with the sof-lex system and shofu polishing system as specied by the manufacturer. to measure the surface roughness of the specimens a prolometer was used. three measurements in different directions were recorded for the ten effect of three finishing and polishing systems on the surface of nanofilled composite resin. a novel research approach original research paper dr. konark b.d.s(hons), m.d.s, senior lecturer, department of conservative dentistry and endodontics, patna dental college and hospital. x 101gjra global journal for research analysis dentistry background: the aims of this study were to evaluate the effectiveness of three nishing and polishing systems on the surface of nanolled composite, and to evaluate the effect of the surface sealant application (prime & bond) on the surface roughness after nishing and polishing procedures of tested composite. material and method: a total of 60 composite discs of dimension 6 x 3 mm (6mm in diameter x 3mm in thickness) were made using a custom made stainless steel mould and then randomly divided into 3 subgroups for nishing and polishing by three different methods; sof-lex, shofu and mylar strip. the average surface roughness (ra, �m) of all specimens was measured with aprolometer. a surface sealant was then applied to all the treated specimens, according to manufacturer's instructions and the average roughness was measured again. result: statistically signicant difference was observed in surface roughness values before and after sealant application when nished and polished with shofu system. the lowest roughness values, before and after sealant application, was obtained when cured under a mylar strip and the highest values were obtained when treated with shofu. conclusion: the mylar strips gave lowest ra values followed by sof-lex followed by shofu and the surface sealant improved the surface texture of tested specimens drastically. abstract keywords : nanolled composite; mylar strips; sof-lex and shofu nishing and polishing system. dr. anju singh* b.d.s, m.d.s, assistant professor, department of dentistry, nalanda medical college and hospital. *corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 102 x gjra global journal for research analysis specimens in each group, the mean ra value was determined for each specimen, and mean ra for each group then was determined. then surface sealant (prime & bond) was applied to all treated specimens and the average roughness (ra) was measured. the results were analyzed statistically by anova f, paired and unpaired 't' test. result the surface roughness values of the tested composite nished and polished with three different systems before and after sealant application have been mentioned. statistically signicant difference was observed in surface roughness values before and after sealant application when nished and polished with shofu system. the lowest roughness values, before and after sealant application, was obtained when cured under a mylar strip and the highest values were obtained when treated with shofu. with anova f, comparing ra values with different nishing and polishing systems for z350. the difference is statistically signicant before (p value 0.04) and even after (p value 0.005) sealant application. discussion many signicant advances have been made since then with regards to improving the properties of earlier resin based restorative materials. these resin materials have progressed from macrolls to microlls and from hybrid to microhybrids, and new materials such as packable and nanolled composites have been introduced to the dental market. each type of composite resin has certain advantages and limitations.6 nanolled composite have been produced with nanolled technology and formulated with nanomerand nanocluster ller particles. this combination reduces the interstitial spacing of ller particles and, therefore, provides increased ller loading, better physical properties and superior polish and gloss retention.2 the mechanism in mechanical nishing and polishing using abrasive particles are part of triobiology, the discipline associated with material science, physics, chemistry and surface engineering. finishing in dentistry refers to the steps of gross contouring of the restoration to obtain desired anatomy while polishing refers to the reduction and smoothening of the surface roughness and scratches created by the nishing instruments in the process of gross reduction and initial polishing.4 dentists have always been encouraged to take time and effort to adequately nish and polish restorations. the clinical and scientic reasons for careful nishing and polishing have been to remove excess ash and rene the margins of the restoration, to reduce the risk of fracture, since a rough surface may be more likely to fracture, to reduce surface imperfections, hence reducing surface area and thus reducing the risk of surface breakdown and corrosion. the other reasons are to produce a smooth surface less likely to retain plaque, to improve oral function of mastication since food slides more easily over polished tooth surfaces, to produce smooth surfaces that facilitate oral hygiene procedures with access to all surfaces, marginal areas and interproximal areas through normal tooth brushing and use of dental oss, to produce smooth restoration contacts leading to less wear on opposing and adjacent teeth and to produce a more aesthetic restoration for the patient.4 it has been reported that the colour measuring geometry inuenced the colour measurement of composite resins with different surface roughness. if the surface conguration has a matte nish there would be an excessive amount of light reected at the surface level and a reduction of light transmission through the material. surface texture controls the degree or scattering or the reection of the light striking on the natural tooth or restorative material. for this reason clinicians experience problems in establishing harmony of the shade, obtained with the original shade that was selected using a shade guide especially after nishing and polishing procedures.3 all abrasive nishing and polishing devices fall into one of three categories as coated abrasive, bonded abrasive or loose abrasives. a fourth classication includes cutting instruments such as uted or multiuted tungsten carbide nishing burs. coated abrasive are nishing devices usually in the form of a paper, mylar strip or some other polymeric backing, wherein the abrasive particles are distributed on the surface of backing or some other symmetric matrix design. aluminum oxide constitutes the most commonly used abrasives compound on coated abrasives discs with silicon carbide. bonded abrasives are devices in which the abrasive particles or media are uniformly dispersed throughout the device matrix. the device is usually an elastomeric material such as rubber or silicone compound but can also be rigid or nonelastic in nature. the last groups classied under abrasive devices are loose abrasives. with respect to use in dentistry loose abrasive polishing pastes contain a ne particle size distribution of either aluminium oxide or diamond particles dispersed in a water soluble vehicle such as glycerine.4 various motions may be critical to the development of optimal surface smoothness. a rotary motion, a planar motion and a reciprocating motion can be employed to polish the surface of resin based material. in rotary motion the axis of rotation is parallel to the surface being smoothened. the planar motion is a rotational movement with the axis of the rotation of the abrasive device perpendicular to the surface being smoothened. reciprocating motion is employed when a nishing strip is pulled back and forth over a surface. the results obtained by fruit and others (1996) comparing different polishing motions showed that for all possible combination of the materials and abrasive grits, the planar motion achieved the lowest average roughness values.7 in our study, the specimens polished with planar motion (sof-lex disks) gave lower surface roughness values than the specimens polished with rotary motion (shofu). several studies stated that the large particles embedded in sof-lex disks tend to rip through the surface of resin composite and, when used with certain hybrid composites, tend to cut and abrade ller particles and resin matrix equally, resulting in a smooth surface.7 for a composite nishing system to be effective the cutting particles (abrasive) must be relatively harder than the ller materials, otherwise the polishing agent will only remove a soft resin matrix and leave the ller particles protruding from the surface. the hardness of aluminium oxide is signicantly higher than silicon dioxide, and generally, higher than most ller materials used in composite formulations.5the trend of soflex discs is to provide a slightly smoother surface with the aluminium oxide abrasive on rigid matrix as this has the ability to atten the ller particles and abrade the softer resin matrix at an equal rate. in the literature, the most common methods used to assess the effectiveness of nishing and polishing instruments include: visual evaluation, scanning electron microscopy and prolometric analysis. we used prolometric analysis to evaluate the surface nish of different composites with different polishing systems. there are two advantages with the mechanical prolometer method used in our study. first the prolometer gives a quantitative aspect through the calculation of (ra) which cannot be obtained with sem, and secondly, it enables the sample surface to be studied more precisely, as the stylus sweeps the sample surface detecting tiny variation.3 in this and other studies mylar strips formed the smoothest surface in all the composite groups tested. the surface obtained with a mylar strip is perfectly smooth and it is rich in resin organic binder. therefore removal of outermost resin by nishing-polishing procedures would tend to produce a harder more wear resistant layer hence an aesthetically stable surface.4 despite volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra careful placement of matrices, removal of excess material and recontouring of restorations is often clinically necessary. this requires some degree of nishing and polishing that will violate the smoothness obtained with a matrix.1-5,8 however even after accomplishing appropriate nishing and polishing technique the surface of all resin composites exhibit micro irregularities that inherently lead to material wear, deterioration and marginal inltration resulting mainly from the abrasive processes to which the restoration is subjected in the oral environment. in an attempt to overcome this problem, using a thin layer of low viscosity resin over polymerized composite restoration has been investigated. this approach is assumed to provide a more uniform, regular surface, thereby, enhancing surface smoothness. although the properties of the latest resin composites have been optimized, indeed, there is still lack of study reporting whether or not the surface integrity of these materials may be enhanced by the use of low viscosity surface sealant. a sufcient ly lowviscosi ty res in agent wi th proper characteristics and formulation, even though not specically developed for such purpose, could be successfully used as a surface sealant. various studies have suggested coating polymerized resin composite with adhesive agent or ssure sealant.9rebonding of composite restoration with unlled resin has been recommended for penetration of the subsurface microcracks and interfacial gaps generated during nishing and polishing procedures.10 in our study surface sealing with prime and bond (dentsply), had a positive effect on surface roughness. the results of this study are in accordance with the results of studies by cyg takuchi, ehg lara, 20039 and nuray attar 2007.2 conclusion the nanocomposite resin tested in this study (z350), mylar strip provided the smoothest surfaces followed by sof-lex followed by shofu. references 1. türkün ls, türkün m. the effect of one-step polishing system on the surface roughness of three esthetic resin composite materials. oper dent 2004;29(2):203-11. 2. endo t, finger wj, kanehira m, utterodt a, komatsu m. surface texture and roughness of polished nanolled and nanohybrid resin composites. dent mater j 2010 mar;29(2):213-23. 3. sarac d, sarac ys, kulunk s, ural c, kulunk t. the effect of polishing techniques on the surface roughness and color change of composite resins. j prosthet dent 2006;96(1):33-40. 4. jefferies sr. abrasive nishing and polishing in restorative dentistry: a stateof-the-art review. dent clin north am 2007;51(2):379-97. 5. ruyter ie. composites characterization of composite lling materials: reactor response. adv dent res 1988;2(1):122-9. 6. attar n. the effect of nishing and polishing procedures on the surface roughness of composite resin materials. j contemp dent pract 2007;8(1):27-35 7. lu h, roeder lb, powers jm. effect of polishing systems on the surface roughness of microhybrid composites. j esthet restor dent. 2003;15(5):297303. 8. uctasli mb, arisu hd, omurlu h, eliguzeloglu e, ozcan s, ergun g. the effect of different nishing and polishing systems on the surface roughness of different composite restorative materials. j contemp dent pract 2007;8(2):89-96. 9. neme al, frazier kb, roeder lb, debner tl. al neme, kb frazier, lb roeder, tl debner. effect of prophylactic polishing protocols on the surface roughness of esthetic restorative materials. oper dent 2002;27(1):50-8. 10. hoelscher dc, neme am, pink fe, hughes pj. the effect of three nishing systems on four esthetic restorative materials. operative dentistry, 1998,23,36-42. oper dent 1998;23(1):36-42. x 103gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra aims and objectives: to study the variation in the size of corpus callosum with advancing age. introduction: the corpus callosum is a prominent body of white matter that connects the two cerebral hemispheres in a homotropic manner with reference to cortex. corpus callosum is readily 1visualised on mri .the midsagittal section of corpus callosum on mri can be used to measure its dimensions in different subregions & this procedure can be employed to estimate normative ageing process. most cross-sectional mri studies proves corpus callosum to be a relatively immune to age(2-7) related shrinkage upto seventh decade of life on the , (8-11)contrary, some studies have shown senescent effects. material and methods this study was carried out in deptt of anatomy, surgery and radiology at dr.rkgmc, hamirpur and dr.rpgmc, tanda. a total of 100 healthy individuals aged between 20-60 years were included in the study and their dimensions of corpus callosum and its subregions on mri scans were noted. individuals were further subdivided into 4 age groups i.e. 2029 years, 30-39 years, 40-49 years and 50-59 years for comparasion. the following sets of measurements were taken 1. length of corpus callosum (lc). 2. thickness of body of corpus callosum at mid point (t). 3. maximum thickness of rostrum (tr). 4. maximum thickness of splenium (ts). 5. height of corpus callosum (hc). 6. maximum and minimum thickness of body of corpus callosum (tmax and tmi). 7. maximum thickness of anterior half of corpus callosum body (tba). 8. maximum thickness of posterior half of corpus callosum body (tbp). 9. genu-fornix length (g-f): distance between anterior edge of genu to anterior edge of columns of fornix. 10. genu-anterior commisure length (g-c): distance between anterior edge of genu to anterior edge of anterior commissure. 11. shortest distance from anterior most point of corpus callosum to cortical surface (a-s) 12. shortest distance from top most point of corpus callosum to cortical surface (t-s). 13. shortest distance from posterior most point of corpus callosum to cortical surface (p-s). 14. length of brain (lb): from frontal pole to occipital pole of brain in midsagittal section. 15. distance from frontal pole of brain to anterior most point of corpus callosum (f-a). 16. distance from occipital pole of brain to posterior most point of corpus callosum (o-p). ratios 17. length of corpus callosum /length of brain (lc/lb). 18. splenial thickness /length of corpus callosum (ts/lc). 19. splenial thickness /length of brain (ts/lb). 20. thickness of body at mid point/length of corpus callosum (t/lc). 21. thickness of body at mid point/height of corpus callosum (t/hc). fig.1.measurment of callosum (midsagittal mri) lc: length of corpus callosum hc: height of corpus callosum age related changes in corpus callosum original research paper kavita nanda assistant professor, department of anatomy, dr. rkgmc hamirpur (h.p.) x 69gjra global journal for research analysis anatomy introduction:this quantitative mri study done on 100 healthy adult individuals between 20-60 years of age reports measurement of different dimensions of corpus callosum and any changes in the dimensions with ageing. methods: mri of corpus callosum of adult healthy individuals aged between 20-60 years were done and morphometric measurements of different parameters i.e. length, width, height and subregions of corpus callosum were noted and compared. results: in our study it was found that1. thickness of splenium, thickness of posterior part of corpus callosum & shortest distance from posterior most point of corpus callosum to cortical surface (p-s) increased with age. 2. length of corpus callosum, length of corpus callosum/length of brain increased upto 39 years and thereafter declined. 3. height of corpus callosum, thickness of body at mid-point, maximum thickness of the body and minimum thickness started to decrease after 50 years. conclusion: the results of this study indicate that ageing effects are more pronounced in genu and anterior part of corpus callosum. abstract keywords : corpus callosum, mri, normal ageing anupam nanda* assistant professor, department of surgery, dr. rkgmc, hamirpur(h.p.) *corresponding author vishal kalia assistant professor, department of anatomy, dr rpgmc, tanda (h.p.) volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 70 x gjra global journal for research analysis fig. 2: measurment of corpus callosum (midsagittal mri) a-s: shortest distance from anterior most point of corpus callosum to cortical surface f-a: distance from frontal pole of brain to anterior most point of corpus callosum t-s: shortest distance from top most point of corpus callosum to cortical surface tmi: minimum thickness of body of corpus callosum p-s: shortest distance from posterior most point of corpus callosum to cortical surface o-p: distance from occipital pole of brain to posterior most point of corpus callosum. fig. 3: measurment of corpus callosum (midsagittal mri) g-f: genu-fornix length g-c: genu-anterior commisure length t: thickness of body of corpus callosum at mid point ts: maximum thickness of splenium fig. 4: measurment of corpus callosum (midsag ittal mri) tba: maximum thickness of anterior half of corpus callosum body tr: maximum thickness of rostrum tbp: maximum thickness of posterior half of corpus callosum body statistical analysispost-hoc test, a variant of anova test was used to do the comparasion between these age groups. anofa was applied to do comparison amongst all groups. results in our study following results were observed: 1. ts, p-s and tp increased with increase in age. 2. hc and thickness of anterior part of corpus callosum(tba) declined after 50 years of age. 3. length of corpus callosum(lc) decreased steadily after 40 years of age. 4. mean difference of tba between age groups 40-49 years and 50-60 years was 0.17143± 0.058 which was statistically signicant with a 'p' value of 0.020. 5. mean difference of tp between 40-49 yrs and 50-60 yrs was 0.1560±0.05572 which was statistically signicant with a 'p' value of 0.031. 6. mean difference of g-f between age groups 20-29 yrs and 50-60 yrs was -0.44033 with a 'p' value of 0.006 which was statistically signicant. 7. mean difference of p-s between age groups 20-29 yr and 40-49 yr was -0.33548± 0.11616 with a 'p' value of 0 .024 which was statistically signicant. 8. mean difference of p-s between age groups 20-29 years and 50-60 years was -0.38300±0.14764 with a 'p' value of 0.053 which was statistically signicant. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra comparison between various age-groups cc para meter 20-29 (n= 30) 30-39 (n= 20) 40-49 (n= 35) 50-60 (n= 15) f; p value mean s.d. mean s.d. mean s.d. mean s.d. lc 7.039 0.5667 7.3085 0.4930 7.0977 0.4909 7.012 0.6042 1.279; 0.286 hc 2.310 0.6649 2.4235 0.6248 2.5566 0.6540 2.442 0.5297 0.817; 0.488 t 0.6043 0.1359 0.601 0.1451 0.6723 0.1582 0.6227 0.1102 1.636; 0.186 tmax 0.8227 0.1409 0.811 0.1609 0.894 0.1855 0.7433 0.0789 **3.629; 0.016 tmi 0.4197 0.0862 0.4705 0.1298 0.4869 0.1091 0.4587 0.0472 2.510; 0.063 -'[tr 3.5273 0.2687 1.078 0.1671 1.0823 0.2170 1.1013 0.2043 0.712; 0.547 ts 1.087 0.1851 1.095 0.1914 1.0991 0.1975 1.128 0.2169 0.150; 0.929 tba 0.7903 0.1671 0.7305 0.1243 0.8394 0.2496 0.668 0.1121 **3.420; 0.020 tp 0.7193 0.1307 0.7195 0.2286 0.806 0.2133 0.65 0.0821 **3.018; 0.034 g-f 2.4317 0.4122 2.665 0.3565 2.5563 0.4628 2.872 0.3403 **4.130; 0.008 g-c 2.6683 0.3252 2.8275 0.2345 2.7331 0.3164 2.7293 0.2774 1.133; 0.340 a-s 3.3157 0.3366 3.464 0.4157 3.3214 0.3393 3.2953 0.2347 1.039; 0.379 p-s 4.1757 0.3602 4.4185 0.5137 4.5111 0.4707 4.5587 0.5742 **3.558; 0.017 t-s 3.568 0.3470 3.7505 0.5660 3.7246 0.4395 3.5273 0.2687 1.535; 0.210 lb 15.4223 0.7792 15.8365 0.8177 15.5151 0.9041 15.768 1.1277 1.151; 0.333 f-a 3.5107 0.3679 3.436 0.4278 3.5426 0.4055 3.4793 0.4894 0.303; 0.823 o-p 5.3643 0.5763 5.535 0.6627 5.6486 0.5358 5.552 0.6234 **1.275; .0287 lc/lb 0.4567 0.0331 0.4614 0.0181 0.4583 0.0338 0.4454 0.0345 0.836; 0.477 ts/lc 0.1543 0.0222 0.1497 0.0230 0.1546 0.0239 0.1626 0.0391 0.705; 0.551 ts/lb 0.0706 0.0122 0.0691 0.0114 0.0710 0.0129 0.0718 0.0144 0.148; 0.931 t/lc 0.0862 0.0197 0.0820 0.0184 0.0950 0.0224 0.0899 0.0210 1.949; 0.127 t/hc 0.2796 0.0942 0.2530 0.0474 0.2737 0.0765 0.2639 0.0662 0.548; 0.651 discussionresults of different studies done on the size changes of coprus callosal with ageing are equivocal. studies conducted by (6) (12) (5)pffefferbaum et al , pozzilli et al johnson sc et al concluded that age related thinning of copus callosum is (13) (9)modest whereas sullivan et al , weis et al and (8)doraiswamy et al reported statistically signicant changes. (11) (9)salat d et al and weis et al reported greater vulnerability in size changes with advancing age in anterior than posterior regions of corpus callosum that is similar to our ndings. weis (9) et al reported signicant decrease in size of genu and anterior part of trunk of copus callosum with age suggesting alteration in frontal and temporal interhemispheric bre system. corpus callosum is located adjacent and superior to lateral ventricle, these changes may be attributed to (11,13)expansion of lateral ventricle in elderly. decrease in corpus callosal size may reect histological changes in cerebrum, such as the loss of synaptic connections and callosal collaterals. (14)study conducted by mori et al in 2005 concluded that mr diffusion tensor imaging(dti) enables examination of white matter tracts and markers of white matter microstuctural integrity at macroscopic resolution in living human beings by (15)measuring water diffusion. assaf and pasternak in 2008 conclude that fractional anisometry (fa) and diffusivity (d) are useful in measuring microstuctural integrity. advanced age is associated with increased occurrence of (16,17)myelin sheath deformations fewer small-diameter (18,19)myelinated bers expanded extra-axonal spaces, and loss of anterior commiussral bres, but not with axonal (20,21)degeneration . age related white matter differences like increased axonal diameter and reduced packing density could result in increased diffusitivity and reduced fa. altough (22,23)myelin inuences both fa and rd these indices are poor (24,25,26,27proxies for local myelin content ). axonal diameter, independent of myelination, appears the strongest (24) anatomical correlate of ad . (28)in 2007, sullivan and pfeefferbaum found that advancing age is associated with reduction in fa on dti studies. study (29) conducted by o'sullivan et al in 2001 concluded that integrity of corpus callosal white matter reduces with advancing age which is usually greater in anterior compared (30) to posterior brain regions. study conducted by bastin et al supported the “frontal aging hypothesis” as there was signicant positive correlation between mean diffusivity (d) and age in genu and negative correlation between fa and age in splenium. these results are similar to our nding where thinning of anterior part of corpus callosum was observed after 50 years of age. some changes in shape of splenium were mediated by age related global brain atrophy and (31) ventricular enlargenment. in 2016, vanessa et al found age related metabolic and microstructural vulnerability of splenium as there was decrease in n-acetylaspartate and t2 and increase in t2'with advancing age. on the contrary, in our study it was found that splenium thickness increased with age (32) upto 60 years. in contrary study conducted by bender et al in 2015 observed no signicant differences in size change for genu or splenium with advancing age. conclusion the results of this study indicate more pronounced ageing effects in genu and anterior part of corpus callosum with advancing age. references 1. pandya dn, seltzer b. the topography of commissural bres. in: lepore f, ptito m, jasper hh, eds. two hemispheres-one brain: functions of corpus callosum. new york: alan r. liss, inc, 1986: 47-74 2. beigon a, eberling jl, richardson bc, roos ms, wong sts, reed br, jagust wj. human corpus callosum in aging and alzhiemer’s disease: a magnetic resonance imaging study. neurobiol aging 1994;15: 393-397 3. cowell pe, allen ls, zalatimo ns. a developmental study of sex and age interactions in human corpus callosum. dev brain res 1992; 66: 187-92 4. dreisen nr, raz n. the inuence of sex, age and handedness on corpus callosum morphology: a meta analysis. psychobiol 1995; 23: 240-47 5. johnson sc, farnworth t, pinkston jb, bigler ed, blatter dd. corpus callosum surface area across the human adult life span: effect of age and gender. brain res bull 1994; 35: 373-77 6. pfefferbaum a, lim ko, desmond j, sullivan ev. thinning of corpus callosum in older alcoholic men: a magnetic resonance imaging study. alcohol clin exp res 1996; 20: 752-57 7. thompson p, narr kl, blanton re, toga aw. mapping structural alterations of the corpus callosum. during brain development and degeneration. in : zaudel e, tacoboni m.eds. proceedings of the nato asi on the corpus callosum. new york: kluwer academic press 2000, in press. 8. doraiswamy pm, figiel gs, husain mm. aging of the human corpus callosum magnetic resonance imaging in normal volunteers. j neuropsychiatr clin neurosci 1991; 3: 392-97 9. weis s, kimbacher m, wenger e, neuhold a. morphometric analysis of corpus callosum using mr: correlation of measurement with aging in healthy individuals. amer j neuroradiol 1993; 14: 637-45 10. davatzikos c, resnick sm. sex differences in anatomic measures of interhemispheric connectivity: correlation with cognition in women but not men. cerebral cortex 1998; 8: 635-40 11. salat d, ward a, kaye ia, janowsky js. sex differences in the corpus callosum with ageing. neurobiology of ageing 1997; 18: 191-97 12. pozzilli c, bastimello s, bozzao a, pierallini a, guibilei f, angentino c et al. no differences in corpus callosum size by sex and aging. a quantitative study using magnetic resonance imaging. j neuroimaging 1994; 4(4): 218-221 13. sullivan ev, pfefferbaum a, adalsteinsson e, swan ge, carmelli d. differential rates of regional brain change in callosal and ventricular size: a four year longitudinal mri study of elderly men. oxford university press, 2002: 438-45 14. mori s, wakana s, nagae pz, zijil v, pcm. mri atlas of human white matter. amsterdam:elsevier, 2005 15. assaf y, pasternak o. diffusion tensor imaging(dti)based white matter mapping in bra in research : a rev iew journal o f molecular neuroscience:hn.2008; 34(1): 51-61 16. bowley mp, cabral h, rosene dl, peters a. age changes in myelinated nerve bres of the cingulate bundle and corpus callosum in the rhesus monkey. the journal of comparative neurology. 2010; 518(15): 3046-3064 17. peters a. the effects of normal aging on myelin and nerve bres: a review. j neurocyst.2002; 31: 581-593 18. marner l, nyengaard jr, tang y, pakkenberg b. marked loss of myelinated nerve bres in human brain with age. the journal of comparative neorology.2003;462(2):144-152 19. tang y, nyengaard jr, pakkenberg b, gunderson hj. age-induced white matter changes in the human brain: a stereological investigation. neurobiol aging.1997; 18(6): 609-615 20. budde md, xie m, cross ah, song sk. axial diffusivity in the primary correlate of axonal injury in the experimental autoimmune encephalomyelitis spinal cord: a quantitative pixelwise analysis. j neurosci.2009;29(9):2805-13 21. nielson k, peters a. the effects of aging on the frequency of nerve bres in rhesus monkey striate cortex. neurobiol aging.2000;21(5):621-28 22. song sk, sun sw, ramsbottom mj, chang c, russel j, cross ah. dysmyelination revealed through mri as increased radial (but unchanged axial) diffusion of water. neuroimage. 2002; 17(3):1429-1436. 23. sun sw, liang hf, cross ah, song sk. evolving wallerian degeneration after transient retinal ischemia in mice characterized by diffusion tensor imaging. neuroimage. 2008;40(1);1-10. 24. beaulieu, c. the biological basis of diffusion anisotropy. in : johansen-berg, h.; behrens, te., editors. diffusion mri: from quantitative measurements to in vivo neuroanatomy. academic press:2012.p.106-26. 25. de santis s, drakesmith m, bells s, assaf y, jones dk. why diffusion tensor mri does well only some of the time: variance and covariance of white matter tissue microstructure attributes in the living human brain. neuroimage. 2014; 89:35-44. 26. kolind sh, laule c, vavasour im, li dkb, traboulsee al, madler b, et al. complementary information from multi-exponential t2 relaxation and diffusion tensor imaging reveals differences between multiple sclerosis lesions. neuroimage. 2008; 40(1):77-85. 27. madler b, drabycz sa, kolind sh , whittall kp, mackay al. is diffusion anisotropy an accurate monitor of myelination? correlation of multicomponent t2 relaxation and diffusion tensor anisotropy in human brain. magn reson imaging. 2008;26(7):874-888. 28. sullivan ev, pfefferbaum a. a neuroradiological characterization of normal adult aging. the british journal of radiology.2007; 80 (spec no 2): s99-s108 29. o’sullivan m, jones ok, summers pe, morris rg, williams scr, markus hs. evidence of cortical “disconnection” as a mechanism of age related cognitive decline. neurology.2001; 57(4):632-638 30. bastin me, maniega sm, ferguson kj, brown lj, wardlaw jm, mac lullich amj, clayden jd. quantifying the effects of normal aging on white matter structures using unsupervised tract shape modelling. neuroimage. 2010 may 15;51(1): 1-10 31. elyers vv, maudsley aa, bronzlik p, dellani pr, lanfermann h, ding xq. detection of normal aging effects on human brain metabolite concentrations and microstructure with whole brain mr imaging and quantitative mr imaging. am j neuroradiol. 2016 march; 37(3): 447-454 32. bender ar, raz naftali. normal-appearing cerebral white matter in healthy adults: mean change over two years and individual differences in change.neurobiol aging.2015 may;36(5):1834-1848 x 71gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 20.vamsee krishna n.cdr introduction during biomechanical preparation, pulp tissue fragments, dentinal llings, necrotic tissue, microorganisms, and intracanal irrigants may extruded from the apical foramen into the periradicular region. the extruded material causes 1periapical inammation and post operative are–ups . all preparation techniques are associated with apical extrusion of some amount of debris, which depends on various factors, including anatomy of the apical area, instrument design and 2,3 4the instrumentation technique . vandevisse and brilliant found that instrumentation with irrigant produced extrusion, whereas instrumentation without irrigant produced no 5collectible debris. martin & cunningham reported that less debris was extruded when the intracanal preparation was performed with and ultrasonic instruments. al-omari & 6dummer veried that involving a linear ling motion techniques, such as the step back techniques, create a greater portion of debris than those involving some sort of rotational motion. the rotary instruments use crown down or cervical aring type preparation that results in less apical extrusion of debris by creating a space large enough for 7 debris to be rinsed away in a coronal direction . single le system have benets such as reduced canal shaping time allowing the clinician to consume more time on cleaning the canal with more advanced irrigation techniques. the aim of this invitro study was to compare the apically extruded debris during the root canal instrumentation using hand protaper, protaper next & protaper gold rotary systems with wave one single le reciprocating system. methodology: sixty freshly extracted, single rooted mandibular incisors without caries or visible cracks were selected for the study. external surfaces of all the teeth were debrided with a hand scaler and were analyzed using the vista scan digital radiographic system in the labial and proximal directions to conrm the presence of single, straight root canals and noncomplicated root canal anatomy. a standard access cavity was prepared for all the samples & canal patency was veried with a iso size #15k le. the working length of each canal was determined by visible method i.e., size #15k le was placed at the major diameter of apical foramen and reduced by 1mm. myers and montgomery model was used in this study for the collection of apically extruded debris. an electronic balance with an accuracy of 10−5g was used to measure the preweight of the eppendorf tubes that are going to be used in the study. a hole was created on each eppendorf tube lid & each tooth was cemented upto the cej using cyanoacrylate gel. a 25-g needle was placed parallel to the tooth which helps as a drainage canula to maintain the air pressure inside and outside the eppendorf tube. then each lid with the tooth and the needle was attached to its eppendorf tube, and the eppendorf tubes were tted into stopper of the vials. these samples were then randomly divided into four groups (n=15) for instrumentation with different le systems. group1: protaper handles (dentsply maillefer, ballaigues, switzerland) were used for instrumentation according to the comparative evaluation of apical extrusion of debris during root canal preparation using four different file systems original research paper dr dattaprasad s professor & hod, department of conservative dentistry & endodontics, cks teja institute of dental sciences & research, tirupati, andhra pradesh, india. x 1gjra global journal for research analysis endodontic the success of root canal therapy is determined by proper access cavity preparation, biomechanical preparation and three dimensional obturation. microorganisms that are apically extruded during chemo-mechanical preparation causes the host to be compromised by a more number of irritants than before. the aim of this invitro study is to quantitatively evaluate the apically extruded debris during the root canal instrumentation using protaper hand, protaper next, protaper gold, wave one single le systems. 60 freshly extracted human mandibular incisors were selected and divided into four groups according to the le system used for biomechanical preparation. apical extrusion of debris was seen in all groups during the root canal preparation procedure regardless of the instrument or the preparation technique used. protaper hand le extruded greatest amount of debris whereas protaper next extrude less amount of debris when compared to that of other le systems (p< 0.05). abstract keywords : protaper next, protaper gold, wave one single file system volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr kumari h post graduate student, department of conservative dentistry & endodontics, cks teja institute of dental sciences & research, tirupati, andhra pradesh, india. dr sunil kumar c professor, department of conservative dentistry & endodontics, cks teja institute of dental sciences & research, tirupati, andhra pradesh, india. dr. n.vamsee krishna * associate professor, department of conservative dentistry & endodontics, cks teja institute of dental sciences & research, tirupati, andhra pradesh, india. *corresponding author dr sunil kumar s reader, department of conservative dentistry & endodontics, cks teja institute of dental sciences & research, tirupati, andhra pradesh, india. dr r bharathi suma senior lecturer, department of conservative dentistry & endodontics, cks teja institute of dental sciences & research, tirupati, andhra pradesh, india. 2 x gjra global journal for research analysis manufacturers instructions. shaping les (sx, s1 & s2) were used for crown down preparation and nishing les (f1 &f2) were used for apical-third preparation of the root canals. group2: protaper next (dentsply maillefer, ballaigues, switzerland) rotary les were used for instrumentation according to the manufacturers instructions. x1(17/0.04) & x2(25/0.06) rotary les were used in an endodontic motor sequentially at 300 rpm speed and torque of 4-5.2n/cm. a brushing out stroke motion was used until working length was reached. group 3: protaper gold (dentsply maillefer, ballaigues, switzerland) rotary les were used for instrumentation according to the manufacturers instructions. shaping les (sx, s1 & s2) and nishing les (f1 &f2) were sequentially used with a slightly in-and-out movement at the speed of 300 rpm & torque of 3-5n/cm until working length was reached. group 4: wave one (dentsply maillefer, ballaigues, switzerland) reciprocating le at a speed of 300 rpm and torque of 2n/cm was used for instrumentation according to the manufacturers instructions. canal preparation was done with wave one primary le of tip size iso 25 in a reciprocating slow in and out pecking motion to the full working length. during instrumentation each sample was irrigated with 9ml of distilled water using side vent endodontic needle. immediately after instrumentation, the eppendorf tubes were removed from the vial and then stored in an incubator at 70°c for 2 days to evaporate the distilled water. after that the eppendorf tubes were post weighed using the same electronic balance. three consecutive measurements were taken and the average values was recorded for each sample in each group to obtain the nal weight of tubes including the extruded debris. the dry weight of the extruded debris was calculated by subtracting the weight of the empty tube from that of the tube containing debris. results: the mean dry weights of extruded debris were analysed statistically using spss version 20.0 soft ware. multiple group comparisons were analysed by using one-way anova followed by student's t-test for pair wise comparisons at a signicant level of p<0.05. the protaper hand showed maximum amount of apical extrusion of debris among all the groups & the least amount of debris was observed in protaper next system. table 1: the mean values of amount of apically extruded debris (in mcg) sd, for all groups table2: paired samples statistics table3: paired samples correlations table 4: anova values of within group and between groups volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra protaper hand 15 0.011 0.006 0.0016 4.887 0.004 protaper next 15 0.005 0.002 0.0006 protaper gold 15 0.006 0.002 0.0006 wave one 15 0.008 0.006 0.002 mean n std. deviation std. error mean pair 1 protaper hand preweight 1.0871647 15 0.00496893 0.00128297 protaper hand post weight 1.09803500 15 0.005635932 0.001455191 pair 2 protaper next pre weight 1.0840640 15 0.00350247 0.00090433 protaper next postweight 1.0891793 15 0.00383242 0.00098953 pair 3 protaper goldpreweight 1.0875993 15 0.00327918 0.00084668 protaper gold postweight 1.0933847 15 0.00477626 0.00123322 pair 4 wave one preweight 1.0865360 15 0.00381726 0.00098561 wave one postweight 1.0944673 15 0.00420370 0.00108539 n correlation sig. pair 1 protaper hand preweight & protaper hand post weight 15 0.336 0.220 pair 2 protaper next pre weight & protaper next post weight 15 0.813 0.000 pair 3 protaper gold preweight & protaper gold post weight 15 0.921 0.000 pair 4 wave one preweight & wave one post weight 15 -0.085 0.764 sum of squares df mean square f p value between group 0.000 3 0.000 4.888 0.004 within groups 0.001 56 0.000 total 0.001 59 groups n mean std. deviation std. error f value p value table 5: post hoc tests multiple group comparisons dependent variable: values tukey hsd *. the mean difference is signicant at 0.05 level. (i) grp (j) grp mean differenc e (i-j) std. error p value 95% condence interval lower bound upper bound protaper hand protaper next 0.0057667* 0.0016571 0.005 0.001379 0.010155 protaper gold 0.0050600* 0.0016571 0.018 0.00672 0.009448 wave one 0.0029267 0.0016571 0.300 -0.001461 0.007315 protaper next protaper hand -0.0057667* 0.0016571 0.005 -0.010155 -0.001379 protaper gold -0.0007067 0.0016571 0974 -0.005095 0.003681 wave one -0.0028400 0.0016571 0.326 -0.007228 0.001548 protaper gold protaper hand -0.0050600* 0.0016571 0.018 -0.009448 -0.000672 protaper next 0.0007067 0.0016571 0.974 -0.003681 0.005095 wave one -0.0021333 0.0016571 0.575 -0.006521 0.002255 wave one protaper hand -0.0029267 0.0016571 0.300 -0.007315 0.001461 protaper next 0.0028400 0.0016571 0.326 -0.001548 0.007228 protaper gold 0.0021333 0.0016571 0.575 -0.002255 0.006521 discussion: the endodontic triad consisting of biochemical preparation, microbial control and complete obturation of the root canal space. an acute inammatory response may develop in the periradicular tissues as a result of insults from the root canal system, which can be mechanical, chemical, or microbial in 5 origin . mechanical and chemical injuries are usually associated with iatrogenic factors, such as overinstrumentation, apical extrusion of debris or irrigant, perforations, etc.,apical extrusion of contaminated debris into the periradicular tissues is one of the principal cause of mid treatment are-up and postoperative pain. passive insertion of the needle & passive irrigation with side vent needles have been shown to provide safer treatment procedure, decreasing the likelihood of considerable amounts of liquid being pushed 8periapically . furthermore, the proximity of the irrigating needle to the apex plays an important role in removing the 9,10canal debris . instrument design plays a role in apical 11extrusion of debris. tınaz et al., concluded that more debris 12was extruded with an increase in apical diameter. elmsallati showed that the short pitch design extruded less debris than 13the medium and long ones.diemer et al., compared the effect of pitch length and stated that the increasing variable pitch decreases the tendency to screw in and also reduces the helical angle which in turn reduces the apical extrusion. apart from instrument design, instrumentation technique also play a role in the apical extrusion of debris. full-sequence rotary instrumentation was associated with less debris 14extrusion compared to reciprocating single-le systems . a common nding is that push-pull instrumentation produces more apical debris than instrumentation techniques that incorporate a rotational force. this leads to the hypothesis that engine driven rotary instruments will produce less debris 12than hand ling techniques . canal preparation in a step back manner led to increased debris extrusion, in comparison to a canal instrumentation with balanced force or rotary technique. it seems that push-pull motions of les during root canal preparation cause more debris extrusion than 7,15techniques that are based on a reaming or rotational action . 6al omari and dummer instrumented 208 canals using eight different hand instrumentation techniques and found that balanced and crown down pressure less technique extruded 16the least amount of debris. ferraz and gomes observed that engine driven nickel-titanium systems were associated with less apical extrusion. apical extrusion of debris tends to be greater with hand instruments than with techniques that use rotary forces because the les may act as pistons that push irrigating solutions and debris towards the apex conversely rotary instruments may move debris along the les, which 7results in debris being expelled cervically . in the present study, extrusion of debris apically occurred independent of the type of instrument used. first protaper hand shows signicantly more debris compared to that of the reciprocating single-le followed by the full sequence rotary niti instruments (p < 0.05). protaper hand extrude more debris compared to that of rotary le. protaper hand and protaper gold rotary systems has same convex triangular 17cross-section and a variable progressive taper . engine driven rotary les contacts the apical area for lesser period of time and also rotational speed and torque is xed for rotary les. protaper hand le prepares the apical area for an extended period of time and rotational movement of the le is an operator controlled variable factor. longer pitch design and extended period of working time at the apex, extrude greater amount of debris by protaper hand system in comparison to the engine driven le systems. this long pitch design of protaper hand has been changed to variable pitch in 18case of protaper rotary les . protaper next system, which uses an offset mass of rotation are made from m-wire technology and have an off-centered rectangular cross-section. this off-centered rectangular design gives the les a snake like swaggering movement and reduces the screw effect by minimizing the contact between 19the le and dentin . waveone is the single-le niti system that work on the reciprocating action and simulate the balanced force technique, as theorized by roane and 20sabala . these les are made of m-wire under specic tensions and heat treatments at various temperatures. the waveone primary le used in this study has tip size 25 & continuously decreasing taper from its tip to its shaft (0.8, 0.65, 0.6, 0.55). in the tip region, the cross-section presents radial lands, while the middle part of the working length and near the shaft, the cross sectional design changes from a modied triangular convex cross-section with radial lands to a neutral rake angle triangular convex cross-section. this design may enhance debris transportation towards apex when used in combination with a reciprocal motion. the variable pitch utes along the length of the instrument considerably improve safety. the counterclockwise (ccw) movement of waveone le is greater than the clockwise (cw) movement. ccw movement advances the instrument, engaging and cutting the dentine. cw movement disengages the instrument from the dentine before it can lock into the canal. three reciprocating cycles complete one complete reverse rotation and the instrument gradually advances into the canal with little apical pressure required. the reciprocation movement is formed by a wider cutting edge angle and smaller release angle. while rotating in the release angle the utes will not remove debris 21but push them apically . protaper and waveone are characterized by a triangular or modied triangular crosssection resulting in a lower cutting efciency and smaller chip space. this design may enhance debris transportation toward 22the apex when used in combination with a reciprocal motion . conclusion: within the limitations of this present in vitro study, apical extrusion of debris was seen in all groups during the root canal preparation procedure regardless of the instrument or the preparation technique used. the amount of apically extruded debris was high in protaper hand followed by wave one, protaper gold and protaper next le systems respectively. references: 1. seltzer, s., & naidorf, i. j. (1985). flare-ups in endodontics: i. etiological factors. journal of endodontics, 11(11), 472-478. 2. patterson, s. m., patterson, s. s., newton, c. w., & kafrawy, a. h. (1988). the effect of an apical dentin plug in root canal preparation. journal of endodontics, 14(1), 1-6. 3. radeva, e. n., & vassileva, r. i. (2014). comparative study of apically extruded debris and irrigant after using two rotary systems (k3, race). journal of imab–annual proceeding scientic papers, 20(1), 459-463. 4. vandevisse, j. e., & brilliant, j. d. (1975). effect of irrigation on the production of extruded material at the root apex during instrumentation. journal of endodontics, 1(7), 243-246. 5. martin, h., & cunningham, w. t. (1982). the effect of endosonic and hand manipulation on the amount of root canal material extruded. oral surgery, oral medicine, oral pathology, 53(6), 611-613. 6. al-omari, m. a. o., & dummer, p. m. h. (1995). canal blockage and debris extrusion with eight preparation techniques. journal of endodontics, 21(3), 154-158. 7. fairbourn, d. r., mcwalter, g. m., & montgomery, s. (1987). the effect of four preparation techniques on the amount of apically extruded debris. journal of endodontics, 13(3), 102-108. 8. brown, d. c., moore, b. k., brown jr, c. e., & newton, c. w. (1995). an in vitro study of apical extrusion of sodium hypochlorite during endodontic canal preparation. journal of endodontics, 21(12), 587-591. 9. reddy, s. a., & hicks, m. l. (1998). apical extrusion of debris using two hand and two rotary instrumentation techniques. journal of endodontics, 24(3), 180-183. 10. hegde, m. n., & thatte, s. (2011). comparison of the amount of apical extrusion of bacteria following the use of different instrumentation techniques-an in vitro study. nitte univ j health sci, 1, 27-32. 11. tinaz, a. c., alacam, t., uzun, o., maden, m., & kayaoglu, g. (2005). the effect of disruption of apical constriction on periapical extrusion. journal of endodontics, 31(7), 533-535. 12. elmsallati, e. a., wadachi, r., & suda, h. (2009). extrusion of debris after use of rotary nickel-titanium les with different pitch: a pilot study. australian endodontic journal, 35(2), 65-69. 13. diemer, f., & calas, p. (2004). effect of pitch length on the behavior of rotary triple helix root canal instruments. journal of endodontics, 30(10), 716-718. x 3gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 14. de-deus, g., brandão, m. c., barino, b., di giorgi, k., fidel, r. a. s., & luna, a. s. (2010). assessment of apically extruded debris produced by the single-le protaper f2 technique under reciprocating movement. oral surgery, oral medicine, oral pathology, oral radiology, and endodontology, 110(3), 390394. 15. ruiz-hubard, e. e., gutmann, j. l., & wagner, m. j. (1987). a quantitative asses sment of canal debris forced periapically during root canal instrumentation using two different techniques. journal of endodontics, 13(12), 554-558. 16. ferraz, c. c. r., gomes, n. v., gomes, b. p. f. a., zaia, a. a., teixeira, f. b., & souza-filho, f. j. (2001). apical extrusion of debris and irrigants using two hand and three engine-driven instrumentation techniques. international endodontic journal, 34(5), 354-358. 17. elnaghy, a. m., & elsaka, s. e. (2016). mechanical properties of protaper gold nickel-titanium rotary instruments. international endodontic journal, 49(11), 1073-1078. 18. ghivari, s. b., kubasad, g. c., chandak, m. g., & akarte, n. r. (2011). apical extrusion of debris and irrigant using hand and rotary systems: a comparative study. journal of conservative dentistry: jcd, 14(2), 187. 19. dincer, a. n., guneser, m. b., & arslan, d. (2017). apical extrusion of debris during root canal preparation using a novel nickel-titanium le system: waveone gold. journal of conservative dentistry: jcd, 20(5), 322. 20. roane, j. b., sabala, c. l., & duncanson jr, m. g. (1985). the “balanced force” concept for instrumentation of curved canals. journal of endodontics, 11(5), 203-211. 21. vallabhaneni, s., more, g. r., & gogineni, r. (2012). single le endodontics. indian journal of dental advancements, 4(2), 822-827. 22. burklein, s., & schafer, e. (2012). apically extruded debris with reciprocating single-le and full-sequence rotary instrumentation systems. journal of endodontics, 38(6), 850-852. 4 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: india has made spectacular progress almost in all areas of life over the years since independence in 1947. however, still large sections of our people have not got their share of development in their life. atrocities, untouchability, involvement in obnoxious and inhuman practice of manual scavenging of night soil are still prevalent in the country. they are mainly the scheduled castes which includes safai karamcharis and manual scavengers. manual scavenging refers to the removal of animal or human waste/excreta (night soil) using brooms, tin plates and baskets from dry latrine and carrying it to disposal grounds some distance away. the toilets often used a container that needed to be emptied daily. according to the 2011 census, the scheduled castes population of our country is 15.82 crores which constitute 18.5% of the total population. out of these the number of manual scavengers is estimated to be around 8.76 lakhs. even after 58 years of independence, the socio-economic conditions of this group are still far below the satisfactory level, and the scavengers are still handling night soil manually. this is undoubtedly a blot on our country. a number of efforts have been made to abolish the system of manual scavenging and to ameliorate the living and working conditions of manual scavengers as well as safai karamcharis. legislation was passed in 1993 namely, the employment of manual scavengers and construction of dry latrines prohibition act, 1993 which inter-alia prohibits use of dry latrines and provides for imprisonment for one year and /or a ne up to rs.2000/on those who employ manual scavengers for cleaning dry latrines. the number of dry latrines in the country is estimated to be around 54 lakhs in urban areas and 24 lakhs in rural areas. to solve the problem of manual scavenging two specic schemes are under implementation. they are (i) integrated low cost sanitation scheme (ilcs) and (ii) national scheme for liberation and rehabilitation of scavengers (nslrs). the rst scheme provides for conversion of existing dry latrines into low cost water borne latrines and construction of new sanitary latrines. the basic aim of the scheme is to liberate the manual scavengers from the obnoxious practice of carrying night soil manually. the nslrs scheme aims at rehabilitation of liberated manual scavengers in alternative and dignied occupations after giving them necessary training and nancial assistance in the form of subsidy, margin money loan and bank loans. despite all these efforts the end result is not very encouraging. in view of this, government of india has now set a target date of 31st december, 2007 by which the obnoxious and inhuman practice of manual scavenging will have to be eradicated totally. in order to achieve this target, the planning commission has formulated a national action plan for total eradication of manual scavenging by 2007. the ministry of urban employment and poverty alleviation has been entrusted to implement the national action plan. it is hoped that the obnoxious and inhuman practice of manual scavenging will be eradicated by 31 december 2007. magnitude of the problem: nearly 80 per cent of the country's population still either defecate in open or use unsanitary bucket latrines or smelly public toilets as per one estimate. this is true even in urban areas where hardly 20 per cent of the population has access to water/ush toilets connected to a sewerage system and only 14 per cent enjoy water-borne toilets connected to septic tanks or leach pits. in rural areas a mere 3 per cent of the population has access to sanitary toilets. this lack of adequate sanitation is responsible for severe health problems. cholera, dysentery, typhoid, para-typhoid, infectious hepatitis and many other diseases can be traced to the unsanitary disposal of human excreta. lack of sanitation also has grave social consequences, the need to have 'night soil' removed has given rise to the profession of 'scavenging' or collecting it from bucket latrines, the streets and other locations. though, this practice has been banned and the indian constitution bans the segregation of those who service this profession, there are many pockets in the country where the practice continues unabated. the indian government had brought one legislation that would ensure abolishment of manual scavengingthe employment of manual scavengers and construction of dry latrines (prohibition) act, 1993. this act has been in force for more than a decade but sadly has been ineffective because of the deeply rooted caste system and caste based discrimination. statement of problem though this vile and inhumane practice was abolished by law in india in 1993, the practice is deeply entrenched in south asian societies. the inhuman practice of manual scavenging still continuous in india. the government in the past has missed the deadline for complete eradication of manual scavenging three times and the latest decline is march 31, 2010. the issue of manual scavengers has emerged in the planning commission documents since the 9th five year plan but after two year plans gone by and the third one in this mid term, the cause of these people are yet to be addressed. there were approximately 3.47 lakh manual scavengers in india in 2006, according to government records, which needed to be rehabilitated. in 1993, the indian parliament enacted a law prohibiting employment of manual scavengers and construction of dry latrines. following it, the government introduced several schemes for rehabilitation of those who engaged in this work. though it is illegal to employ or to indulge in manual scavenging, in practice, it very much exists across the country irrespective of states performance on social and economic development parameters. the national human rights commission of india (nhrc) has termed manual scavenging as one of the worst violation of human rights and dignity. people employed in this profession suffer from acute health problems; subject to determination and are treated as a study on problems faced by manual scavengers working as temporary contract labourer's for removal of sewer obstructions in sewer system and slit removal at manholes and allied works in chennai metropolitan water supply and sewerage board, chennai, tamil nadu original research paper dr. s. sudharsan assistant professor, department of social work (aided), madras christian college x 59gjra global journal for research analysis arts keywords : mr. perumal* social worker, poineer trad, chennai* corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 60 x gjra global journal for research analysis untouchables. attempts to take them out of profession has not always met with success as it becomes difcult for them to become a part of the society and for the society at large to accept them. a large programme focusing on the upliftment and overall development of manual scavengers will only help to eradicate this blot on our society. the condition of scavengers community in tamilnadu is a matter of grave concern for the entire right thinking person world over. it is regrettably noted that the ofcial attitude of the government has not changed towards these communities. scavenger community has all along been living in the rural and urban areas serving the middle classes, upper elites, feudal lords, yet none of them ever bothered or cared for those who clean their shit, enter deep into the sewage pit to continue the sewage line. the condition of manual scavenging community is miserable. since most of the people from the community are uneducated. social evils are prevalent in the community. poverty gives birth to different things including alcoholism, wife beating gambling. need of the study: the present study attempts to analyze the problems related to manual scavenging, impacting the marginalized sections of the society and the enabling role played by the government of india. this is one of the caste based occupation in the country. the study is linked to human rights from the perspective of night soil removers. it aimed to determine the work related issues in day to day life of manual scavenger's factors because their access towards the welfare measures is restricted in the corporation of chennai. after the examination of those factors the research will a be tool to bring strategies to solve the inhuman practice. there is also need for intervention by government for the rehabilitation of the affected manual scavengers (in particular death victims). without exemption, just adequate rehabilitation needs to be carried out in a participatory manner especially with the active involvement of the most marginalized groups including scs and sts. for the rehabilitation of the manual scavengers there is a need of study in a systematic manner the social, economic and cultural conditions of the manual scavengers. general objectives: a study on problems faced by manual scavengers working as temporary contract labourer's for removal of sewer obstructions in sewer system and slit removal at manholes and allied works in chennai metropolitan water supply and sewerage board, chennai, tamil nadu specific objectives: ÿ to study the socioeconomic conditions of manual scavengers ÿ to examine the livelihood conditions and work related issues of the manual scavengers. ÿ to analyze the government measures towards manual scavengers ÿ to determine the problems of manual scavengers in physical and mental health perceptions. ÿ to elicit the rehabilitation opinion from the respondents. field of study this study was conducted in corporation of chennai in tamil nadu. the corporation of chennai (previously madras) is the oldest municipal institution in india established on the 29th september 1688. chennai is located on the coromandel coast on the northern end of the state of tamil nadu. the city stretches along the coromandel coast much of its superb sandy beach and extends inland. its irregular shape covers about 426 sq. km. the estimated present population of chennai is 6.5 million. chennai corporation is removing 50005200 mt of solid waste per day through 966 conservancy vehicles and maintaining kodungaiyur and perungudi dumping grounds for dumping the solid waste. the total birth reported in chennai city is 400 per day and death is 180 per day.chennai metropolitan water supply and sewerage board (cmwssb or metrowater) was established in 1978 under an act of tamil nadu (act 28) as a statutory body for exclusively attending to the growing needs of and for planned development and appropriate regulation of water supply and sewerage services in the chennai metropolitan area with particular reference to the protection of public health and for all matters connected therewith or incidental thereto. from 1.8.1978, the water supply and sewerage services in chennai city were taken over by the board (cmwssb) from the corporation of chennai with assets and liabilities connected with water supply and sewerage services. the assets and liabilities of ground water division of pwd, responsible for water supply to industries in manali belt were also taken over by the cmwssb.chennai metropolitan area (cma), comprising of chennai city and contiguous area around was notied in 1974. it extends over 1,189 sq. km. and includes chennai city corporation area, 16 municipalities, 20 town panchayats, 1 cantonment and 214 village panchayats spread over in 10 panchayat unions in thiruvallur and kancheepuram districts. the present chennai city corporation area is 176 sq. km. chennai (earlier called as madras) is the fourth largest metropolitan city in india situated on the shores of the bay of bengal and is the capital of tamil nadu state. chennai metropolis lies in the latitude between 12o50'49” and 13o17'24” and longitude between 79o59'53” and 80o20'12”. the land is a flat coastal plain. the topography of chennai city is extremely at with average slope of less than 0.7m per km. three rivers viz. kosathalaiyar, cooum and adyar pass through chennai metropolitan area and these rivers are placid and meander on their way to the sea (bay of bengal). buckingham canal, a man made canal is another large waterway which runs north-south through this metropolis. as per the 2011 census, the population of chennai city was 46.81 lakhs (4.681 million) and the total population in cma was 70.41 lakhs (7.041 million). the present population of chennai city as on mar'2010 is estimated as 55 lakhs (5.5 million). though the operation of cmwssb is limited to city corporation area in general, the board is also extending its services to the surrounding urban local bodies (about 7.88 sq.km. in extension areas and manali new town) and has already initiated measures to provide services for the entire chennai metropolitan area (cma) sewerage services: in early 1890, surface drains in the city were connected to pumping stations and the wastewater conveyed for disposal away from inhabitation. the proposal for comprehensive drainage scheme to cater to the needs of a topographically at, fast growing city was formulated in 1907 and works were initiated in 1910 and completed during 1914 in stages. the systems were designed for the population of 6.5 lakhs expected in 1961 at 114 lit. per capita per day of water supply. the system originally consisted of a network of force mains and brick gravity sewers served by 3 pumping stations at royapuram, purasaiwalkam and napier park and ultimately discharging wastewater into the sea at kasimedu on the northeastern boundary of the city. with the ultimate objective of improving the service delivery to the consumers, the c. m. w. s. s. board is taking every step to create a motivating environment for its employees particularly field level workers working in unhygienic conditions. the following safety equipments and accessories are provided to the workers. chennai zone sewerage field workers (i.e; manual scavengers) details: chennai metropolitan water supply and sewerage board providing 250 monthly salaried and 288 daily wage contract volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra field workers for working in depots in cmwssb for removal of sewer obstructions and silt removal at manholes by using mechanical equipments and allied for one year research design: this research is a descriptive study is aimed to describe the social, economic and cultural conditions of the manual scavengers. universe: the researcher had chosen chennai metropolitan water supply and sewerage board (cmwssb) field workers working in depots for removal of sewer obstructions in sewer system & slit removal at manholes and allied works. the allotted sewer workers for chennai zones i – xv are 250 nos. sampling method: proportionate stratied sampling. it enhanced the representatives of the sample by giving proper representation of manual scavengers in all xv areas of the chennai zone. size of the sample refers to the number of items to be chosen from the universe to form a sample size. the size of the sample must be optimum. the sample size is determined by the parameters of size of the population. considering all these facts the sample size is 50 in the total number of sewer worker allotted under chennai metropolitan water supply and sewerage board (cmwssb) will be selected for the study. tools of data collection: the researcher used structured interview schedules, participative observation schedules as tools for primary data collection. direct observation of resources, infrastructure created, and other physical structures or otherwise known as participant observation. triangulation: triangulation is the application and combination of several research methodologies in the study of the same phenomenon. sources of data: the search for answers to research questions is called collection of data. data are facts and other relevant materials, past and present, serving a bases for study and analysis. the researcher went to the eld and collected the primary data by means of face-to-face interview with the respondents. the researcher also gone through reference materials and documented data from published secondary sources like books journals, periodicals, cover letters, reports websites etc. the researcher also spent sufcient time in interacting and discussing the topic of the study with different experts in the eld. preparation of tools in consultation with the experts and professors and social workers in the particular eld, the tools for this study are prepared. pretesting: in order to nd out the applicability and validity of the tool a well prepared interview schedule was given to 4 respondents in vandalur, urapakkam, nerkundram and tiruverkadu areas. based on the pre testing on 20th january 2013 the researcher added, deleted and edited some questions on these heads. actual data collection: the data collection was done at different stages in the month of 15th february – 5th march 2013. the researcher built rapport with manual scavengers and their family members and meet the respondents directly in their eld area the data is collected conceptual definition manual scavengers: “the manual removal of human and animal excreta using brooms, small tin plates, and baskets carried on the head. the allocation of labour on the basis of caste is one of the fundamental tenets of the hindu caste system. within this system dalits have been assigned tasks and occupations which are deemed ritually polluting by other caste communities such as sweeping, disposal of dead animals and leatherwork. by reason of their birth, dalits are considered to be "polluted", and the removal of human and animal waste by members of the "sweeper" community is allocated to them and strictly enforced.” (united nations commission on human rights, sub-commission on the promotion and protection of human rights, working group on contemporary forms of slavery, 27th session, geneva, 27-31 may 2002) operational definition manual scavengers: the manual removal of human and animal excreta using brooms, small tin plates, and baskets carried on the head. the allocation of labour on the basis of caste is one of the fundamental tenets of the hindu caste system. within this system dalits have been assigned tasks and occupations which are deemed ritually polluting by other caste communities such as sweeping, disposal of dead animals and leatherwork. by reason of their birth, dalits are considered to be "polluted", and the removal of human and animal waste by manual scavengers working as temporary contract labourer's for removal of sewer obstructions in sewer system and slit removal at manholes and allied works in chennai metropolitan water supply and sewerage board, chennai, tamil nadu. limitations of the study: during the study the researcher found all of the respondents as scattered in different zones of chennai. main findings: 1. thirty and above forty categories for comparison it is found that the predominance of productive age group is signicant. 2. majority 70 percent of the manual scavengers are illiterate. 3. the origin place of the respondents. predominantly the scavengers are from rural areas. merely 40 percent of the respondents are from tiruvamnamalai district. 4. each and every night soil workers are married. 5. all of them follow hinduism as a religion and belonging to the arunthathiyar/ malaikuravar/adidravidar community they are so called untouchables. 6. there is no proper housing for more than 60 percent of the manual scavengers in chennai they were living in rented and leased house. 7. mostly 80 percent responded were migrated from other district for manual scavenging work. the practice of x 61gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra s.no are a name of the zone no. of ward ward numbers no. of monthly s.alaried manual scavengers allotted 1 i thiruvottiyur 14 1-14 6 2 ii manali 7 15-21 5 3 iii madhavaram 12 22-33 4 iv tondiarpet 15 34-48 38 5 v royapuram 15 49-63 30 6 vi thiru-vi-ka nagar 15 64-78 29 7 vii ambattur 15 79-93 10 8 viii anna nagar 15 94-108 25 9 ix teynampet 18 109-126 45 10 x kodambakkam 16 127-142 32 11 xi valasaravakkam 13 143-155 4 12 xii alandur 12 156-167 13 xiii adyar 13 170-182 26 14 xiv perungudi 11 168,169 183-191 15 xv solzhiganallur 9 192-200 total 250 manual scavenging continues in most states. 8. predominately the manual scavenger was not participated in the social events. 9. there is no toilet facility available at homes of manual scavengers. this poor housing facilities affecting the children’s social and physical environment to study at home psychologically they are not conductive for their education and health. 10. majority of 66 percent of the respondents have debts. a great majority cases have no savings to rely upon in times of trouble. 11. the manual scavengers borrow money from neighbors’ and contractor mostly for the purpose of their children education and considerable proportion of the debt amount is spent on medical expenses. merely a small amount of 30 percent is spent for construction of house. 12. the severe health problems faced by manual scavengers are cholera, dysentery, typhoid; para-typhoid, infectious hepatitis and many other diseases can be traced to the unsanitary disposal of human excreta. lack of sanitation also has grave social consequences, the need to have 'night soil' removed has given rise to the profession of 'scavenging' or collecting it from bucket latrines, the streets and other locations. 13. all of them were involved in manual scavenging working as temporary contract eld workers for removal of sewer obstructions in sewer system and slit removal at manholes and allied works in chennai metropolitan water supply and sewerage board (cmwssb), chennai, tamil nadu. 14. preponderance of the respondents perform their work in groups and also individuals. 15. predominantly 64 percent of the respondents think about the essentiality of alternative employment 16. predominantly it is clear that manual scavengers are not availed proper safety equipments health problems faced by the manual scavengers are sometimes mistakenly identied to be because of their lack of awareness. sanitary workers are unwilling to wear gloves as these gloves are either not meant for heavy work, or that these gloves are difcult to work with. 17. manual scavengers itself used as a equipment to clean the big chennai. 18. manual scavengers facing more physical, mental and social problems. this has severe repercussions for their health. 19. majority of them are faced head injury, leg injury, suffocation, fainting, burning of eyes and nose burning or bleeding. concomitant with the issue of manual scavenging, there is a view that “right to health” must be included in the fundamental rights of indian citizens, without any discrimination. the workers are affected by cardiovascular degeneration, infections like hepatitis and leptospirosis, skin problems, prevalence of helicobacter, respiratory system problems and altered pulmonary function parameters. they may also be prone to psychological disorder. they are exposed to infections by hand-to-mouth contact. the manual scavengers are also highly affected by gastric cancer. pre-placement treatment and periodic treatment for manual scavengers along with an insurance protection are some plausible solutions to the problem at hand. 20. compensation received by the respondents for their injuries and ill health due to working conditions. forty ve percent o f the respondents not received any compensation. thus very clearly explains about the work place discrimination. 21. it reveal the work satisfaction of the respondents. merely 5 percent of the respondents are not satised about their work. “in particular manual scavenging is a caste based occupation discriminating us in the society” from the own words of the respondents. 22. preponderance of 90 percent of the respondents is tried for alternative self employment for their livelihood options but they said it was failure due poor economic conditions. 23. it is very clear in the above table that all of them were not much aware to rise their voices against the discrimination and lack of welfare measures. almost 96 percent of them were not approached court for their rights. 24. the manual scavengers work ing in chennai metropolitan water supply and sewerage board are totally ignorant about the schemes/ polices/programmes. suggestions & conclusion 1. executive/judicial power may be conferred on the commission on the lines of other commissions. 2. additional posts to meet the legitimate requirements of the commission as already recommended to the government may be created without further delay. in addition, creation of group d post may reconsider. 3. it is reiterated that all post including of personal staff may be lled up on deputation basis 4. ministry of welfare should write to all chief minister in continuation of prime minister's letter dated 20.09.1996 to extended all facilities and cooperation and nd time to meet the commission. 5. additional space for the ofce of the ofce of the commission may be al lot ted to accommodate chairperson, vice chairperson, member and ofcers as per their status and also the additional staff, if sanctioned. 6. in order to ensure timely payment of dues to safai karamcharies, the legal provision of relevant acts is enforced strictly to ensure payment of provident fund and gratuity in time and defaulting employer be dealt with severely under the provision of law. 7. adequate promotion avenues ensuring at lest three vertical promotions be created based on experience, technical or other qualication of safai karamcharies. this can be ensured by reserving certain percentage of posts in clerical percentage of posts in clerical and other cadres and also introducing time scale promotions after a specied number of years in a particular scale of pay. 8. handling of fth, garbage etc be totally mechanized and safai karamcharis should be provided with all protective with all protective equipments and devices. 9. all local bodies should provide primary , secondary and tertiary medical facilities to there work and there should be in-built mechanism for quarterly check up of such karamcharis, their families and adequate insurance cover ,wherever necessary, to meet secondary and tertiary level medical expenses for which premium should be paid by the employer . 10. safai karamcharis should be provided additional allowances equal to 10% of the basic pay as risk allowances to compensate them for the risk they are constantly exposed to state government should take initiatives and have it uniformly made applicable in all local bodies. risk allowance should also be paid to daily wage/part time workers. 11. municipal bodies should construct new colonies for safai karamcharis with adequate facilities for roads, underground drains, and electricity, water supply, personal toilets, dispensaries and recreational facilities. since by and large , the women folk of safai karamcharis are working ladies, each colony of safai karamcharis must be provide with a crèche. 12. the commission strongly recommends that the employment of manual scavengers' ad construction of dry latrines (prohibition) act, 1993 should be adopted by utter pradesh and rajasthan immediately and where the act is applicable the state may apply the rules under its provision for speedy implementation of provisions of the acts. 13. although many states government have denied the volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 62 x gjra global journal for research analysis existence of dry latrines in their sates but the fact remains that dry latrines are still in existence in many states and scavengers also clean the night soil from open space, road and drains which indirectly amounts to removal of night soil. their status is not different from those who are cleaning dry latrines. therefore, the states should take cognizance of the fact and take immediate steps to liberate these scavengers. 14. the commission is gratied to know than awareness about disposal of soil waste is there in few municipal corporations and accordingly taking steps to maintain the cleanliness of the cities. it is therefore, that other bodies should also come forward and take initiatives about disposal of solid waste and garbage. 15. the decline in allocating of funds for the scheme by ministry is coming in the way for smooth functioning the scheme. therefore, it is suggested that adequate allotment of funds to state government may be ensured. 16. the commission strongly suggest that the denition of scavengers should not only include all persons engaged in manual handling of night soil or human all persons engaged, sewage etc. the commission has brought this fact to the notice of ministry of social justice& empowerment but ministry has not considered the request favorably as perhaps the ministry's endeavors is for rehabilitation of people falling in the scope of the larger interest of safai karamcharis the matter may be reconsidered to revise the denition. 17. the survey conducted or being conducted by the state government of scavengers is not at all comprehensive. the commission feels that there is ample justication for conducting a fresh and comprehensive survey by reputed organization to ensure its efciency within a stipulated time. 18. the commission reiterates that there should be exibility in designing training courses particularly of technical nature and the duration of training period may be enhanced from six month to one year for securing gainful employment and as far as possible training should be giving in government run institution to ensure better qualities of training to safai karamcharis and better scope for rehabilitation. 19. the commission recommends that the project cost of rs. 50,000 may be enhanced to rs 5, 00,000 per beneciary so that safai karamcharis may be property rehabilitated. 20. it is suggested, that state level and distt. levels monitoring committees should meet once in three month to review the progress of schemes without fail as envisaged in the schemes without fail as envisaged in the scheme and the proceeding should be sent to this commission the purpose of evaluation. conclusion: india has made spectacular progress almost in all areas of life over the years since independence in 1947. however, still large sections of our people have not got their share of development in their life. atrocities, untouchability, involvement in obnoxious and inhuman practice of manual scavenging of night soil are still prevalent in the country. even after 58 years of independence, the socio-economic conditions of this group are still far below the satisfactory level, and the scavengers are still handling night soil manually. this is undoubtedly a blot on our country. a number of efforts have been made to abolish the system of manual scavenging and to ameliorate the living and working conditions of manual scavengers as well as safai karamcharis. the national commission for safai karamcharis was constituted on 12th august, 1994 for a period of 3 years under the provision of the national commission for safai karamcharis act, 1993 to promote and safeguard the interests and rights of safai karamcharis. the national commission has, inter alia, been empowered to investigate specic grievances as well as matters relating to implementation of programmes and scheme for welfare of safai karamcharis. the commission is required to be consulted on all major policy matters affecting safai karamcharis. the term of the commission was extended from time to time and the tenure of the present commission has been extended through a resolution of govt. of india upto 31.12.2007. a legislation was passed in 1993 namely, the employment of manual scavengers and construction of dry latrines prohibition act, 1993. to solve the problem of manual scavenging two specic schemes are under implementation. they are (i) integrated low cost sanitation scheme (ilcs) and (ii) national scheme for liberation and rehabilitation of scavengers (nslrs). the rst scheme provides for conversion of existing dry latrines into low cost water borne latrines and construction of new sanitary latrines. the basic aim of the scheme is to liberate the manual scavengers from the obnoxious practice of carrying night soil manually. the nslrs scheme aims at rehabilitation of liberated manual scavengers in alternative and dignied occupations after giving them necessary training and nancial assistance in the form of subsidy, margin money loan and bank loans. despite all these efforts the end result is not very encouraging. in order to achieve this target, the planning commission has formulated a national action plan for total eradication of manual scavenging by 2007. the ministry of urban employment and poverty alleviation has been entrusted to implement the national action plan. the continuation of the inhuman practice of manual scavenging is a profanity not only on those involved in this practice but on the country and putting an end to it is the responsibility of the country as a whole references 1. the employment of manual scavengers and construction of dry latrines (prohibition) act, 1993. ministry of housing and urban poverty alleviation, govt. of india. 2. "manual scavengers become fashion models." bbc. 4 july 2008. 3. "manual scavengers: indian railways in denial". oneworld south asia. 25 february 2013. 4. manual scavenging. international dalit solidarity network. retrieved 8 april 2013. 5. united nations commission on human rights, sub-commission on the promotion and protection of human rights, working group on contemporary forms of slavery, 27th session, geneva, 27–31 may 2002. 6. the 'untouchable' indians with an unenviable job asia world the independent 7. bill prohibiting manual scavenging in india in monsoon session 2012. the hindu. 9 april 2012. 8. "delhi rst state to ban manual scavenging." hindustan times. 27 february 2013. 9. bindeswar pathak, road to freedom; rehabilitation and abolition of manual scavengers, 2007. 10. geetha ramasamy, india stinking, 2005. 11. brief report on national public hearing on "rehabilitation of manual scavengers and their children in india", 28th march 2012, indian social institute, new delhi. 12. united nations commission on human rights, sub-commission on the promotion and protection of human rights, working group on contemporary forms of slavery, 27th session, geneva, 27–31 may 2002 13. maggie black, ben fawcett. (2012). the last taboo: opening the door on the global sanitation crisis. routledge. 14. b. n. srivastava (editor). (1997). manual scavenging in india: a disgrace to the country. concept publishing company. 15. "manual scavenging: court summons principal secretaries". the hindu. 14 september 2004. 16. "india's manual scavengers: how to abolish a dirty, low-status job." the economist. 10 july 2008. 17. "un rights chief welcomes movement to eradicate manual scavenging in india." un news centre. 31 january 2013. 18. oct 3, 2012: washing off this stain will need more (the hindu). x 63gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: microalbuminuriais associated with cardiovascular mortality in t2 dm patients long before cv events occur. atherosclerosis has manifested as intimal thickening of the arterial beds and recent studies using ultrasound has been shown that carotid atherosclerosis expressed as increased intima-media thickness (imt) correlates with coronary disease. microalbuminuria is a sign of generalised vascular disease and increased vascular permeability, it could be related to carotid artery imt. in one study by willey k a et al, t2 dm patients with an increased albumin excretion rate had increased imt of cca, independent of bp levels. the aim of this study was to investigate the relationship between microalbuminuria and cca-imt in t2dm patients and their statistical comparison with control non-diabetic subject. material and methods: it is a hospital based observational cum case control study, conduced at medical opd & wards at sms hospital jaipur over a period of 1 year. cases were selected an age & sex matched pts of t 2 dm between age of 30 to 70 year.controls were selected as age and sex matched person without t2 dm. group a :subjects with t 2 dm n=20 group b :age & sex matched control group n=10. exclusion criteria : 1. age :< 30 or > 70 year. 2. patients of copd, cva, hepaticand renal disease, anemia, pregnancy, malignancies, hypothyroidism, fever. imt was measured by b mode ultrasound is supine position and each carotid wall and segment scanned independently from continuous angles to identify the thickest intima media site. estimation of imt was done 1 cm before the bifurcation of both cca. for each subject imt-cca was calculated to be the average of the left and right cca-imt. albuminuria :persistent microalbuminuria(>20-200 g per minute) was estimated by elisa in two of three consecutive sterile overnight urine samples. data analysis : the students unpaired “t” test was used to establish signicance when the groups were compared with each other. pearson product moment correlation coefcient (r) was used for variable performance between the study groups. table 1 age & sex and mean imcroalbuminuria levels of study subjects mean microalbuminuria (mg /day) table 2 duration of diabetes, cca-imt and microalbumi nuria of all niddm patients table 3 microalbuminuria and mean cca-imt of study subjects relation between common carotid artery intima media thickness and microalbuminuria in t2 dm patients original research paper dr. mansa ram saran p.s., department of medicine ,shrikalyan govt. hospital, sikar x 25gjra global journal for research analysis medicine aims and objectives : to ascertain the relationship between the temporal occurance of microalbuminuria and common carotid artery-intima media thickness(cca-imt) in patientts with t2dm. material and methods : the study included patients suffering from t2dm (n=20) and age & sex matched control subjects (n=10). patients and control subjects were examined for intima media thickness by b mode ultrasound. cca-imt was calculated 1 cm before bifurcation by the average of the left and the rights cca-imt. microalbuminuria was measured in two overnight sterile urine samples. results : a statistically signicant correlation was observed between microalbuminuria and ccaimt in female patients with t2dm and in all patients with t2dm. a statistically signicant cor relation was observed between the duration of dm and microalbuminuria. also a statistically signicent correlation observed between duration of dm and cca-imt. conclusion: there was a statistically signicant correlation was observed between presence of microalbuminuria and ccaimt in t2dm patients. in t2dm patientsmicroalbuminuria was associated with increased cca-imt. abstract keywords : dr. sukh chain* j.s. department of medicine shrikalyan govt. hospital, sikar *corresponding author dr. jaya dadhich department of pharmacology, sms medical college, jaipur volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra age group (years) control nidom male female male female 31-40 0 0 135 0 41-50 0 20.7 210 130 51-60 23 24 250 277.5 61-70 0 0 165 120 duration of diabetes (years) n microabluminuria (mg/day) cca-imt (mm) 0-1 5 154 0.80 1.1-2 1 200 0.98 2.1-3 2 190 0.90 3.1-4 6 220.8 1.05 4.1-5 4 225 0.95 5.1-6 1 250 0.85 6.1-7 1 280 0.89 microalbuminur ia (mg/day) control niddm male female male female 0-30 0.90 (n=5) 0.83 (n=5) 100-130 0.77 (n=1) 0.79 (n=2) 26 x gjra global journal for research analysis this study was undertaken to study diabetic patients for the occurrence of microalbuminuria and to document the accelerated changes of atherogenesis by measuring intimamedia thickness of common carotid arteries. these two parameters have now been established as occurring in diabetic patients as its sequalae and represent the beginning of end organ damage. these early changes eventually contributes to end stage renal disease (esrd), cerebral strokes, ischaemic heart disease and peripheral vascular disease. estimating the presence of microalbuminuria and increase in cca-lmt would help in undertaking measures to decelerate its progression to catastrophic events and also to predict prognosis of individual patients of t2dm. microalbuminuria represents microangiopathy and increase in cca-imt represents macroangiapathic complication of t2dm. numerous studies have documented that these two parameters predict initiation ofcomplication occurrence of diabetes mellitus. the correlation coefcient (r) between microalbuminuria and ccaimt in our study revealed that in the female t2dm patient group and combined male and female t2dm patient group, the correlation was statistically signicant (p<0. 05). its association with carotid plaque and/or stenosis might be of importance to detect early atherosclerotic lesions in the carotid arteries. ln our study, on determining the signicance of the correlation coefcient (r) between duration of diabetes and cca-imt, we found that there was a statistically signicant positive correlation in female t2dm group and it was absent in the male t2dm and all cases of t2dm groups. the vascular permeability which permits glomerular leakage of albunin may also be found in other vessels thereby permitting the escape of lipoproteins into the arterial walls. microalbuminuria is a manifestation of widespread atherosclerosis. microalbuminuria reects disruption of the integrity of endothelial junctions and not only albumin but other components of circulating blood like lipoproteins etc. may also leak. when this leak occurs in the arterial intima and media, the atherogenic process is hastened and the consequences of atherogenesis are preponed. these sequence of events are well corroborated in our study where we observed that levels of microalbuminuria increase berore the increase in cca-imt. conclusions and summary: a statistically signicant correlation was observed between microarbuminuria and cca-imt in female t2dm patient group and also in all t2dm patient group. no such correlation was observed in the male t2dm patient group.it is concluded from this study that increase in urinary albumin excretion occurs earlier in patients of t2dm than the increase in ccaimt. both these variables are statistically signicantly related to age and duration ofdiabetes.microarbuminuria is a microangiopathic complication oft2dm and represents a manifestation of widespreadatherosclerosis. preventive measures have a denite rolein reducing microatbuminuria and decelerating the progressof macroangiopath iccom plica tions of t2dm. references 1. viberti gc, keen h. relevance to pathogenesis and prevention of diabetic nephropathy. diabetes 1984; 33;686-692. 2. schmitz a, vaeth m. microalbuminuria: a major risk factor in niddm. a 10 year follow-up study of 503 patients. diabetic med 1988; 5:126-134. 3. damsgaard em, mogensen ce. microalbuminuria in elderiyhyperglycemic patients and controls. diabetic med 1986; 3 : 432-435. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 131-160 0.96 (n=2) 161-190 0.95 (n=1) 0.71 (n=1) 191-220 1.03 (n=2) 0.93 (n=1) 221-250 0.95 (n=2) 0.85 (n=1) 151-280 0.97 (n=2) 1.06 (n=2) 28.anuradha.cdr introduction chronic kidney disease (ckd) is one of the most commonly occurring noncommunicable diseases in india with [1,2]prevalence ranging from 1 to 13% and is associated with signicant morbidity, mortality and economic burden. production of active vitamin d, 1,25 dihydroxycholecalciferol (calcitriol) requires the hydroxylation of the cholecalciferol molecule at both the 1� and the 25 position hydroxylation at the 25 position occurs in the liver, whereas hydroxylation of the 1� position occurs in the kidney; this latter process is impaired in ckd with resulting deciency in active vitamin d. 25hydroxyvitamin d [25(oh)-vd] is the main circulating form of vd and its plasma levels are routinely measured as a marker of vd status. expanding roles of the vitamin d endocrine system beyond calcemic regulation and its deciency has not only been found to be widely associated with chronic kidney disease in humans, but to also accelerate the disease [3]progression. the virtual ubiquitous expression of the vdr in all nucleated cells, the presence of a functional 1�hydroxylase in at least 10 different tissues apart from the kidney, and the very large number of genes that are under direct or indirect control of 1,25(oh) d all point toward a more 2 universal role for the vitamin d endocrine system than just regulation of calcium/phosphate/bone metabolism.urine albumin has been recommended as a sensitive marker for chronic kidney disease by us national kidney foundation guidelines and is also a marker for generalized vascular endothelial dysfunction. recent observational evidence suggests strong links between low vitamin d levels and a range of cardiovascular conditions, including stroke, myocardial infarction, hypertension, and diabetes. low vitamin d levels can result in vascular smooth muscle cell proliferation, endothelial cell dysfunction, vascular and myocardial cell calcication, and increased [4]inammation. interventional studies are beginning to explore whether vitamin d supplementation can modify vascular health and prevent cardiovascular disease. greatly increased (16-fold) incidence of cardiovascular disease, particularly myocardial infarction, cardiac failure, sudden cardiac death and stroke has been observed in ckd patients. in ckd, arteriosclerosis becomes the dominant lesion. as a consequence, cardiac disease in patients with ckd can represent a spectrum from left ventricular hypertrophy associated with hypertension, to classical myocardial ischaemia, both irreversible (as in myocardial infarction) and reversible, and progressing to brotic myocardial disease with a high risk of sudden death, which is very common in patients with esrd. the electrocardiogram (ecg) records the electrical activity of the heart at the skin surface and is important in detection of cardiac rhythm ˝evaluate the status of serum 25-hydroxyvitamin d with urinary albumin creatinine ratio and to see its association with ecg changes in chronic kidney diseases original research paper anuradha bharosay* mbbs, dgo, phd, associate professor, department of biochemistry, chirayu medical college and hospital, bhopal (mp) , india *corresponding author medical science aims: evaluate the status of serum 25-hydroxyvitamin d with urinary albumin creatinine ratio and to see its association with ecg changes in chronic kidney diseases. study design: cross-sectional study. place and duration of study: department of biochemistry, department of medicine, department of nephrology chirayu medical college and hospital, bhopal, madhya pradesh between june 2019 to november 2019. methodology: 100 known or newly diagnosed ckd patients above 18 yrs of age were included. patients on dialysis, vitamin d therapy, obstructive nephropathy, gout, or having h/o ihd were excluded from the study. egfr was calculated by ckd-epi formula and patients were grouped into various stages of ckd based on kdoqi classication. spot urinary albumin(immunoturbidimetric method) and urinary creatinine(buffered kinetic jaffes reaction) were done on cobas integra 400 plus and acr was determined. albuminuria (acr) categories in ckd were listed as a1 : <30mg/g ; a2: 30-300mg/g and a3: >300mg/g quantitative determination of total 25-hydroxyvitamin d in human serum was done on cobas e411 based on electrochemiluminescence binding assay. 25-oh vitamin d deciency , insufciency and sufciency were dened as levels <30 nmol/l , 30-50 nmol/l and > 50 nmol/l.12 lead ecg was done at the time of admission and interpretation done by a qualied physician based on accepted standard criteria. result: out of 100 ckd patients 45 were in stage v, 36 in stage iv,14 in stage iii and 5 were in stage ii. 94% of patients were found to have vitamin d deciency. 72% had vitamin d <30 nmol/l out of which 88.8% patients were in stage iv and stage v ckd. mean acr was 344.9±163.5. a signicant association was observed (p<0.05) between acr and vitamin d as well as severity of ckd and vitamin d deciency. ecg abnormalities were observed in 75% patients with 57% ecg abnormality present in ckd patients with vitamin d <30nmol/l. signicant association (p<0.05) was observed between vitamin d status and ecg abnormalities. conclusion: 25-hydroxyvitamin d has been observed to have a renoprotective as well as cardioprotective role in ckd patients. this study can be of immense utility for alleviating progression and cardiovascular risk in ckd patients abstract keywords : kidney disease outcome quality initiative (kdoqi); chronic kidney disease(ckd) ; electrocardiogram(ecg) ;albumin creatinine ratio(acr) volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra tariq jalaly mbbs, md, professor, department of medicine, chirayu medical college and hospital, bhopal (mp), india vivek vikram bharosay mbbs, md, professor, department of pathology, chirayu medical college and hospital, bhopal (mp),india palak talreja mbbs, junior resident, department of medicine, chirayu medical college and hospital, bhopal(mp),india 20 x gjra global journal for research analysis abnormalities, cardiac conduction defects and detection of myocardial ischemia. ecg remains an essential tool for evaluation of cardiovascular disease and is important in detection of cardiac rhythm abnormalities, cardiac conduction defects and detection of myocardial ischemia. resting ecg abnormalities are common in patients with ckd [5]and they independently predict future cardiovascular events the aim of our study is to evaluate 25-oh vitamin d status with acr and to assess its relation with cardiovascular events in patients presenting with ckd at chirayu medical college and hospital. materials and methods: the study design was cross-sectional in nature and was conducted by the department of biochemistry in collaboration with the department of medicine and pathology at chirayu medical college and hospital, bhopal, madhya pradesh, over a period of 6 months from june 2019 to november 2019. sample size of 100 was calculated with 95% condence level and all patients above 18 yrs of age with known or newly diagnosed ckd were included. this work was approved by the institute ethics committee and selection of cases was done from in-patient wards, icu and from the department of medicine and nephrology, chirayu medical college and hospital ,bhopal. the aim of the study and the protocol was explained to the patients and written informed consent was taken from the patients or nearest relatives before inclusion in the study. patients on vitamin d therapy, malignancies, obstructive nephropathy, gout, or having h/o ihd were excluded from the study. patient was considered to have ckd 2if estimated gfr (egfr) was less than <60 ml/min/1.73m or if there was persistent proteinuria for 3 or more months. egfr was calculated by ckd-epi formula which has been found to be more accurate mainly due to a substantial decrease in systematic differences between mgfr and egfr bias. patients were further grouped into various stages of ckd based on kdoqi classication as dened by nice guidelines [6-8]2012. . albumin-to-creatinine ratio (acr) is the rst method of preference to detect elevated protein. spot urinary albumin (immunoturbidimetric method) and urinary creatinine (buffered kinetic jaffes reaction) were done on cobas integra 400 plus analyzer ,roche diagnostics, gmbh, mannheim, germany using the cobas c pack reagent and acr was determined. albuminuria (acr) categories in ckd were listed as a1 : <30mg/g ; a2: 30-300mg/g and a3: >300mg/g. as serum 25(oh)d concentration is an excellent reection of the vitamin d status due to rapid conversion of vitamin d into [9 ] 25(oh)d and its long plasma half-life quantitative determination of total 25-hydroxyvitamin d in human serum was done on cobas e411,roche-diagnostics gmbh, mannheim, germany. methodology was based on electrochemiluminescence binding assay. 25-oh vitamin d deciency , insufciency and sufciency were dened as [10]levels <30 nmol/l , 30-50 nmol/l and > 50 nmol/l . 12 lead electrocardiograms (ecg) was done at the time of admission along with estimation of serum total 25-hydroxyvitamin d. interpretation of ecg was done by a qualied physician [11]based on accepted standard criteria .ecg abnormalities were identied and mainly included st-segment depression/elevation, t-wave inversion, ventricular conduction defects, av block ,lvh. statistical analysis : data analysis was done by spss version 23. for normality test shapiro–wilk test was used. pearson chi square test was used for categorical variables to examine differences across 3 groups of 25oh vitamin levels: group 1 >50 nmol/l, group 2 : 30–50 nmol/l; and group 3: ≤30 nmol/l. one way anova was used to compare means among two or more groups. compliance with ethical standards: the study was approved by the institutional research ethics committee (institutional ethics committee, cmch,bhopal) and certify that the study was performed in accordance with the ethical standards as laid down in the 1964 declaration of helsinki and its later amendments or comparable ethical standards. the aim of the study and the protocol was explained to the patients and written informed consent was taken from the patients or nearest relatives before inclusion in the study. results: number of patients included in the study were 100 and entirely comprised of predialysis patients. hypertensive patients with ckd were 70 and non -hypertensive patients with ckd were 30. patients with frank diabetes were 50% , prediabetic 36% and non diabetic were 14 %. mean age of patients was 44±14 years with 46% males and 54% females. 55% were in the age group of 18 – 45 yrs, 37% in age group of 46 – 65 yrs and 8 % were in age group of >65 yrs. the clinical and demographic characteristics of the patients with known or newly diagnosed ckd are presented in table 1. table 1: baseline characteristics across 25-oh vitamin d categories hypertensive and diabetic patients with ckd were found to have lower vitamin d as compared to non hypertensive and prediabetic and non diabetic ckd patients. 2 mean egfr of patients was 20.3 ml/min/1.73m (calculated by ckd-epi formula) and mean spot urinary acr was 261.9 mg/g. 81% of ckd patients with urine acr >300mg/g were found to have vitamin d <30 nmol/l as shown in fig 1.hypertensive patients on ace inhibitors were 28% out of which 10% had acr >300 mg/g. figure 1 vitamin d and albumin creatinine ratio in ckd patients 45% of patients were in stage v, 36% in stage iv,14 % in stage iii and 5% in stage ii based on kdigo criteria .mean duration of ckd was 3.6±4 months. 94% of patients were found to have vitamin d deciency with 72% having vitamin d <30 nmol/l as shown in table 2. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra vitamin d deciency (<30nmol/l) vitamin d insufciency (30-50nmol/l) vitamin d sufciency (>50nmol/l) p value no. 72 22 6 age (yrs) 55.6±12.5 54.2±10.2 32.4±14 <.001 males 65.2% (30) 26 % (12) 8.6% (4) 0.32 females 77.7 % (42) 18.5% (10) 3.7% (2) bmi (kg/m2) 28.52±4.56 24.22±3.64 22.4±3.4 <0.001 hypertension 77.8% (56) 18.6% (13) 1.4% (01) <0.05 non hypertensive 22.2% (16) 30% (09) 16.7% (05) diabetic 52.8% (38) 50 % (11) 16.6 % (1) 0.11 pre diabetic 36.1% (26) 36.4 % (8) 33.3 % (2) non diabetic 11.1% (08) 13.6 % (3) 50 % (3) spot urine acr (mg/g) 390.7±158.7 230.4±161.9 185.6±110.7 <0.0001 x 21gjra global journal for research analysis table 2 vitamin d distribution in ckd patients (@ signicance at p <0.05) 77% of patients in stage v and 80.5% in stage iv ckd were found to have serum vitamin d < 30nmol/l as shown in fig.2. figure 2 : distribution of vitamin d in ckd patients ecg abnormalities were observed in 75% patients with 57% ecg abnormality present in ckd patients with vitamin d <30nmol/l. signicant association (p<0.05) was observed between vitamin d status and ecg abnormalities as shown in table 3. proportion of patients with abnormal ecg ndings is shown in fig.3. 32 % of the total ecg abnormalities detetected were lvh. table 3 vitamin d association with ecg (@signicance at p<0.05) figure 3 proportion of ecg abnormalities discussion signicant association of acr with 25-hydroxy vitamin d deciency in our study supported renoprotective action of vitamin d and could be due to withdrawl of inhibitory effect of vitamin d on the renin angiotensin system (raas). vitamin d has been shown to suppress the transcription of renin, inhibiting the raas and ultimately leading to a reduction in proteinuria through hemodynamic and non-hemodynamic pathways and has been observed to be an independent inverse predictor of disease progression and death in ckd [12]patients . angiotensin ii (aii) is the main effector of the raas and exerts its vasoconstrictor effect predominantly on the postglomerular arterioles, thereby increasing the glomerular hydraulic pressure and the ultraltration of plasma proteins. previous clinical studies have shown an inverse relation between [13]circulating vitamin d and renin levels. . ace inhibitors have a proteinuria reducing effect which accounted for reduced acr in hypertensive patients. ecg abnormalities were found to be more in ckd patients with severe vitamin d deciency. higher incidence of ecg abnormalities in ckd patients with vitamin d <30 nmol/l in our study could be explained by a regulatory effect of vitamin d on cardiomyocytes and vascular smooth muscle cells. our ndings were consistent with other studies which showed vitamin d to have benecial effects on most cells of the vascular wall with an inverse association between 1,25(oh) d 2 [14,15]levels and blood pressure or plasma renin levels. . increased thrombogenicity and decreased brinolysis have been observed in vdr-null mice which further explains the cardioprotective role of vitamin d. antiinammatory actions of vitamin d have been reported to play an important role in a t h e r o g e n e s i s a n d i n h i b i t i o n o f c e r t a i n m a t r i x metalloproteinases (mmps) that are important in plaque instability and are known to increase in mi, notablymmp-9 [16]andmmp-2. . in ckd dysregulation of vitamin d metabolism with raised levels of circulating fgf-23(phosphaturic hormone) and renal 24-hydroxylase (cyp24a1), the catabolic enzyme involved in 25(oh)d and 1,25(oh)2d3 degradation, contributes to vitamin d-deciency in kidney disease. raised fgf 23 in ckd as a result of dysregulation of vitamin d metabolism might contribute to cardiotoxic effect and ecg [17]abnormalities as observed in the present study . serum vitamin d levels decline early in the course of kidney dysfunction and with progression of ckd severity of vitamin d deciency has been found to increase in the present study. conclusion: low vitamin d status in the present study has been found to be associated with micro albuminuria and greater ecg abnormalities suggesting reno protective and cardio protective effect of vitamin d in ckd patients. clinical signicance: cardiovascular disease is a major cause of morbidity and mortality in patients with chronic kidney disease. screening of ckd patients for vitamin d status can be done to attain the noncalcemic benet on cardiovascular protection. however excess of vitamin d can also have deleterious effects hence proper prospective, large-scale randomized trial are needed before recommendation of routine supplementation of 25(oh)-vd to alleviate associated adverse outcomes and reducing the impact of ckd on healthcare resources. references : 1 min b. effects of vitamin d on blood pressure and endothelial function. korean j physiol pharmacol. 2013;17(5):385–92. 2. scragg r, sowers mf, bell c. serum 25-hydroxyvitamin d, ethnicity, and blood pressure in the third national health and nutrition examination survey. am j hypertens. 2007 3. bodyak n, ayus jc, achinger s, shivalingappa v, ke q, chen ys, et al. 4. activated vitamin d attenuates left ventricular abnormalities induced by dietary sodium in dahl salt-sensitive animals. proc natl acad sci u s a. 2007;104(43):16810–5. 5. aihara k, azuma h, akaike m, ikeda y, yamashita m, sudo t, et al. disruption of nuclear vitamin d receptor gene causes enhanced thrombogenicity in mice 2004;279(34):35798–802. 6. stöhr r, schuh a, heine gh, brandenburg v. fgf23 in cardiovascular disease�: innocent bystander or active mediator�2018;9(june). volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra stages vit d (nmol/l) chi square df p value<30 30 -50 >50 ckd stages ii 02 (2.8%) 01 (4.5%) 02 (33.3%) 13.13 6 0.041 iii 06 (8.3%) 07 (31.8%) 01 (16.7%) iv 29 (40.3%) 05 (22.7%) 02 (33.3%) v 35 (48.6%) 09 (40.9%) 01 (16.7%) stages vit d (nmol/l) chi square df p value<30 30 -50 >50 ecg normal 15 (20.8%) 6 (27.3%) 4 (66.7%) 6.283 2 0.043 abnormal 57 (79.2%) 16 (72.7%) 2 (33.3%) 22 x gjra global journal for research analysis introduction the urachus is a remnant of a channel between the bladder and the umbilicus where urine initially drains in the foetus stduring the 1 trimester of pregnancy. thurachus usually seals off and obliterates around the 12 week of gestation and all that is left is a small brous cord between the bladder and umbilicus called the median umbilical ligament. diagnosis of a persistent urachus/urachal cyst remains challenging due to the rarity of this lesion and the nonspecic nature of its symptomatology. case report a 35-yr. old male presented in outpatient department of cha with complains of pain in lower abdomen (suprapubic region) for last 15 days and umbilical sepsis with periumbilical erythema for 8 days. no history of nausea, vomiting or change in bowel or bladder habits. systemic examination revealed periumbilical erythema and tenderness in suprapubic region with soft abdomen. erythema subsided with intravenous antibiotic therapy for one week. ultrasonography of abdomen and pelvis showed heterogeneous mass of size ~4.4x2.8 cm in midline extending from anterior wall to urinary bladder. laparotomy was performed through an infraumbilical incision, which revealed a cyst surrounded by an inammatory mass extending into the dome of the urinary bladder with two surrounding brous cords. the infected urachal cyst and brous cords were excised and sent for histopathological analysis to rule out any evidence of malignancy. postoperative period was uneventful and patient was discharged in satisfactory condition. histopathological analysis of the resected specimen showed chronic granulomatous inammation with no evidence of malignancy. on follow-up, patient is doing well with no episode of pain abdomen or bowel and bladder disturbances. discussion urachus, developmentally is the upper part of the bladder, both of which arise from the ventral part of the cloaca and thallantois. descent of bladder from 5 month of development into the foetal pelvis pulls the urachus with it resulting in formation of urachal canal. the lumen of this canal progressively obliterates during the foetal life, with eventual formation of brous tract in early adult life. histologically, composed of 3 layers: 1) innermost layer: modied transitional epithelium similar to urothelium 2) middle layer: broconnective tissue 3) outermost layer: smooth muscle continuous with detrusor muscle urachal anomalies occur when there is incomplete seal off of the urachal lumen results in following abnormalities. types: 1) patent urachus (50%): when the urachus did not seal off and there is a connection between the bladder and the umbilicus. 2) cyst (30%): when a section of the urachus did not seal off, but there is not a connection between the bladder and umbilicus. a case report of an infective urachal cyst in adult original research paper dr. pranjal anil banthia rd3 year resident, department of general surgery, b.j. medical college, civil hospital, ahmedabad. general surgery keywords : dr. hitendra k desai assistant professor, department of general surgery, b.j. medical college, civil hospital, ahmedabad. dr. purvesh doshi* nd2 year resident, department of general surgery, b.j. medical college, civil hospital, ahmedabad. *corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 14 x gjra global journal for research analysis it is rare in adults; more common in men than women. in adults, most common variety is urachal cyst, with infection being usual mode of presentation. route of infection is haematogenous, lymphatic, direct or ascending from bladder. commonly cultured organisms are enterococcus faecium, proteus spp., streptococcus viridians and fusobacterium spp. our case highlights the potential complications related to congenital urachal anomalies, presenting with as umbilical sepsis with supra pubic pain. diagnosis of an infected urachal cyst made after radiological investigations. the risk of urachal malignancy is high among adults with poor prognosis. histologically, the innermost layer of the urachus is mainly transitional cell. adenocarcinoma is the predominant histological type and most are mucinous. this is probably due to metaplasia arising from chronic inammation. the prognosis for urachal adenocarcinoma does not differ signicantly from nonurachal adenocarcinoma and is relatively poor, with a 5-year survival of 37% and a 10-year survival of 17%. ultrasound scan can help to make diagnosis in 77% of patients. as in our case, ultrasound nding gave the diagnosis of urachal cyst showing collection/mass from anterior abdominal wall to urinary bladder. ct scan or mri scan is essential in case of malignancy. diagnosis is often made following exploratory laparotomy for an unexplained acute abdomen. the treatment of choice for urachal cyst is by complete primary excision. however, yoo et al. in their study suggested a twostage procedure involving initial incision and drainage followed by later excision of the urachal remnant. complete excision is important because malignant transformation of the remnant is possible. traditionally, open excision has been the approach of choice. however, a laparoscopic approach is also an attractive alternative in recent years. the advantage of this approach is good view and the minimal risk of incomplete excision of the urachal remnant. funding no funding. references 1. hammond g, yglesias l, davis je. the urachus, its anatomy and associated fascia. anat rec 1941; 80:271–4. 2. nimmonrat a, na-chiangmai w, muttarak m. urachal abnormalities: clinical and imaging features. singapore medical journal 2008;49(11):930–5. 3. risher wh, sardi a, bolton j. urachal abnormalities in adults: the ochsner experience. south med j 1990;83(9):1036–9. 4. yoo kh, lee sj, chang sg. treatment of infected urachal cysts. yonsei medical journal 2006;47(3):423–7. 5. begg rc. the urachus. its anatomy, histology and development. j anat 1930;64(pt 2):170–83. 6. ashley ra, inman ba, routh jc, rohlinger al, husmann da, kramer sa. urachal anomalies: a longitudinal study of urachal remnants in children and adults. j urol 2007;178(4 pt 2):1615–8. 7. grignon dj1, ro jy, ayala ag, johnson de, ordóñez ng. primary adenocarcinoma of the urinary bladder: a clinicopathologic analysis of 72 cases. cancer 1991;67(8):2165–72. 8. yohannes p, bruno t, pathan m, baltaro r. laparoscopic radical excision of urachal sinus. journal of endourology 2003;17(7):475–9. 9. groot-wassink t, deo h, charfare h, foley r. laparoscopic excision of the urachus. surg endosc 2000;14(7):680–1. 10. cutting cw, hindley rg, poulsen j. laparoscopic management of complicated urachal remnants. bju int 2005;96(9):1417–21. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 15gjra global journal for research analysis introduction: patella fractures account for almost about 1% of all 1musculoskeletal system fractures. the treatment of patella fractures may sometimes damage the underlying articular surface and lead to traumatic arthritis and cause long-term problems like joint stiffness, muscle weakness and reduction of function. the most common surgery performed is open reduction & internal xation with k wire and tension band wiring. however, the incision utilised for the surgery is extensive and the extent of damage to the surrounding soft tissue including retinaculum is massive and can lead to tissue adhesions. there is always a concern about the occurrence of infection and cosmesis. in today's era of minimally invasive surgery, the technique of using percutaneous cannulated screws promises to be fast, offering early functional recovery and reduced occurrence of traumatic arthritis. we orchestrated the study with the aim of studying the effectiveness of percutaneous cannulated screw method of xation of transverse patella fractures. material & methods this was a retrospective study conducted in the department of orthopaedics at our institute from august 2017 & july 2018 that analysed 12 patients (7 males & 5 females) with transverse patella fracture operated between by the minimally invasive technique of 2 percutaneous cannulated screws. the average follow-up period was 9 months (12-14 months). the average age was 49 years (38-69 years). the cause of the fracture was noted in all cases. we analysed the radiologic union, knee rom and postoperative lysholm score. in all cases the surgical technique involved application of pneumatic tourniquet to the patient in supine position under spinal or general anaesthesia, reduction of the fracture using towel clip under uoroscopic guidance and insertion of guidewires of 4mm cannulated cancellous screw through a small incision of about 0.5-1 cm in the proximal patella. after accepting the position of guidewire drilling and subsequent insertion of nal screw was done. final reduction was conrmed on image intensier (figure 1). figure 1: final reduction was conrmed on image intensier after routine closure, knee extension cylinder splint was applied with knee held in complete extension. the next day after surgery bedside knee mobilisation upto 90° was started. isometric exercises for the quadriceps were taught and weight bearing mobilisation as per pain tolerance was advised. about 6 weeks post-surgery, knee bending beyond 90° was allowed. lateral radiographs of the knee were analysed for articular surface damage & evidence of arthritis. lysholm score for each patient was calculated. results the most common cause of trauma was road trafc accident. radiological evaluation revealed that all fractures healed uneventfully. there were no reports of broken screw or non union in any patient. normal range of motion upto 120° of exion was achieved in 11 knees (91.66%). one patient recovered upto 90° of knee exion due to non-compliance to physiotherapy. there were no cases of stiffness. the average lysholm score was 93.7 (85-100 points) at nal follow-up. this implied minimal loss of function for the patients postoperatively. there were no reports of wound complication and cosmetically healing was perfectly acceptable to the patient. there were no incidence of infection in our patients. outcome of percutaneous cannulated screw fixation in patellar fractures original research paper abhinav jogani senior registrar, department of orthopedics, seth gs medical college and kem hospital, mumbai. orthopaedics purpose: to assess the outcome of percutaneous cannulated screw xation in transverse patellar fractures materials and methods: this was a retrospective study conducted in the department of orthopaedics at our institute from august 2017 & july 2018 that analysed 12 patients (7 males & 5 females) with transverse patella fracture operated between by the minimally invasive technique of 2 percutaneous cannulated screws. the average follow-up period was 9 months (12-14 months). the average age was 49 years (38-69 years). the cause of the fracture was noted in all cases. we analysed the radiologic union, knee rom and postoperative lysholm score. results: there were no reports of broken screw or non-union in any patient. normal range of motion upto 120° of exion was achieved in 11 knees (91.66%). one patient recovered upto 90° of knee exion due to non-compliance to physiotherapy. there were no cases of stiffness. the average lysholm score was 93.7 (85-100 points) at nal follow-up. this implied minimal loss of function for the patients post-operatively. there were no reports of wound complication and cosmetically healing was perfectly acceptable to the patient. there were no incidence of infection in our patients. all fractures healed uneventfully. normal range of motion was achieved in 11 knees (92.9%). average lysholm score was 95.9 at nal follow-up. conclusion: screw xation seemed to be useful for treatment of transverse patellar fracture except in comminuted fractures. the advantage of this technique was the preservation of extensor mechanism, simplicity, short operation time and good cosmesis. abstract keywords : tushar rathod* associate professor, department of orthopedics, seth gs medical college and kem hospital, mumbai. *corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 82 x gjra global journal for research analysis discussion the patella provides a lever arm to the femoral quadriceps and extensor apparatus. it plays an important role in increasing the power of the knee joint extension. the aim of fracture treatment is to ensure continuity of the extensor mechanism and to ensure that the incidence of complications related to the articular surface of the patella are reduced. since the patella happens to be subcutaneously placed in the lower limb, traditionally any and every xation modality that has been utilised for fracture xation like k wire or tension band/cerclage wires are often responsible for soft tissue irritation of the anterior knee region. literature reports the incidence of complications related to wire cerclage to be as 2high as 47%. these complications prolonged recovery and necessitated additional surgery. various modalities of treatment used to x patella fractures include k wire tension band wiring or encirclage or percutaneous cannulated screws. many attempts have been made to perform minimally invasive surgery using 3,4arthroscopy assisted reduction. proposed advantages include short surgical time, smaller incision, less risk of infection and more satisfaction of patients who desired cosmesis, decompression of intra-articular hematomas, removal of loose bodies or fracture pieces and direct visualization of the articular surface for reduction. even while performing open approach, arthroscopy has the distinct advantage of offering a clearer evaluation of articular 4congruity with magnied visual eld. 3tandogan studied arthroscopic-assisted percutaneous screw xation of select patellar fractures and achieved decent results. the soft tissue disturbance was less than that of a routine open xation. yet it is difcult to apply on a regular basis because of limitations of setup requirement and expertise of arthroscopic techniques which may have a learning curve. 5edwards et al in their landmark study of 30 years follow-up of patella fractures laid down the guidelines for recommended 6 treatment. whittle states that a disruption of the extensor mechanism or 2 to 3 mm of displacement is an indication for 7surgical treatment. benjamin et a is stated in biomechanical cadaveric experiments recommended that screw xation should be utilised for transverse patellar fractures in patients who have good bone quality. in patients who sustain patellar fractures with comminution and/or osteopenia, choice of xation is modied tension band xation. simple wiring techniques alone may not provide sufcient xation to allow immediate range of motion a single bone would be useful for pipe screw xation. the patella provides attachment to the quadriceps mechanism. this group of muscles extend along the borders of the patella as retinaculum which is an accessory knee extensor. sometimes in cases of patella fractures this accessory extensor group can provide some degree of knee extension. but if there is complete detachment of extensor mechanism with patella and retinacular damage no active knee extension will be possible. the advantage of open technique of patellar xation involves that retinacular tears can be visualised and repaired if required according to weber 8 9et al . carpenter noted that there is a disadvantage of k wire and tension band wiring method of xation that it cannot be used in complex or comminuted fractures. the vascular supply of the patella is through a branch of the upper, middle, and lower patellar arteries. open reduction may damage the patellar peripheral vascular plexus and can cause a non-union or avascular necrosis of the patella. in our study there was an advantage of being able to preserve the blood supply well and hence minimise the chances of vascular damage. routinely reported postoperative complications of patella fractures include infection, xation failure, knee stiffness and posttraumatic osteoarthritis. such complications have not been reported in our study. in recent years, early joint movement has become critical for optimising results. in some cases we had to use passive or active assisted range up to 90 degrees immediately postsurgery for ensuring early joint movement. allowing light exercise and enforcing early weight bearing led to enhanced functional recovery and shortened the rehabilitation time. however, our limitation was smaller sample size and short follow-up. future studies can be targeted at larger sample sizes and longer follow-up to achieve higher level of evidence. conclusion hence we conclude that cannulated cancellous screw xation can be safely used in the treatment of transverse patella fractures except comminuted type. it is relatively simple and minimally invasive, does not affect the overall function, the operation time is relatively short, associated complication rate is lesser and is considered to be cosmetically satisfactory to the patients. references 1. lotke pa, ecker ml. transverse fractures of the patella. clin orthop relat res. 1981;(158):180-4 2. hung lk, chan km, chow yn, leung pc. fractured patella: operative treatment using the tension band principle.injury. 1985;16:343-7 3. tandogan rn, demirors h, tuncay ci, cesur n, hersekli m: arthroscopicassisted percutaneous screw xation of select patellar fractures. arthroscopy, 18: 156-162, 2002. 4. turgut a, gunal i, acar s, seber s, gokturk e: arthroscopic-assisted percutaneous stabilization of patellar fractures.clin orthop relat res, 389: 57-61, 2001. 5. edwards b, johnell o, redlund-johnell i: patellar fractures: a 30-year followup. acta orthop scand, 60: 712-714, 1989 6. whittle ap: fractures of lower extremity. campbell's operative orthopaedics. 10th ed. st. louis, mosby: 2796-2804, 2003 7. benjamin j, bried j, dohm m, mcmurthy m: biomechanical evaluation of various forms of xation of transverse patellar fractures. j orthop trauma, 1: 219-222, 1987 8. weber mj, janecki cj, mcleod p, nelson cl, thompson ja: efcacy of various forms of xation of transverse fracture of the patella. j bone joint surg am, 62: 215-220, 1980 9. carpenter ej, kasman r, matthews ls: fractures of the patella. instr course lect, 43: 97-108, 1994 volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 83gjra global journal for research analysis introduction as per, the world health organization (who)1972, denition of blindness as a visual acuity of 3/60 or less in better eye or visual eld is less than 10 degrees, irrespective of the level of visual acuity, it is estimated that currently there are 45 million individuals worldwide who are bilateral blind and another 135 million people in the world that have severely impaired [1].vision in both eyes the importance of corneal disease as a major cause of blindness in the world today remains second [2].only to cataract it is estimated that ocular trauma and corneal ulceration result in 1.5 to 2 million new cases of [3].corneal blindness annually ninety per cent of them occur in developing countries; and it has now been recognized as a [4].silent epidemic in india, there are approximately 6.8 million people who have corneal blindness, with vision less than 20/200 in at least one eye and of these, about a million have bilateral corneal blindness. it is expected that the number of corneal blind people in india will increase to 10.6 million by [5].2020 a recent national survey by the government of india (1991-2001) estimated that corneal lesions are responsible for [6].9% of all blindness in our country aims and objectives ÿ to study the demographic determinants of corneal trauma by vegetative & organic materials. ÿ to compare the association of fungal and bacterial infection after corneal trauma by different kinds of vegetative and organic material. method of examination the study included 132 walk-in patients seen in the department of ophthalmology in tertiary hospital with history of corneal trauma by vegetative material. their ocular manifestation, clinical course and prognosis were assessed over a period of november to april. documentation of all patients included socio-demographic features, duration of symptoms, predisposing factors, slit lamp bio microscopy ndings, associated ocular conditions, other systemic diseases, therapy received prior to presentation, visual acuity at the time of presentation, treatment given, response to treatment and the clinical outcome. table – 1 demographic characteristics of patients with corneal trauma. table – 2 association of fungal and bacterial infection with different kinds of vegetative and organic material corneal trauma. result and discussion of the total 132, patients 92 (69.70%) were males and 40 (30.30%) were females with corneal trauma. males were more prone to corneal trauma because of their nature of work and 7outdoor occupation. thylefors et al. , males tend to have more 8 eye trauma than females.gothwal et al. , male (86.8%) were 9affected. vijaya s. rajmane et al , all found the maximum number of cases were in the middle decades of age group a study on demographic determinants and association of fungal and bacterial infection with different modes of corneal injuries original research paper dr monika mahilong* assistant professor dept. of ophthalmology gmc bilaspur chhattisgarh 495001*corresponding author x 35gjra global journal for research analysis ophthalmology in present study, 132 patients attending the department of ophthalmology, pt. j. n. m. medical college & dr. b. r. ambedkar memorial hospital, raipur during the period of 1year and 6 months, with corneal trauma by different kinds of vegetative and organic material, from november,2011 to april,2013. the study showed, maximum patients in middle decades with range of 21-50yrs. most of the patients were males (69.30%) and belong to rural background (71.21%). the majority of patients (59.85%) were farmers or agricultural workers. two peak seasons were observed rst october to march (62.88%) due to harvesting season and second in april to june (25.77%) due to summer vacation of school going children. the predominant traumatic agent in our study was paddy leaf injury (51.51%) and most of the patients after corneal trauma presented with corneal ulceration (75.76%). abstract keywords : corneal injuries, demographic determinants dr m l garg professor& dept. of ophthalmology gmc raipur dr s kujur associate professor & & dept. of ophthalmology gmc raipur volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra demographic determinants numbers percentage gender male 92 69.70% female 40 30.30% age distribution <20 yrs. 22 16.67% 2130 yrs. 23 17.42% 31-40 yrs. 39 29.54% 41-50 yrs. 29 21.98% >50 yrs. 19 14.39% residence rural 94 71.21% urban 38 28.79% occupation farmer 61 46.21% labors 18 13.64% household 19 14.39% service 10 7.58% students/ children 24 18.18% seasonal variation janmar 25 18.94% apr-jun 34 25.76% jul-sep 15 11.36% oct-dec 58 43.94% traumatic agents koh +ve gram +ve koh+ve + gram+ve sterile not done total (124) paddy leave 44 08 07 09 0 68 wooden stick/chip 09 03 02 05 19 38 insects 0 2 0 2 2 6 cow tail 0 2 0 4 0 6 finger nail 0 0 0 1 5 6 total 53 16 9 23 31 132 36 x gjra global journal for research analysis 10 11between 21 – 50 yrs. patel s et al , (43.9%). srinivasan m et al , 12(43.4%). r.c. gupta et al , (35.8%), all found that among various type of traumatic agent, paddy leaf was most common. in this study, paddy leaf (51.51%) appear to be most common mode of corneal trauma, however in the study by r 32nath et al . fungal keratitis was demonstrated in 65.2% patients which was higher as compared to our study. it was observed that, fungal keratitis was associated with paddy leaf trauma were 51(38.64%) conclusion fungal ulcers were more common than bacterial ulcers. fungal ulcers should be suspected in every patient with a corneal lesion occurred by vegetative and organic material and should be ruled out before commencing topical medication. early diagnosis with prompt identication of the pathogenic organism is mandatory to initiate appropriate therapy for corneal injuries to restores good vision. references: 1. the prevention of blindness: report of a who study group. geneva, world healthorganization, 1973: 10–11 (who technical report series, no. 518). 2. whitcher jp, srinivasan m, upadhyay mp: corneal blindness: a global perspective. bull world health organ 2001, 79:214–221. 3. global initiative for the elimination of avoidable blindness. who: geneva; 1997. (unpublished document) who/pbl. 97-61 rev.1. 4. whitcher jp, srinivasan m. corneal ulceration in developing world: a silent epidemic. br j ophthalmol 1997;81:622-3. 5. india: a vision 2020 handbook on equipping a secondary eye hospital. january 20,2010. <http://www.vision2020india.org>. 6. govt. of india. national survey on blindness. 1999-2001. report 2002 7. thylefors b. epidemiological patterns of ocular trauma. australian and new zealand journal of ophthalmology, 1992, 20: 95–98. 8. vk gothwal, s adolph, s jalali and tj naduvilath. demography and prognostic factors of ocular injuries in south india. australian and new zealand journal of ophthalmology (1999) 27, 318–325 9. vijaya s. rajmane1*, mangala p. ghatole2 and sarita n. kothadia prevalence of oculomycosis in a tertiary care centre al ame en j med s c i (2 011 )4 (4 ) :3 3 4 -3 3 8. 10. patel s., dhakhwa k., badhu b. p., khanal b., chaudhary s.,arya s. k. epidemiological as well as microbiological prole of suppurative keratitis and its outcome. 11. srinivasan m, gonzales ca, george c, et al.: epidemiology and aetiologica diagnosis of corneal ulceration in madurai. south india. br j ophthalmol 1997, 81:965–971. 12. r. c. gupta, a. m. jain, r. m. kushwaha, k. jaiswal, s. tiwari. “prole of various types of corneal ulcer in a tertiary eye care centre”. journal of evolution of medical and dental sciences 2013; vol2, issue 24, june 17; page: 4429-4434. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction adrenocortical carcinoma is a rare disease (incidence 0.72 person per one million) in which malignant cells form in the outer layer of the adrenal gland (adrenal cortex).a tumor may be functioning (makes more hormones than normal) or may be non-functioning (does not make more hormones than normal). most acc are functioning and cause signs and symptoms according to the increase hormonal levels. early diagnosis and removal of the tumor has better survival rate. case report a 60 year old male patient was admitted with chief complain of abdominal pain and sudden weight loss in last one month and newly detected diabetes mellitus (rbs : 375) and hypertension (164/92). investigations routine workup revealed an unremarkable hemogram and serological investigations were within normal limits hba1c: 16.1 24 hrs urinary vma levels: 1.6 mg/24 hrs (2.0-13.2) s.aldosterone level: <0.97 ng/dl (1.76-23.2) s.cortisol: 17.93 (2.68-10.5) free metanephrine level: 1.20 pg/ml (0-65) usg abdomen : right kidney : 90 x 50 mm. no evidence of hydronephrosis or calculus approximately 10x8x8 cm sized nixed echogenic lesion with internal vascularity in noted in right suprarenal region, superiorly it abuts segment vi of right lobe of liver with loss of fat plane , anteriomedially the lesion abuts the infrahepatic ivc with preserved fat plane. no evidence of hydronephrosis or calculus impression : malignant mass arising from right adrenal gland. triple phase cect abdomen and pelvis : large well dened heterogenous density lesion within right suprarenal region measuring 87 x 96 mm in axial plane with craniocaudal extension of 95mm. right adrenal gland is not visualized separately. lesion shows few internal hyper dense hemorrhagic areas. on contrast administration, lesion shows mild heterogenous enhancement with internal traversing pathological vessels, predominantly supplied by inferior adrenal artery. lesion shows early washout with internal hypodense non enhancing necrotic area. superiorly : lesion abuts right lobe of liver and right hemi diaphragm st ndanteriorly : abuts 1 and 2 part of duodenum inferiorly : abuts cortex of upper pole of right kidney causing its caudal displacement. lesion abuts hepatic exure of colon anteromedially , abuts intra and infrahepatic inferior vena cava. management patient was planned for exploratory laparotomy and right adrenalectomy. after opening the peritoneal cavity , diffuse right adrenal mass of approx. 12x10 cm of size , irregular in shape abutting liver , ivc and duodenum. mass was necrotic with friable consistency. patient was discharged on pod : 7 . post op was uneventful a rare case of adrenocortical carcinoma: a case report original research paper dr. bhavesh dave professor and head of department, department of general surgery, smt. n.h.l. municipal medical college, ahmedabad. dr. yajurvendra gohil rd3 year resident, department of general surgery, smt. n.h.l. municipal medical college, ahmedabad. x 85gjra global journal for research analysis general surgery adrenocortical carcinoma (acc) is a rare, heterogeneous malignancy with a poor prognosis. accs may be hormone functioning and non-functioning , sign and symptoms develop depending upon the excessive hormone secreted. surgical resection is the preferred treatment option . presenting a 60 year old male patient with complaints of abdominal pain , weight loss , hypertension and hyperglycemia diagnosed as malignancy in adrenal gland in cect abdomen , operated for right open adrenalectomy. histopathological examination suggestive of : adrenocortical carcinoma abstract keywords : adrenocortical carcinoma , malignancy , surgical intervention. dr. kirit parmar professor, department of general surgery, smt. n.h.l. municipal medical college, ahmedabad. dr. paras lalwani rd3 year resident, department of general surgery, smt. n.h.l. municipal medical college, ahmedabad. dr. harshil shah* rd3 year resident, department of general surgery, smt. n.h.l. municipal medical college, ahmedabad. *corresponding author dr. simran bhalla rd3 year resident, department of general surgery, smt. n.h.l. municipal medical college, ahmedabad. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 86 x gjra global journal for research analysis and patient was normotensive and euglycemic on discharge histopathological examination: adrenal cortical carcinoma of the right adrenal gland . t3nxmx discussion adrenal cortex has 3 parts: zona glomerulosa which secretes aldosterone (mineralocorticoids), zona fasciculata which secretes cortisol, corticosterone and cortisone (glucoc orticoids), zona reticularis which secretes dehydroe piandrosterone (androgen) . acc mainly affects adults, children may be affected too. the median age at diagnosis is 46 years. 3 important prognostic factors: ÿ completeness of resection ÿ stage of disease ÿ pathological grade most common sites of metastasis are the lung , liver , peritoneum and less commonly bones and major veins . palliation of metastatic functioning tumors may be achieved by resection of both the primary tumor and metastatic lesions. unresectable or widely disseminated tumors may be palliated by adrenolytic therapy with mitotane antihormonal drugs , systemic chemotherapy and/or radiation therapy . 5 year survival with stage 4 tumor is usually less than 20%. radical open surgical excision is the treatment of choice for patients with localized malignancies and remains the only method by which long term survival is approximately 38-46% various differential diagnosis of acc includes adrenal adenoma, pheochromocytoma, neuroblastoma , ganglio neuroma , stromal neoplasm like lipoma or myelolipoma which can be differentiated on the basis of biochemical radiological and hpe investigations. conclusion acc is a very rare tumor of adrenal cortex and should be suspected in individuals with adrenal mass and newly detected hypertension, hyperglycemia and various other features due to increase hormonal levels. cect abdomen pelvis revealing central areas of necrosis and hemorrhage with relative contrast retention and calcication points more towards acc. surgical resection remains the mainstay of treatment. chemotherapy and radiotherapy to bone metastasis with surgical removal of localized functioning metastases may be attempted in stage iv tumor but 5 year survival is less than 20 %. although chemotherapy (mitotane) has shown disease free progression , but no overall survival have been demonstrated so far for stage i and ii disease. references 1. sabiston textbook of surgery 1st south asian edition 2. bailey and love short practice of surgery 27th edition 3. smith and tanagho’s general urology , 19th edition 4. campbell-walsh urology , 11th edition volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction benign prostatic hyperplasia is one of the most common urological diseases affecting millions of men worldwide. the pooled prevalence of bph worldwide is estimated to be 26.2%, where the prevalence is 14.8 % in younger males aged 40 and it is 36.8 % in males aged 80 and above. it is characterised by a benign overgrowth of prostatic tissue around the urethra which ultimately constricts the urethral opening, resulting in lower urinary tract symptoms. the symptoms associated with luts include urgency, frequency, nocturia, incomplete urination and weak stream. the condition is associated with interference in daily activity of patients to produce a negative impact on quality of life. many other complications associated with bph include acute urinary retention, chronic urinary retention, urinary tract infections (utis), formation of bladder calculi, hematuria and damage to bladder walls and kidneys. the management of bph is divided into conservative, medical and surgical with latest technological advances but each of them has its own limitations. approximately, 10% of patients who have undergone transuretheral prostectomy or open prostectomy for bph has subsequently develop cancer. although, surgery is the choice for treatment, but due its expensiveness and number of complications, ayurvedic approach towards the disease can provide promising results. in ayurveda classics, there is vast description of group of obstructive uropathies under the heading of “mutraghata”. in vatasthila vyadhi, which is a type of mutraghata may have some similarity with benign prostate hyperplasia on the basis of symptoms like achala unnata granthi (singly movable and elevated swelling), vinmutranilasanga (retention of urine, faeces and atus), bastiadhmana (distention of urinary bladder), vedanachaparabastou (excretion pain in bladder). in vatasthila, the predominant feature is “vibandha” or “avarodha”. according to acharya dalhana, vata is the main factor in the pathogenesis of mutragahata. in the classics, acharya sushruta decided general line of management of all types of mutraghata by use of kashaya, kalka, sarpi, bhakshaya, avaleha, payasa, kshara, madya, asava, swedana, basti and uttarbasti and formulations told in context of ashmari and mutrodavarta diseases. hence keeping all these in mind, clinical study using tilanala kshara mentioned in rasatarangini, which advocates its use in managing urine obstruction, was designed as a treatment modality in bph. case report case 1: a 65 years old male patient with chief complaint of dribbling micturition, frequent micturition and nocturia since 5 months was presented in institute hospital. on examination, patient was afebrile, conscious, well-oriented, responding to verbal commands. the patient was treated on the basis of opd. the patient is known case of hypertension and diabetes since 6 years. he was on anti-hypertensive drug telma 40 (40mg) once daily and glycomet (500mg) twice a day. on examination, pulse rate was 80/min and blood pressure was 170/100 mmhg. on the basis of his clinical presentation, routine haematological investigations, blood sugar (f&pp), urine routine and microscopic, serum psa and was investigated. ultrasonography for prostate enlargement was performed. all the haematological and biochemical investigations were within normal limits. his serum psa level was also in normal limit. the ultrasonography reveals prostatomegaly (measures 4.3 x 5.0 x 3.7 cm, volume 42cc). after getting diagnosed with bph, the treatment with tilanala tilanala kshara in the management of benign prostatic hyperplasia (bph) – a case study original research paper bharat bhushan pg scholar, college of ayurveda, bharati vidyapeeth (deemed to be university), pune x 1gjra global journal for research analysis ayurveda th thbenign prostatic hyperplasia is associated with ageing process and most frequently seen in 5 and 6 decade of men. it has signicant impact on the health as well as it decreases the quality of life of the person suffering from it. ayurveda classics have described it under the heading of mutraghata and have similarity to its subtype vatasthila, with predominant symptoms of urgency, dribbling micturition, urine retention etc. there is no permanent and safe cure with modern medicine, except surgical invasion, which will lead to more complications. a 65 years patient diagnosed with prostatomegaly has visited the o.p.d. of bharati ayurveda hospital, bharati vidyapeeth university,pune. the presentation of patient was comparable to vatasthila, a subtype of mutraghata and the treatment was carried out as per the classics. the patient was given tilanala kshara along with regulated diet and lifestyle. assessment was made using international prostate symptom score (ipss) on 0, 5, 10, 15 day of treatment. at the end of the treatment there was considerable improvement in the subjective parameters. the observations revealed that the use of tilanala kshara can play a key role in the management of patients suffering from bph. further controlled pilot studies are required to establish the proof of efcacy in a systematic way. @ summary benign prostatic hyperplasia is among the most common urological diseases in men and estimated to be 26.2% in men between the age group of 40-60 and above. there is a benign overgrowth of prostatic tissue resulting in lower urinary tract symptoms. the condition further leads to interference in daily activity of patients and create a negative impact on the quality of life. the management of bph can be done by medical and surgical interferences but they are associated with few limitations. ayurveda has its own principles in treating the condition, among which use of kshara is one of them. the present paper deals with administration of tilanala kshara in a patient with clinical presentation of bph. the assessment score using international prostate symptom score (ipss) has shown signicant improvement in the subjective parameters. hence, the use of tilanala kshara can be used as an alternative treatment protocol for the disease bph. abstract keywords : benign prostatic hyperplasia, mutraghata, vatasthila, tilanala kshara, ipss volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra amit a. paliwal* assistant professor, college of ayurveda, bharati vidyapeeth (deemed to be university), pune *corresponding author 2 x gjra global journal for research analysis kshara was carried out for 15 days along with follow up. material and method tilanala kshara was prepared as per classical text and administered in dose of 500 mg half an hour before meal orally with luke warm water for 15 days. assessment criteria sign and symptoms on the basis of relief of nocturia, frequency, dribbling, and urgency were scored by using international prostate symptom score (ipss) sheet on 0, 5, 10 and 15th day. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra in the past month not at all less than 1 in 5 times less than half the time about half the time more than half the time almost always 1. incomplete emptying (how often have you had the sensation of not emptying your bladder?) 0 1 2 3 4 5 2. frequency (how often have you had to urinate less than every two hours?) 0 1 2 3 4 5 3. intermittency (how often have you found you stopped and started again several times when you urinated) 0 1 2 3 4 5 4. urgency (how often have you found it difcult to postpone urination?) 0 1 2 3 4 5 5. weak stream (how often have you had a weak urinary stream?) 0 1 2 3 4 5 6. straining (how often have you had to strain to start urination?) 0 1 2 3 4 5 none 1 time 2 times 3 times 4 times 5 times 7. nocturia (how many times did you typically get up at night to urinate?) 0 1 2 3 4 5 total i-pss score: 1-7: mild8-19: moderate 20-35: severe quality of life due to urinary symptoms delighted pleased mostly satised mixed mostly dissatised unhappy terrible if you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that 0 1 2 3 4 5 6 observations and result ipss 0 day 5th day 10th day 15th day incomplete emptying 3 3 3 2 frequency 2 2 2 1 intermittency 1 1 1 2 urgency 2 2 2 2 weak stream 2 2 2 2 straining 2 1 1 2 nocturia 3 3 2 2 quality of life due to urinary symptoms 4 3 3 3 total 19 18 16 16 discussion b.p.h. is a frequent nding in older men and about three fourth of all men over 60 years of age experience its symptoms. prostatectomy, the primary approach to the management of bph, accounts for 38% of all major urological surgery in usa. in india, it has been reported that post-operative mortality is 3% and a high morbidity of nearly 20% is found in immediate post-operative phase with 2 – 3 % late complications including incontinence and up to 15% of potency problems (ref. d. d. karanjwala 1990). all these considerations provided a rm launch pad to foray in to the therapeutic alternatives, which could be provided from the heritage of ayurveda, the science of life. kshara is alkaline substance obtained from ash of plants, minerals and animal products. it is superior among the sharp and subsidiary instruments because it can perform chedana (excision), bhedana (incision), lekhana (scrapping) and destroys the tridoshaja disorders. tila possess madhu-katukashaya-tikta rasa, guru-snigdha guna, ushna virya, madhura vipaka and have vatahara property, thereby balances the vitiated vata in mutraghata. the kshara being alkaline substances have high content of potassium, thereby they act as diuretics, hence relieves the obstruction present in bph. thus, by above all the properties of tilanala kshara, it acts effectively in reducing the sign and symptoms of bph and improves the quality of life of them patient suffering from this disease. conclusion however, the exact etiology of bph is unknown, being a disease caused by vitiated vata and urine obstruction being the predominant symptom, the oral administration of tilanala kshara proves effective to lessen the sign and symptoms. in ipss score, there was relief in incomplete voiding, frequency, intermittency, straining, weak stream and nocturia along with improvement in the qualilty of life. x 3gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra since, there is need for an alternative tool which is less invasive and with minimal complications; this study could be utilized in the management of bph patients. this study can provide a stepping stone for further research in adopting ayurvedic drug for the management of bph. references: 1. mcvary, k. t., roehrborn, c. g., avins, a. l., barry, m. j., bruskewitz, r. c., donnell, r. f., ... & ulchaker, j. c. (2011). update on aua guideline on the management of benign prostatic hyperplasia. the journal of urology, 185(5), 1793-1803 2. speakman, m. j., & cheng, x. (2014). management of the complications of bph/boo. indian journal of urology: iju: journal of the urological society of india, 30(2), 208. 3. bostw bostwick, d. g., cooner, w. h., denis, l., jones, g. w., scardino, p. t., & murphy, g. p. (1992). the association of benign prostatic hyperplasia and cancer of the prostate. cancer, 70(s1), 291-301.ick dg, cooner wh, denis l, jones gw, scardino pt, murphy gp. the association of benign prostatic hyperplasia and cancer of the prostate. cancer, 70(s1),pp.291-301. 4. singhal gd, mitra j, shukla kp, sharma kr. susrutasamhita, ancient indian surgery vol. 3, reprint ed. delhi: chaukhamba sanskrit pratishthan; 2007. p.443. 5. ambikadutta shastri, sushruta samhita, chaukhamba sanskrit sansthan, varanasi, 14th edition, 2003, uttartantra 58/6. 6. ambikadutta shastri, sushruta samhita, chaukhamba sanskrit sansthan, varanasi, 14th edition, 2003, uttartantra 58/27-28. 7. sharma s. rasatarangini, shastri k (editor), 11th ed., motilal banarasidas publication, new delhi; 1979, chaturdasha taranaga,81. 8. ambikadutta shastri, sushruta samhita, chaukhamba sanskrit sansthan, varanasi, 14th edition, 2003, uttartantra 11/3. orientation programs are designed and implemented by different academic institutions globally for students transiting from high school to undergraduate course, with the objective of familiarizing the students with campus environment and academic programs, and help them in adjusting (taylor be et al, 1996). as per devi jn et al. (2016), in india, students aged 17—19 years enter medical profession, with varied psychological characteristics such as fear of ragging, feeling of homesickness, peer pressure, parental pressures, language problems, and adjustments to hostel life and food. they come from different sociocultural backgrounds and have diverse expectations from the medical profession and after entering, they are expected to understand and appreciate the medical subjects. to facilitate this transition from school phase to a professional course, the medical council of india (mci) has introduced a foundation course of 2 months in the “regulations on graduate medical education, 2012.” according to the medical council of india vision 2015, “foundation course will be of 2 months duration after admission to prepare a student to study medicine effectively. this period aims to orient students to national health scenarios, medical ethics, health economics, and learning communication skills, life support, computer learning, soc io logy and demographics , b iohazard safe ty, environmental issues and community orientations”. furthermore, as it has been accepted by stern dy (2006) that “professionalism is a core competency of physicians. clinical knowledge and skills (and their maintenance and improvement), good communication skills, and sound understanding of ethics constitute the foundation of professionalism. rising from this foundation are behaviors and attributes of professionalism, accountability, altruism, excellence, and humanism, the capstone of which is professionalism.” a previous study by singh s et al. (2007) showed that most of the students do not have any preceding knowledge of the forthcoming professional demands except for a few internet, language, and time management skills. hence, the medical education unit (meu) of jagannath gupta institute of medical sciences and hospital (jgimsh), budge budge, west bengal designed and evaluated a two week long orientation and foundation program for the rst-year mbbs students, batch 2019—2020, august 19—31, 2019 to orient the fresh batch of students about national health scenarios, medical ethics, learning skills and communication, life support, computer learning, sociology and demographics, biohazard safety, and community orientation. the purpose of the foundation course was to introduce students to all aspects of the medical education that is to be imparted to them during the next years. the course content included: i. orienting the students to all aspects of the medical college environment; ii. equipping students with certain basic, but important skills required for patient care; iii. enhancing communication, language, computer and learning skills of the students; iv. providing opportunity for peer and faculty interactions and an overall sensitisation to the various learning methodologies; materials and methods orientation program and foundation course was organized by the meu, jgimsh for the incoming rst-year mbbs students of 2019-2020 batch. prior approval for the study was obtained from the institutional ethics committee of jgimsh. 150 students voluntarily participated in this two week long program held from august 18—31, 2019, and gave written informed consent for the same. the entire program consisted of lectures, small group discussions, hospital and rural health training centre visits and this included group activities, interactive forum, role plays, and clinical bed-side demonstrations. the entire program was facilitated by 50 facilitators and they motivated students to participate actively. students' feedback was obtained by a pre-designed and prevalidated anonymous questionnaire. the students evaluated the course on the following broad parameters: content and design; facilitators evaluation; knowledge, skills and condence before and after the course on attitude, ethics and communication, computer efcacy, hospital and health centre visits. statistical analysis of the collected data was performed using ms excel 2017. a study on impact of orientation program and foundation course at entry level on first-year mbbs students original research paper chatterjee anant associate professor, department of community medicine, jagannath gupta institute of medical sciences and hospital, budge budge, kolkata medical science objectives: to assess the continued usefulness and relevance of foundation course in priming students to the multiple arenas of medical curriculum. to study the perception of medical ethics in the students who hae enrolled in the new cirruculum. methodology: foundation course was conducted for 250 incoming mbbs students of 2019 batch and initial student feedback obtained by an pre designed and pre validated anonymous questionnaire to assess the usefulness and relevance of the foundation course. results: in the feedback, most of the students understood the program and felt that the skills taught can be implemented. more than half of the students had a proper idea about the professionalism of being a doctor .a small part of the study population understood but felt the skills difcult to implement while a negligible portion did not understand at all. conclusion: this study makes it clear that there is a lasting impact of foundation course in acquainting students with multiple arenas of medical curriculum. it is the rst decisive step in the long journey of medical education and should be a regular feature in the curriculum. abstract keywords : orientation program, foundation course, medical education, mci curriculum, indian medical graduate volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra majumdar sayantani* assistant professor, department of anatomy, jagannath gupta institute of medical sciences and hospital, budge budge, kolkata*corresponding author dey arijit senior resident, department of forensic medicine, all india institute of medical sciences, new delhi 62 x gjra global journal for research analysis results table 1: feedback of students on content and design of the foundation course (n=141) table 1 shows feedback of students on content and design of the foundation course. out of 150 students, 141 responded with the feedback, whereas 9 did not respond. 96% (n=135) students found the program relevant, 95% (n=134) students found the program comprehensive, while 97% (n=137) students found the orientation program easy to understand. fig. 1: feedback of students on content and design of the foundation course table 2: feedback of students on teachers/ facilitators (n=141) table 2 shows feedback of students on teachers/facilitators, where 141 students responded with feedback. 98.5% (n=139) students stated that the facilitators were knowledgeable, 96% (n=135) students found the teachers were well prepared for the program, 97% (n=136) students stated that their queries were responded, 97% (n=136) students found the teachers were punctual and 98% (n=137) students found that facilitators had good communication skills. fig.2: feedback of students on teachers/ facilitators volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra parameters strongly disagree disagree agree strongly agree relevant 1 5 37 98 comprehensive 0 6 58 76 easy to understand 1 3 36 101 parameters strongly disagree disagree agree strongly agree knowledgeable 1 1 12 127 well prepared 1 4 29 106 responsive to questions 2 2 25 111 punctual 1 3 37 99 good communication skills 1 2 36 101 table 3: feedback of students on knowledge, skills and condence on different competencies competence related to course poor fair good excellent orientation with departments, facilitators, facilities, course work (n= 146) before 47 57 34 8 after 3 7 87 49 learning about healthcare delivery system (n=137) before 53 55 25 4 after 1 6 75 55 learning about attitude, ethics, professional development and communication skills (n=138) before 23 57 41 17 after 0 7 65 66 language and skill development (n=135) before 37 54 34 10 after 1 3 65 66 computer skills in medical education (n=127) before 18 34 47 28 after 3 16 66 42 importance of sports and entertainment during medical education (n=136) before 27 42 52 15 after 13 19 64 40 table 3 compares the students' response on knowledge, skills and condence on different competencies, before and after the program. before the course, only 28.7% (n=42) students had a good or excellent knowledge while 71.2% (n=104) had poor or fair knowledge about orientation with departments, facilitators, facilities, course work. however, after the program, these were converted to 87% (n=136) and 13% (n=10) respectively. with the usage of grading, the students perception provided mean values of 2.1(before the course) and 3.3 (after the course) respectively. when skills and condence on learning about healthcare delivery system is compared before and after the program, it is observed that before the course, just 21% (n=29) students had a good or excellent knowledge while 79% (n=108) had poor or fair knowledge in this area. however, after the program, these were converted to 95% (n=130) and 5% (n=7) respectively. with the usage of grading, the students perception provided mean values of 1.9(before the course) and 3.3 (after the course) respectively. if students' response on knowledge, skills and condence on learning about attitude, ethics and professional development and communication skills is compared before and after the program, it is observed that before the course, 42% (n=58) students had a good or excellent knowledge while 58% (n=80) had poor or fair knowledge about these areas. however, after the program, these were converted to 95% (n=131) and 5% (n=7) respectively. with the usage of grading, the students perception provided mean values of 2.4(before the course) and 3.4 (after the course) respectively. regarding language and skill development it is observed that before the course, 33% (n=44) students had a good or excellent knowledge while 67% (n=91) had poor or fair knowledge. however, after the program, these were converted to 97% (n=131) and 3% (n=4) respectively. with the usage of grading, the students perception provided mean values of 2.1(before the course) and3.5 (after the course) respectively showing a signicant improvement after the sessions. if computer skills in medical education is compared before and after the program, it is seen that before the course, 59% (n=75) students had a good or excellent knowledge while 41% (n=52) had poor or fair knowledge; which were converted to 85% (n=108) and 15% (n=19) respectively after the program. with the usage of grading, the students perception provided mean values of 2.7(before the course) and 3.2 (after the course) respectively. finally, regarding response on the importance of sports and entertainment during medical education, while before the course, 49% (n=67) students had a good or excellent knowledge and 51% (n=69) had poor or fair knowledge, after the program, these were converted to 76% (n=104) and 24% (n=32) respectively. with the usage of grading, the students perception provided mean values of 2.4 (before the course) and 3.0 (after the course). x 63gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra discussion different orientation programs are implemented globally to acclimatize the students of an institution to the campus environment, familiarize them with the teaching programs, helping them to adapt to the academic challenges, and guide their transition from high school into undergraduate programs. in india, students get admission to a medical college based on their merit at the qualifying national eligibility-cum-entrance test undergraduate examination as per the indian medical council (amendment) act, 2016. an indian medical graduate (img), as per mci, should possess requisite knowledge, skil ls, att i tudes, values and responsiveness, to enable him or her to function effectively as a physician of the community while being globally relevant. as medicine is a challenging profession that demands the study of a large volume of knowledge, acquisition of novel clinical skills, self-directed learning, ethical behaviour and professional attitudes, the mci has suggested conducting a foundation course of 2 months for the rst-year mbbs students with the aim of producing competent indian medical graduates. this inspired the meu faculties at jimsh, budge budge, west bengal to design, implement, and evaluate an orientation program and foundation course for 2019-2020 batch of rst year mbbs students. the feedback was taken from them both before and after the course, which was implemented by 50 facilitators. several studies on orientation training for first m.b.b.s students in india have concentrated on the assessment of the students' knowledge, attitudes and perceptions about selected subject areas immediately before and after the program. one such study by shankar p et al. (2012) revealed that the median knowledge and attitudes scores increased after the program. in another study by mittal r et al. (2013), the students were given a pre and post program test, which showed an improvement of 37.3% in the post test average over the pre-test one. the best pre-test performance was 75% while that in the posttest was 100%. a study by mahajan r et al. (2015) evaluated the orientation program from students' perspective and both faculty and students' perspectives, to recommend revised program. in the present study by chatterjee anant et al, feedback of students on content and design of the foundation course reveals that 96% (n=135) students found the program relevant, 95% (n=134) students found the program comprehensive, while 97% (n=137) students found the orientation program easy to understand. 98.5% (n=139) students stated that the facilitators were knowledgeable, 96% (n=135) students found the teachers were well prepared for the program, 97% (n=136) students stated that their queries were responded, 97% (n=136) students found the teachers were punctual and 98% (n=137) students found that facilitators had good communication skills. a comparison of students' response on knowledge, skills and condence on different competencies before and after the orientation program showed a drastic improvement. before the course, only 28.7% (n=42) students had a good or excellent knowledge about the departments, facilitators, facilities, course work while 71.2% (n=104) had poor or fair knowledge. however, after the program, these were converted to 87% (n=136) and 13% (n=10) respectively. the awareness created in students with respect to place (learning environment and facility), teaching schedules and timetables, personnel (faculty, staff and mentors) indicates a tremendous improvement after attending the sessions. when the ndings on learning about healthcare delivery system is compared before and after the program, there is an improvement in good or excellent knowledge from 21% (n=29) (before course) to 95% (n=130) (after course) while poor or fair knowledge in this area dropped from 79% (n=108) (before course) to only 5% (n=7) (after course). the feedback on the eld visits to the rural health training centre provided a strong orientation to the health care delivery system. when the students' response on learning about attitude, ethics and professional development and communication skills are compared before and after the program, it is seen that while only 42% (n=58) students had a good or excellent knowledge before the course, it improved to 95% (n=131) after the course. at the same time, poor or fair knowledge about these areas dropped from 58% (n=80) (before course) to only 5% (n=7) (after course).this nding indicates students' marked improvement on values, behaviour, ethics, communication and personality development after the program. before the course, only 33% (n=44) students had a good or excellent knowledge about language and skill development, which got improved to 97% (n=131) after the course completion. before the course, 59% (n=75) students had good or excellent knowledge about computer skills in medical education, which got improved to 85% (n=108) after the program was concluded. this nding shows that even before the course, many students were familiar with computer skills. 49% (n=67) students had a good or excellent knowledge on the importance of sports and entertainment during medical education before the course, which was further improved to 76% (n=104) after conducting the course, which indicates that the students were familiar with the importance of extra-curricular activities mainly physical, even prior to the course. all these ndings in the present study are similar to other similar studies conducted in indian scenario (david ma, 2013; shankar pr, 2014; srimathi t, 2014; patel j et al, 2017) and this reects the utility and necessity of such orientation programs in the current context of mbbs education. it has been suggested by cruess sr et al. (2008) that role modeling is an effective means of teaching professionalism. in the current orientation program, senior faculty and medical education unit members acted as facilitators for various interactive sessions. it has been observed that learners watch, embrace and mimic attitudes and behaviors of role models. it is found to be more effective to teach and assess professionalism in early medical learners who have just entered medical school with huge expectations and ideals, as observed by stern dy (2006). hence, it can be summarized that there is a denite and lasting advantage of a structured foundation course, which can help alleviate students' anxieties and guide them to cope with forthcoming professional requirements. conclusion this study makes it clear that there is a denite and lasting advantage of orientation program for students entering the mbbs course. the data indicates that there was remarkable improvement after the students attended the entire course, showing that there is an actual internalization of the skills taught during the program.the cognitive, affective and communication competencies of the students were adequately addressed during the foundation course. apart from the academic areas, computer ability, sports and team spirit as well as personality, attitude and ethics were also dealt with. the interactive and responsive sessions of the program were highly appreciated by majority of the students who recommended further such programs every year on a regular basis. many studies suggest that teaching of scientic research competencies should start early in undergraduate medical education and continue throughout the pre-clinical and clinical years as it helps in the research-oriented career in their future. to summarize, orientation will help in improving the students to cope with multiple demands of medical education and to ensure that they develop into well-rounded personalities and outstanding in the community. references 1. cruess sr, cruess rl, steinert y. role modelling – making the most of a powerful teaching strategy. bmj 2008; 336:718—21. 2. david ma. foundational orientation program for medical students. education in medicine journal;2013:5(2):140—4. 64 x gjra global journal for research analysis 3. devi jn, kumari as, murty ds. the impact of orientation program for first m.b.b.s students in the transformation of perceptual learning into experiential learning –an insight. iosr journal of dental and medical sciences.2016;15(6):40-45. 4. mahajan r, gupta k. evaluation of orientation program for fresh mbbs entrants: faculty and students’ perspective. int j appl basic med res. 2015; 5(1):50—53. 5. medical council of india. regulations on graduate medical education 2012. new delhi : medical counci l o f india; 2012. avai lable f rom: http://www.mciindia.org/tools/announcement/revised_gme_2012.pdf. 6. medical council of india (homepage on the internet). vision 2015. available from http://www.mciindia.org/tools/announcement/mci_booklet.pdf. 7. mittal r, mahajan r, mittal n. foundation programme: a student’s perspective. int j appl basic med res. 2013;3(1):52—4. 8. patel j, akhani p. a study of perception of rst-year mbbs students toward orientation program and foundation course at entry level.natl j physiolpharmacol 2017;7(9):920-923. 9. shankar p, karki b, thapa t, singh n. orientation program for rst year undergraduate medical students: knowledge, attitudes and perceptions. education in medicine journal, 2012: 4(1):57-63. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 65gjra global journal for research analysis introduction laparoscopic cholecystectomy has revolutionized the treatment of gallstone disease, being the most remarkable surgical innovations of 20th century. as all other surgical interventions, laparoscopic cholecystectomy is also associated with number of complications, which may range from mild to serious and even life threatening at times. to prevent such complications routine drainage was adopted in laparoscopic cholecystectomy because of the fear of collection of bile or blood, requiring open procedures and to allow carbon dioxide insufated during laparoscopy to escape via the drain site, thereby decreasing the shoulder pain. on the other hand, drain use may increase infective complications and delay discharge. this serves as a basis to undertake present study to compare the effect of drain versus no drain use on outcome of laparoscopic cholecystectomy. materials and methodology the study was conducted at the department of general surgery by senior faculties, at publicly funded tertiary care institution. 50 patients with symptomatic gallstone disease were admitted for elective surgery from october 2016 to october 2018. after obtaining writtten informed consent, the patients were divided into two groupsgroup a and group b on random basis, group a: (n= 25) sub-hepatic space was drained by an abdominal drain (ryle's tube no. 20) which was brought out through mid axillary port. group b: (n= 25) non-drainage of sub-hepatic space all patients were subjected to laparoscopic cholecystectomy under general anesthesia. laparoscopic cholecystectomy was performed using three port or four port technique. in 25 patients in group b non-drainage of sub-hepatic space was used, in the group a sub-hepatic space was drained by a abdominal drain (ryle's tube no. 20) which was brought out through mid axillary port. all the patients in both experimental and control group were evaluated for outcome measures postoperatively including abdominal pain (visual analogue scale), shoulder pain, drain site infection, wound infection, fever, duration of post-operative hospital stay, nausea, vomiting, hemorrhage. results and discussion ÿ in the present study symptomatology distribution of patients shows rhc pain most common symptom followed by nausea / vomiting in both drain and no drain group. minor symptoms are epigastric pain, fever and right shoulder pain. ÿ both groups are homogenous in term of symptoms (p = 0.7013) ÿ in present study, 15 patients with intra-operative adhesions need for drain kept while 4 patients with intraoperative adhesions did not need for drain kept. ÿ in laparoscopic cholecystectomy, intra-operative adhesions increase need for drain kept and this difference is statically signicant. (p value= 0.0002) ÿ in present study, 3 patients have normal calot's triangle absent, in which 2 have mirizzi syndrome and one patient have absent cystic duct. in all three patients drain kept. out of three patients, one patient had biliary leak occurred in post-operative period and manage conservatively, and remaining 2 patient had only drain site pain occurred. ÿ but in present study, need for drain in abnormal calot's triangle patients is statistically insignicant (p value= 0.074). this may be due to small sample size. ÿ laparoscopic cholecystectomy with drain took slightly more time than laparoscopic cholecystectomy without drain but this difference was statistically signicant.(p value=0.0001) ÿ consequently, more operative time requirement in drain thgroup may be due to anterior axillary 4 port insertion and keeping the drain. a comparative study of role of drain in laproscopic cholecystectomy in cases of calculas cholecystitis original research paper dr. jayesh v. parikh hou and professor, department of general surgery, b.j. medical college, civil hospital, ahmedabad. general surgery laparoscopic cholecystectomy has become the gold standard treatment for gall stone disease. this procedure is also associated with difculties and complications. so, many surgeons adopted drainage of gb fossa after procedure to drain bile or blood to check for injury to cbd or vessels, which is protective. putting a drain is also associated with post op pain, longer hospital stay. this study is about merits and demerits of putting a drain in gb fossa of 50 patients undergoing elective laparoscopic cholecystectomy. abstract keywords : laparoscopic cholecystectomy; calculus cholecystitis dr. parth r. dalal assistant professor, department of general surgery, b.j. medical college, civil hospital, ahmedabad. dr. vasant t. padhiyar* rd 3 year resident, department of general surgery, b.j. medical college, civil hospital, ahmedabad. *corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra symptoms no. of patients with drains (n=25) no. of patients without drains (n=25) rhc pain 24 24 epigastric pain 7 10 nausea / vomiting 20 18 fever 7 4 right shoulder pain 0 0 intra-operative adhesions normal calot's traingle intraoperative duration present absent present absent average duration no. of patients with drains (n=25) 15 10 22 3 106.8± 11.44min no. of patients without drains (n=25) 4 21 25 0 79.6± 15.13min 12 x gjra global journal for research analysis ÿ incidence of post-operative pain is more in patients with drain group (average pain score 6.6) as compared to no drain group (average pain score 3.8) and this value is statistical signicant (p value = 0.0001). ÿ the study of sharma et al found similar ndings that patients with drain group had higher pain score (average pain score 5.41) as compared to no drain group (average pain score 3.45) with p value = 0.005. ÿ in present study, without drain group most (76%) of patients were discharged within 3 days of operation while in with drain group most (76%) of patients were required post-operative hospital stay 4-7 days and 16% of patients were more than 7 days. conclusion in this study, results indicate that routine drainage of gallbladder bed after elective laparoscopic cholecystectomy cannot be benecial. drainage causes more postoperative pain, prolongs the operative time, increase drain site pain and infection, wound infection and prolongs the hospital stay. however, in selected patients with potential bile leak e.g. imperfect closure of cystic duct, bile staining of liver bed suggesting the possibility of missed accessory duct, difcult cholecystectomy due to inamed gallbladder and/or adhesions, abnormal calot's triangle, drainage can be benecial. at the same time drainage shouldn't be done only for the false sense of security as it can neither prevent postoperative biliary peritonitis nor bleed, unless great care is taken during surgery. difcult laparoscopic cholecystectomy can be judge by preoperative criteria of high wbc count, palpable gall bladder, previous attack of acute cholecystitis, previous abdominal surgery and usg ndings of thickened gallbladder wall, impacted stone at neck and pericholecytic collection and intra-operative criteria of inamed gallbladder, intraperitoneal and peri-gb adhesions, structural anomalies and abnormal calot's triangle. patients with absent of such criteria's can be operated with three port laparoscopic cholecystectomy, without drain and can be discharged within 24-48 hours. final conclusion can be drawn by doing this study for operation done by experience senior surgeon, larger sample size and longer follow-up. references 1) evolution of cholecystectomy: a tribute to carl august langenbuch. indian journal of surgery 2004;66:97-100. 2) textbook of clinical embryology by vishram singh, 1st edition, page no. 165. 3) bailey and love short practice of surgery 25th edition chapter 63 4) gray’s anatomy, 39th edition, page no. 243-245. 5) singh v, trikha b, nain ck, singh k, bose sm. epidemiology of gallstone disease in india: a community-based study. journal of gastroenterology 2001; 16: 560-563. 6) laparoscopic cholecystectomy an evidence based guide by ferdinando agresta, 1st edition, page no. 23,24. 7) laparoscopic surgery of the abdomen by bruce v. macfadyen, 1st edition, chapter 15, page no.127 8) maingot ’s abdominal operat ions 11th edi t ion, laparoscopic cholecystectomy, pg: 859 9) mastery of surgery, 5th edition, chapter 97 10) abc of tube, drain, line and frame by wiley-blackwell, 1st volume, chapter 8, page no. 44 11) gupta a, shrivastava uk, kumar p, burman d. mini laparoscopic versus laparoscopic cholecystectomy: a randomized controlled trial. j tropical gastroenterology 2005; 26 (3): 149-151 12) kathmandu university medical journal vol. 14 | no. 1 | issue 53 | jan-mar 2016 sharma a, gupta sn: drainage versus no drainage after elective laparoscopic cholecystectomy volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra post-operative pain post-operative hospital stay mild moderate severe 1-3 days 4-7 days >7 days no. of patients with drains (n=25) 0 20 5 2 19 4 no. of patients without drains (n=25) 9 16 0 19 6 0 x 13gjra global journal for research analysis introduction urinary tract stones are one of the three most common diseases in the eld of urology in addition to urinary tract infections and benign prostate enlargement. in indonesia urinary tract disease still occupies the largest portion of the number of patients in the urology clinic. the incidence and denite prevalence of this disease in indonesia cannot be established with certainty. from domestic data published, there was an increase in the number of kidney stone patients who were treated at ciptomangunkusumo hospital from year to year starting 182 patients in 1997 to 847 patients in 2002, this increase was largely due to the availability of non invasivekidney stone breakers. eswl (extracorporeal shock wave lithotripsy) which covers 86% of all treatments (eswl, 1pcnl, and open surgery) . in the last 3 decades the approach to urinary stone therapy has undergone substantial changes. the existence of minimally invasive and endourological procedure that can directly access visually both the upper urinary tract forces conventional surgery to be the second choice.endourology referred to here is percutaneous nephrolithotomy (pcnl) which was rst introduced in 1970, is an operation by placing a tool in the body to break or take stones. understanding of the anatomy of renal vascularization, good radiological quality, and improved access to good punk will reduce the risk of complications, especially bleeding, as well as expertise in multiple puncture to access the upper part of the kidney, and 2complex kidney stones. pcnl monotherapy has the advantage of taking large size stones with minimal morbidity, especially stones in the inferior kalik, now pcnl is the main choice for the treatment of kidney stones that are> 20 mm in size, kidney print stones, and 3inferior calyx stones of> 10 mm. published research usually only shows variables of fever, postoperative pain, blood loss, the incidence of urosepsis, or the presence of certain preoperative variables that affect kidney surgery, including age, obesity, type of nephrostomy used. only one multiple regression analysis of the group design showed preoperative hemoglobin, multiple renal access, and stone size as predictors of independent 4perioperative transfusion. this study aims to compare the cost effectiveness of pcnl compared to open surgery seen from all aspects. methods this study is an analytical study with a cross sectional design to see a comparison of the cost effectiveness between open surgery with percutaneous nephrolithotomy (pcnl) in patients with nephrolithiasis at h. adam malik general hospital, medan. this research was conducted at the h. adam malik general hospital in medan. samples were all patients with nephrolithiasis who underwent open surgery or percutaneous nephrolithotomy (pcnl) in the h. adam malik hospital medan from january to december 2018. inclusion criteria were patients with nephrolithiasis> 2 cm in all renal regions or <2 cm in the lower calix. patients with nephrolithiasis that differ between pcnl and open surgery, and have concomitant diseases such as diabetes mellitus, hypertension, malnutrition, secondary infections, blood clotting disorders, and consumption of blood-thinning drugs are excluded. sample collection uses the consecutive method. the variables collected were type of surgery, cost of action, duration of action, need for blood transfusion, length of stay, and complications. categorical variables are presented by number or frequency (n) and percentage (%). continuous variables are represented by mean ± standard deviation or median value. test the normality of numerical variables in the research subjects using the kolmogorov-smirnov or sapphiro-willk test. unpaired t tests or mann-whitney tests were used to compare the numerical data of the two groups, while categorical data were tested using chi square or fisher test. processing and analysis of statistical data using spss statistical software, the value of p <0.05 was said to be statistically signicant. results of a total 67 patients, 44 patients underwent percutaneous nephrolithotomy (pcnl) while 23 other patients underwent the open pyelolithotomy procedure. the mean age in the pcnl group was 49.68 (± 10.78) years compared to the open pyelolithotomy group of 49.13 (± 8.74) years. based on gender variables, it was found that male and female sexes were 22 (50%) in the pcnl group compared with 14 men (60.9%) and 9 women (39.1%) in the open pyelolithotomy group. cost effectiveness comparison of open surgery with percutaneous nephrolithotomy (pcnl) in nephrolithiasis patients in h. adam malik hospital medan original research paper m. bob muharly rambe department of surgery, medical faculty of universitas sumatera utara, haji adam malik general hospital medan x 27gjra global journal for research analysis surgery urinary tract stones are one of the three most common diseases in the eld of urology in addition to urinary tract infections and benign prostate enlargement. percutaneous nephrolithotomy (pcnl) monotherapy has the advantage of taking large stones with minimal morbidity, especially stones in the inferior calyx. this study aims to compare the cost effectiveness of pcnl compared to open surgery seen from all aspects. this study is an analytical study with a cross sectional design to see the comparison of the cost effectiveness between open surgery with percutaneous nephrolithotomy (pcnl) in patients with nephrolithiasis in the h. adam malik general hospital medan in the period of january december 2018. based on the results, it was found that pcnl procedures are superior in terms of cost-effectiveness compared to open pyelolithotomy with relatively shorter duration of action, shorter duration of treatment and less complication of action than open pyelolithotomy. abstract keywords : pcnl, open surgery, nephrolithiasis, cost effectiveness ramlan nasution* department of surgery, medical faculty of universitas sumatera utara, haji adam malik general hospital medan*corresponding author syahmirsya warli department of surgery, medical faculty of universitas sumatera utara, haji adam malik general hospital medan volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 28 x gjra global journal for research analysis table 1. patient' characteristics the factors assessed in this study were complications when intraoperative and postoperative. based on the data it was found that complications occurred in 20 cases of pcnl (45.5%) and 15 cases of open pielolitotomy. a common complication is bleeding, which occurred in 14 cases of pcnl (31.8%) and 12 cases of open pielolitotomy (52.1%). in table 2 we conduct a cost-effectiveness analysis to compare the effectiveness of pcnl compared to open pielolitotomi. there are several variables that are measured and analyzed to determine the effectiveness of the pcnl procedure against the open pyelolithotomy procedure. table 2.cost-effectiveness analysis ausing the mann-whitney test because data is not normally distributed busingchi square in table 2, an analysis between pcnl and open pielolitotomy is presented. for variable duration of operation, there was a statistically signicant difference between the pcnl procedure and open pielolitotomi, where the average duration of pcnl surgery was shorter, namely 172.39 (± 52.94) minutes compared to open pielolitotomy for 217.39 (± 80.96) minute. p value obtained in this variable is 0.015. furthermore, the length of treatment days comparison was seen in patients who underwent the pcnl procedure and open pielolitotomy. the result was that patients who underwent pcnl had a shorter duration of treatment with 4.20 (± 0.97) days compared to open pielolitotomy with 7.26 (± 1.25) days. there is a statistically signicant difference in this variable, with a p value of 0.001. while based on the variable transfusion needs, there were 14 patients who underwent pcnl and needed blood transfusion (31.8%) compared with 14 people in the open pielolitotomy group (60.9%) who needed blood transfusion. there is no statistically signicant difference in this variable with a p value of 0.766. fewer complications occurred in the group of patients who underwent pcnl where there were 20 people in the pcnl group who had complications (45.5%) compared to 15 people in the open pielolitotomy group (65.2%). the result, there is a statistically signicant difference in this complication variable, as evidenced by the p value of 0.034. table3. cost-effectiveness analysis by average costeffectiveness ratio (acer) based on the results of acer calculations, it was found that pcnl had a lower acer on both the hourly duration of the operation and the length of stay, with acer rp. 3,500,000 per hour of operation and rp. 1,100,000 per day. discussion of the 67 patients, 44 patients underwent pcnl and 23 patients underwent the open pielolitotomy procedure with an average age in the pcnl group of 49.68 (± 10.78) years compared to the open pielolitotomy group of 49.13 (± 8.74) years. the average age obtained in this study is quite similar to that of zhang et al., namely 54.3 ± 411.6 (19-80) for pcnl 5and 50.5 ± 11.1 (28-66) for open pielolitotomy according to nakamon et al average age obtained for pcnl 51.42 ± 8,80 and 48,3 (20-66) for open pielolitotomy. the duration of pcnl in the study was found to be similar to zhang et al., namely 172.39 (± 52.94) minutes and 156.6 ± 41.2 (85-285) minutes. whereas the duration of surgery on open pielolitotomy in the study was found to be faster than that of zhang et al, namely 217.39 (± 80.96) vs. 282,1 ± 54,5 (187340). and compare to study by nakamon et al, namely 52,62 (± 20,68) minutes and open pielolitotomi 84 (57-124) minutes for study by cakici et al the duration was faster. the duration of surgery more signicant in these studies, zhang et al, nakamon et al and cakici et al (p=0,015 and <0,001). in this study, length of stay in pcnl patients was 4.20 (± 0.97) and open pielolitotomi 7.26 (± 1.25), where zhang et al. found a longer treatment time of 6.2 ± 2.7 (2-17) for pcnl,according to nakamon et al found the length of stay longer,namely 4,78 (2,65) whereas for open pielolitotomy the time of treatment was found to be 10.3 ± 1.8 (8-14) (zhang 2019), and shorter in cakici et al 5,5 (3-8) the number of blood transfusions in open pielolitotomy was found to be more than for pcnl, ie 60.9% (n = 14) vs. 31.8% (n = 14), although not signicantly different (p = 0.237). in the study of zhang et al., there were more blood transfusions in the open pielolitotomy group, namely 4/11 (36.4%) vs. 12/61 (19.7%). however, contradictory results were found where total bleeding in pcnl was higher than in open pielolitotomy, 695.5 ± 531.8 (10-2512) ml and 613.6 ± 528.7 (100-1800) ml. the different result show in cakici et al for open pielolitotomi no need of tranfusion with the decrease of hemoglobin 1,8 (0,34,7) mg/dl with estimation blood loss 400-600 cc. in this study complications were found in 20 people in the pcnl group (45.5%) and 15 in the open pielolitotomy group (65.2%), with no statistically signicant differences. the most common complication in the open pielolitotomy group was bleeding (52.1%, n = 12). according to the uae algorithm, kidney stone therapy based on location and stone size, for upper and middle pole stones or renal pelvis with for stones more than 20 mm pcnl is the main therapeutic choice. while open surgery is generally volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra characteristics pcnl open pyelolithotomy age (year) 49,68 (±10,78) 49,13 (±8.74) gender male 22 (50%) 14 (60.9%) female 22 (50%) 9 (39.1%) diagnosis pyelumst 23 (52,3%) 3 (13.0%) print st 14 (31,8%) 18 (78.3%) inferior calyx st 4 (9,1%) 0 (0%) multiple calyx st 3 (6,8%) 2 (8.7 %) complication bleeding 14 (31,8%) 12 (52.1%) fever 6 (13,6%) 8 (34.7%) sepsis 0 (0%) 4 (17.3%) wound infection 0 (0%) 2 (%) without 24 (54,5%) 8 (34.7%) variable pcnl open pielolitotomi p duration (minute) 172,39 (±52,94) 217,39 (±80,96) a0,015 length of stay (day) 4.20(±0.97) 7.26 (±1.25) a0,001 transfusion b0,237 yes 14 (31,8%) 14 (60.9%) no 30 (68,2%) 9 (39.1%) complication b0,034 yes 20 (45,5%) 15 (65.2%) no 24 (54,5%) 8 (34.7%) cost-effectiveness variable acer pcnl (in 1000 rupiah) acer open pyelolithotomy (in 1000 rupiah) surgery duration 3.500 per hour 4.100 per hour length of stay 1.100 per day 1.272 per day performed on indications of unavailability of pcnl facilities, failure of eswl and pcnl measures, large size of multiple stones that require repeated eswl and pcnl, presence of urinary anatomical abnormalities, extreme obesity, and contraindications to pcnl. cost-effectiveness analysis, which is a comparative analysis of effective intervention or treatment taking into account the costs incurred for conducting an intervention, is conducted to compare which procedure are taken to obtain maximum effects with minimal costs. costs included in the ina-cbg's package that are calculated in costs include the direct medical costs which consist of drug costs, hospitalization fees, doctor fees (services), administration fees, laboratory fees, and medical equipment costs. cost-effectiveness calculation is stated in acer value (average cost-effectiveness ratio). results from acer were interpreted as average costs per clinical outcome unit. based on the rates of ina-cbg's regional 1, type a hospitals, pcnl and open pyelolithotomy belong to the same category, namely the upper urinary tract procedure. this category has a package of costs ranging from rp. 22,979,300 to rp. 31,916,200. whereas in terms of rates, the two procedures have different rates of rp. 13,324,000 for pcnl and rp. 18,653,000 for open pyelolithotomy. based on the results of the acer calculation, it was found that pcnl had lower acer both on the aspect of hourly duration of operation and length of stay, with acer rp. 3,700,000 per hour of operation and rp. 1,100,000 per day of care. based on the acer value, it was found that the pcnl was more costeffective than the open pyelolithotomy because the acer value was more and with consideration pcnl had lighter side effects in terms of bleeding, fever, sepsis and surgical wound infection. therefore, pcnl can be recommended as an option in the treatment of kidney stones measuring over 2 cm both based on medical indications and the cost effectiveness of actions. conclusion: based on the results of cost-effectiveness analysis studies, it was found that pcnl procedures were superior in terms of cost-effectiveness compared to open pyelolithotomy with relatively shorter duration of action, shorter duration of treatment and less complication of action than open pyelolithotomy. suggestions for future research are to conduct studies with a wider sample and more homogeneous data to assess the costeffectiveness of both actions, and study can continue to compare other therapeutic modalities so as to achieve modalities with high cost-effectiveness in channel stone therapy urinary tract. references: [1] jayaraman, uc., and gurusamy, a. (2018), “review on uro-lithiasis pathophysiology and aesculapian discussion” iosr journal of pharmacy. 8(2), 30-42. [2] bawari s, sah an, tewari d. (2016),“urolithiasis: an update on diagnostic modalities and treatment protocols.” indian journal of pharmaceutical sciences. apr 30;79(2):164-74. [3] bartoletti r, cai t., (2008), “surgical approach to urolithiasis: the state of art. clinical cases in mineral and bone metabolism.” may;5(2):142. [4] ganpule ap, vijayakumar m, malpani a, desai mr. (2016), “percutaneous nephrolithotomy (pcnl) a critical review.” international journal of surgery. dec 1;36:660-4. [5] zhang fby, lin wr, yang s, hsu jm, chang hk, et al. (2017), “outcomes of percutaneous nephrolithotomy versus open stone surgery for patients with staghorn calculi.”urological science. x 29gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction menopause is a natural physiologic mechanism in a women's body when she stops menstruating. the average age of 1menopause in asian women is 46years . postmenopausal bleeding (pmb) is considered as an episode of bleeding ≥12 2months after the last regular menstrual period . pmb rings alarm of an ominous and a serious nature since genital pathologies constitutes 73% of all gynecological disorders in older women at this age with pmb. it affects 1 in 10 1postmenopausal females older than 55yrs . the most common cause of pmb is atrophic endometritis/ 3,4vaginitis (30%) followed by exogeneous estrogens use (15325%) , endometrial polyp (10%), endometrial hyperplasia (5%) but it is the endometrial cancer (15%) which requires prompt exclusion. the life time risk of developing endometrial carcinoma is 1.1% and can have good prognosis if diagnosed 5early . risk factors includes life style choices e.g smoking, caffeine, 3obesity , alcohol intake, family history of genital or breast malignancies, exogenous estrogen (hrt, tamoxifen) chronic anovulation (pcos), familial (lynch syndrome type1), patient on chemotherapy especially on alkylating agents, nulliparity and medical disorders like diabetes and 3hypertension . dilatation and curettage under anesthesia has been the standard diagnostic tool in abnormal uterine bleeding but is 6poor test in benign conditions besides being invasive . transvaginal ultrasound (tvs) is an efcient and acceptable non invasive method for early detection of endometrial 7pathology in postmenopausal women .the thickened endometrium post menopause is the most signicant ultrasonographical ndings implicating some pathology. hence, if the endometrium is ≤ 4mm as measured by tvs, endometrial abnormality can be excluded with a high 8probability . saline infusion sonohysterography (sis), a noninvasive and well tolerated modality is being considered as a safe alternative to hysteroscopy in the extended evaluation of pmb. sis has been preferred over traditional tvs as it provides excellent visualization of endometrial cavity and easily differentiate between polyps and submucous myoma due to its added advantage of saline being used as distension media 9and negative contrast . hysteroscopy is considered as well tolerated, accurate and 10sensitive procedure in investigation of pmb which allows direct visualization and biopsy of diffuse or focal abnormalities of endometrium. it is however, a rather invasive 11method and carries a false negative rate of 3% . it also requires expertise and well-equipped facility along with anesthetist support. the authors aimed to evaluate the diagnostic accuracy of tvs with and without sis compared to hysteroscopy in women having pmb. materials and methods in this prospective, cross sectional study conducted in a tertiary care hospital between jan 2018 to december 2018, 37 women attending the gynecology opd, presenting with pmb were enrolled. women with acute pid, cervical, vaginal and ovarian malignancies, women on hrt/ tamoxifen, with known coagulopathies and with known contraindication to anesthesia were exempted from the study. after a detailed history (including personal and menstrual history), examination, necessary investigations and informed consent, all women underwent tvs with a transvaginal transducer of 7.5mhz. the endometrium was assessed for thickness, regularity, echogenicity, homogeneity and presence of any mass (size, texture, multiplicity, regularity of margins). after tvs patients were subjected to sis with the help of a 8f foley's catheter with guided wire. the ndings of sis were noted and compared with that of tvs. within a period of 2-4 weeks, same patients underwent hysteroscopy under suitable anesthesia. the endocervical canal and uterine cavity were inspected for any endometrial abnormalities (atrophy, thickening, focal abnormalities) and focal lesions. findings were noted and endometrial biopsy saline infusion sonohysterography can be an efficient modality for evaluation of postmenopausal bleeding in place of hysteroscopy original research paper dr shivani agarwal* md consultant gynecologist department of obsterics and gynecology kasturba hospital, darya ganj delhi x 11gjra global journal for research analysis gynecology postmenopausal bleeding (pmb) requires prompt exclusion of malignancy for reduction of morbidity and mortality risks. a screening method with high specicity and sensitivity would prevent invasive procedure and aid in accuracy. the objective of present study was to evaluate the role of transvaginal ultrasound (tvs), saline infusion sonohysterography (sis) and hysteroscopy (hs) in diagnosis of pmb. a total of 37 women with pmb attending gynecology opd in kasturba hospital were enrolled and subjected to tvs, sis and hs. results were compared with histopathology as gold standard. the most frequent cause of pmb was endometrial polyp (29.7%) followed by endometrial hyperplasia (24.3%), endometrial atrophy (21.6%), submucous myoma (13.5%) and endometrial carcinoma (10.8%). overall sensitivity, specicity, positive predictive value (ppv) and negative predictive value (npv) of tvs was found to be 78.6%, 92.6%, 73.7% and 92.3% respectively but that of sis and hysteroscopy were 82.4%, 94.3%, 74.6%, 94.1 and 82.7%, 96.9%, 81.2%, 94.2% almost at par respectively. tvs extended to sis whenever required is recommended to be the preliminary investigation of choice in pmb. abstract keywords : tvs, sis, hysteroscopy, postmenopausal bleeding dr uma singh md student department of obsterics and gynecology kasturba hospital, darya ganj delhi *corresponding author dr suman lata mendiratta consultant gynecologist and medical superintendent department of obsterics and gynecology kasturba hospital, darya ganj delhi volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 12 x gjra global journal for research analysis was taken from suspicious areas and sent for histopathology. pap smears of all were done to exclude cervical pathology. the data of all the three procedures viz. tvs, sis, hs along with results was coded and analyzed with spss. the histopathological examination of directed biopsy was considered as the gold standard. appropriate statistical analysis of the data was done in terms of : sensitivity, specicity, ppv and npv. results the age, menarche. menopause, parity and duration of menopause are shown in table 1. the mean age at presentation in this study was about 55 years with mean duration of menopause being 6.97±6.44 years. large number of patients (73%) had symptoms within rst 10 years of attaining menopause table 1: clinical characteristics of study population (n=37) apart from bleeding per-vaginum, pelvic pain was the second most common symptom followed by dyspareunia and post coital bleeding. mean duration of symptoms noted in study population was 5.57±1.53 months. all of the patients reported within a year of onset of symptoms. maximum patients (67.56%) had no history of any associated medical conditions the most frequent cause of pmb found was endometrial polyp (29.7%) followed by endometrial hyperplasia (24.3%), endometrial atrophy (21.6%), submucous myoma (13.5%) and endometrial carcinoma (10.8%). the table 2 shows the diagnostic accuracy of three methods performed. table 2: diagnostic accuracy of tvs, sis and hysteroscopy among different pathologies in women with postmenopa usal bleeding (n=37) overall sensitivity, specicity, ppv and npv of tvs was found to be 78.6%, 92.6%, 73.7% and 92.3% respectively while that of sis and hysteroscopy were 82.4%, 94.3%, 74.6%, 94.1 and 82.7%, 96.9%, 81.2%, 94.2% respectively for various pathologies noted. discussion postmenopausal bleeding is considered to be caused by 3endometrial neoplasia until proven otherwise . since 90% of women with endometrial carcinoma present with vaginal bleeding, accepted practice includes a detailed evaluation of 12women with pmb . even a single episode of pmb must be evaluated. although pmb is most commonly due to benign lesions, such as endometrial atrophy, polyps and broids, it is essential to exclude endometrial carcinoma. most common pathology for postmenopausal bleeding in this study was found to be endometrial polyp (29.7%), followed by endometrial hyperplasia (24.3%), endometrial atrophy (21.6%), submucous myoma (13.5%) and endometrial carcinoma (10.8%) which was similar to the studies conducted 13 14by bronz et al and b. bingol et al . the comparison between the overall diagnostic accuracy of tvs, sis and hysteroscopy clearly indicates that, hysteroscopy had a higher diagnostic value ( 82.7% sensitivity, 96.9% specicity, 81.2% ppv and 92.3% npv) compared to tvs (78.6% sensitivity, 92.6% specicity, 73.7% ppv, 92.3% npv) but it was almost comparable to sis (82.4% sensitivity, 94.3% specicity, 74.6% ppv and 94.1% npv) all the three modalities were able to diagnose all cases of endometrial atrophy with 100% sensitivity and specicity 14which was comparable to study conducted by b. bingol et al (2010). hysteroscopy yielded a higher sensitivity (88.9 vs 77.8) in diagnosing endometrial hyperplasia than both tvs and sis, whereas specicity, ppv, npv of the three modalities were comparable. the sensitivity and ppv of tvs in diagnosing endometrial polyp were lower than both sis (fig.1) and hysteroscopy due to masking of small polyps by a very hyper-echo-dense 15endometrium. goldstein et al also stated the same fact that small structural abnormalities can be easily missed and it is not always possible to differentiate between endometrial and myometrial abnormalities on tvs figure 1: endometrial polyp on saline infusion sonohyst erography among submucous myoma patients, hysteroscopy had comparatively lesser sensitivity of 66.7% as compared to sis (80%). this may be because of the fact that sis is able to better delineate the endometrium-myometrium interface which was 14in conconance to study conducted by banu bingol et al . the sensitivity of all the three modalities in diagnosing endometrial carcinoma was 75% while ppv of hysteroscopy was clearly better than tvs and sis. sis couldn't reliably discriminate between benign and malignant focal lesions which is revealed by the fact that 2 cases of hyperplasia were actually carcinoma in the study. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra range mean ±s.d age 45-77 years 54.95 ± 7.36 years menarche 8-16 years 13.03 ± 1.97 years menopause 43-55 years 48.0 ± 2.78 years duration of menopause 1-24 years 6.97 ± 6.44 years parity 0-6 3.62 ± 1.47 pathological diagnosis sensitivity specicity ppv npv over all tvs 78.6 92.6 73.7 92.3 sis 82.4 94.3 74.6 94.1 hs 82.7 96.9 81.2 94.2 endometrial atrophy tvs 100 100 100 100 sis 100 100 100 100 hs 100 100 100 100 endometrial hyperplasia tvs 77.8 100 100 93.4 sis 77.8 100 100 93.3 hs 88.9 100 100 96.6 endometrial polyp tvs 72.7 88.5 72.7 83.8 sis 81.8 92.3 81.8 92.3 hs 83.3 96 90.9 92.3 submucous myoma tvs 80 96.7 80 96.7 sis 80 93.8 66.7 96.8 hs 66.7 96.8 80 93.8 endometrial carcinoma tvs 75 90.9 50 89.2 sis 75 93.9 60 96.9 hs 75 96.7 75 96.9 with respect to gold standard histopathological diagnosis, the diagnostic accuracy of tvs in the detection of uterine abnormalities in postmenopausal women was found to be limited. tvs has been reported to fail in differentiating between submucous myoma, endometrial polyp and proliferative endometrium. tvs extended to sis, as a procedure was easily tolerated by patients and proved its diagnostic value similar to hysteroscopy in the detection of endometrial abnormalities among postmenopausal bleeding patients hysteroscopy as stated in the literature, provided most accurate description of the endometrial cavity with biopsy as gold standard. sis with its 82.4% sensitivity, 94.3% specicity, 74.6% ppv and 94.1% npv emerged as an excellent tool, which was comparable to hysteroscopy. conclusion sis can be performed safely and easily as an outpatient procedure. it has a comparable diagnostic accuracy as hysteroscopy with an added advantage of its cost effectiveness and non invasive nature. hence sis can be considered as a diagnostic tool in pmb, especially in remote areas where expertise for hysteroscopy, infrastructure, o.t are not available and when patient has severe co-morbidities making them unt for anaesthesia which is required for hysteroscopy. sis is also helpful if there is a discrepancy between the ndings on the tvs and the endometrial biopsy. tvs being an easy, safe, cost effective and a non invasive procedure with high negative predictive value is considered as an appropriate rst line investigation for evaluating all cases of postmenopausal bleeding along with endometrial pipelling (ep). whenever any abnormality is suspected on tvs/ep, either sis or hysteroscopy can be considered for further evaluation. hysteroscopy can be considered as both diagnostic and therapeutic modality, with a superior diagnostic accuracy than sis as it allows direct visualization of pathology and provision to take a targeted biopsy. however, it is invasive, highly specialized and operator dependent procedure requiring operation theatre, services of anesthetist etc. thus, it requires a specialized center and admission facility. hence, tvs extendable into sis as an outpatient investigative procedure is recommended to be the preliminary investi gation of choice in pmb. references: 1. karmarkar, p. j., wilkinson, a., rathod, m. (2014).histopathological evaluation of postmenopausal bleeding.iosr journal of dental and medical sciences,13(10),53–7. 2. breijer, m.c., timmermans, a., van doorn, h.c., mol bwj., opmeer, bc.(2010). diagnostic strategies for postmenopausal bleeding. obstet gynecol int,85,08-12. 3. cooper, n.a.m., clark, t.j.(2008). management of postmenopausal bleeding. c j gynecol oncol,13(2),44–51. 4. brand, a.h.(2007).the woman with postmenopausal bleeding. aust fam physicia,. 36(3),116–20. 5. american college of obstetricians and gynaecologists. acog committee opinion no. 426.(2009). the role of transvaginal ultrasonography in the evaluation of postmenopausal bleeding. obstet gynecol,113(2 pt 1)-462 6. büyük, e., durmuşo�lu, f., erenus, m., karakoç, b.(1999). endometrial disease diagnosed by transvaginal ultrasound and dilatation and curettage. acta obstetricia et gynecologica scandinavica.78(5),419-22. 7. schoenfeld, a., levavi, h., hirsch, m., pardo, j., ovadia, j. (1998). transvaginal sonography in postmenopausal women. j clin ultrasound, 1,350-58. 8. acog committee opinion. (2018).the role of transvaginal ultrasound in evaluating the endometrium of women with postmenopausal bleeding. american college of obstetrician and gynaecologists,131(5),e124-129. 9. brown, s.e., coddington, c.c., schnorr, j., toner, j.p., gibbons, w., oehninger, s. (2004).evaluation of outpatient hysteroscopy, saline infusion hys te rosonography, and hys te rosa lp ingography in in fe r t i le women.74(5),1029–34. 10. haller h., matecjcic n., rukavina b., krasevic m., rupcic s., mozetic d.(1999). transvaginal sonography and hysteroscopy in women with postmenopausal bleeding. int j gynaecol obs,54(2),155–9. 11. gull, b., carlsson, s., karlsson, b., ylöstalo, p., milsom, i., granberg, s.(2000). transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding: is it always necessary to perform an endometrial biopsy?.am j obstet gynecol,182(3),509–15. 12. munot, s., lane, g.(2000). modern management of postmenopausal bleeding. trends urol gynaecol sex heal,20–4. 13. bronz, l., suter, t., rusca, t.(1997). the value of transvaginal sonography with and without saline instillation in the diagnosis of uterine pathology in pre and postmenopausal women with abnormal bleeding or suspect sonographic ndings. ultrasound obstet gynecol,9(1),53–8. 14. bingol, b., gunenc, m.z., gedikbasi, a., guner, h., tasdemir, s., tiras, b.(2011).comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography and hysteroscopy in postmenopausal bleeding. arch gynecol obstet,284(1),111–7. 15. goldstein, r.b., bree, r.l., benson, c.b., benacerraf, b.r., bloss, j.d., carlos, r.(2001). evaluation of the woman with postmenopausal bleeding.society of radiologists in ultrasound-sponsored consensus conference statement,20(10),1025–36. x 13gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra case vignette: mr. a is a 59 year old, male married, muslim, resident of gujarat was seen 7-8 months back in psychiatry outpatient department , with complains of hyperactivity, talkativeness, sleep impairment, anger irritability, hyper charitable behavior and psychotic features as self talking , gesturing, hearing of voices. his mental status examination showed pressure of speech, psychomotor agitation and irritable mood. the patient was started with low dose antipsychotics and benzodiazepine. the patient was again reviewed for treatment for worsening after stopping his psychiatric medications for last 2 months. the relatives denied for complete recovery in the treatment period. his sleep had been disturbed with describe his need only 1-2 hours of rest all day. he would remain away from home all night, roam nearby alleys, and leave the doors of his house open at day. he would stare at open spaces, continue to speak in indecipherable words, and get angry if interrupted. he would easily get irritable, throw plates of food, push, strangle and even claw his wife at times. the patient was started treatment on outpatient basis but failed to improve leading to his admission. his medical history showed history of percutaneous coronary intervention at right coronary artery after angiography 3 years back, with controlled hypertension and his regular medications included adequate doses of ant platelet, antihypertensive and statins regularly. he had no signicant contributory past and family history of any psychiatric illness. he used to smoke tobacco since last 10 years, with 10-12 bidis per day. the relatives were not aware for any history of head trauma. examination: the patient was vitally stable with pulse and blood pressure within normal ranges. the patient was well groomed with clear consciousness but raised psychomotor activity, attention difcult to hold, with euphoric mood, impaired judgement and no insight of his illness. there were signicant hyper charitable thoughts for the society, but no grandiosity, suicidality or perceptual abnormality. memory, intelligence, attention / concentration and abstract thinking were normal. the neurological examination was too unremarkable. laboratory / radiological investigations: the serum chemistry was within normal limits. the chest x ray and ecg were unremarkable. the patient was diagnosed as manic without psychotic features based on the history presented. treatment was included as anti epileptic, antipsychotic and benzodiazepine. being the rst manic episode in his life, an mri recording was suggested which presented with the changes showing chronic subdural hemorrhage noted involving bilateral frontoparietotemporal convexity measuring 10 mm on right side and 7.7 mm on left side. a referral was made to the neurosurgical department and started on a low tapered dosing of steroid for a fortnight with no operative management advice. the patient was discharged with mild improvement in manic symptoms with continuation of neuro surgical line of management. discussion: bipolar mania is always considered a part of nonorganic affective disorders, with epidemiological studies suggesting a lifetime prevalence of around 1% for bipolar type i in the general population and seems to decrease with age. only 10 % of all patients with bipolar disorder present with a rst (2,3)episode after the age of 50 . a subdural hematoma presents with diagnostic difculty especially in elderly population. a subdural hematoma usually precipitated after repeated anticoagulant use in elderly from atrophied parasagittal veins in elderly than young making them more predisposed to (4)bleed .the symptoms develop more gradually in elderly, which can come into notice at a later phase with symptoms of (5)dementia, affective and psychotic disorders . patho physiology : organic lesions associated with manic syndromes involve the areas of the brain that modulate neuro vegetative functions (5)and emotion. right-sided lesions have been reported more frequently in patients with organic mania, but left-sided and (6)diffuse lesions have also been reported. any focal or diffuse degenerative or irritative lesion in these areas could conceivably precipitate a manic episode. distinction between idiopathic and secondary mania idiopathic bipolar disorder should be diagnosed only after all organic causes have been ruled out with careful medical and neurological assessment made. organic mania generally develops in patients who are older than 35 years of (7)age. irritability and assaultive behavior were more common than euphoria in a group of patients with posttraumatic (7)mania . the family history of affective disorders is less common in organic mania in comparison with idiopathic (6,7)mania. a case report-organic manic original research paper dr. sanjukta ghosh 3rd year resident, department of psychiatry, smt. nhl medical college, ahmedabad psychiatry manic syndromes are generally a part of affective disorder in psychiatry, but can also be a part of neurological, metabolic or toxic origin. the clinician needs to distinguish idiopathic bipolar mania from the rest of organic disorders. the cardinal symptom of mania is an abnormally and persistently elevated, expansive or irritable mood with persistently raised goal directed activity. in patients with the rst episode of mania, a thorough information about current (1)symptoms, past, medical and addiction with decision of the appropriate laboratory and radiological investigations be made. abstract keywords : subdural hematoma, secondary mania, organic mania, oldage dr. yatri patel* 3rd year resident, department of psychiatry, smt. nhl medical college, ahmedabad. *corresponding author dr. nimesh c. parikh professor and head, department of psychiatry, smt. nhl medical college, ahmedabad volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 44 x gjra global journal for research analysis conclusion: 1st manic episode in elderly should have extensive differential diagnosis and is rarely a rst manifestation of bipolar manic episode. unless proven on the contrary after detailed evaluation, a rst manic episode in elderly should always be considered a secondary mania. a preliminary screen should include (1) a careful history, including drug ingestion, medications, and recent infection, (2) neurological examination, looking especially for focal signs, (3) eeg, (4) skull x-ray lms, ct or mri , and (5) toxic screening. any (7) abnormality should be followed by more elaborate studies. pharmacological treatment of the acute condition is largely the same as for primary mania in elderly but with doses lower than for younger adults because slower metabolism and (8)sensitivity to side effects references (1) eric w. larson, m.d., department of psychiatry and psychology; elliot richelson, m.d.,department of psychiatry and psychology and department of pharmacology (2) depp ca, lindamer la, folsom dp, gilmer t, hough rl, garcia p et al. differences in clinical features and mental health service use in bipolar disorder across the lifespan. am j geriatr psychiatry. 2005; 13: 290-8 . (3) depp ca, jeste dv. bipolar disorder in older adults: a critical review. bipolar disord. 2004; 6: 343-67 medline . doi: 10.1111 / j.1399-5618.2004.00139.x. (4) first manic episode in the elderly--consider a subdural haematoma due to head trauma as cause.marijnissen rm, bakker m, stek ml.ned tijdschr geneeskd. 2010;154:a1235. (5) cummings jl: organic psychoses: delusional disorders and secondary mania. psychiatr clin north am 9:293311, june 1986 (6) shukla s, cook bl, mukherjee s, godwin c, miller mg: mania following head trauma. am j psychiatry 144:9396, 1987 (7) krauthammer c, klerman gl: secondary mania: manic syndromes associated with antecedent physical illness or drugs. arch gen psychiatry 1978; 35:1333–1339 (8) young rc, klerman gl: mania in late life: focus on age at onset. am j psychiatry 1992; 149:867–876 volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 45gjra global journal for research analysis introduction maternal mortality remains one of the most intimidating health challenges in our country and reduction in the same has been one of the focus areas of work. national rural health missions (nrhm) goal is to reduce mmr to 100 per 1,00,000 live births by 2012. sample registration systems (srs) estimates that 9% of all maternal mortality is due to unsafe abortions. one of the key contributing factors for this situation is the lack of knowledge and skills among health care personnelsin primary health care system to provide high 1quality emergency obstetric care (emoc) and mtp services. the latest worldwide estimates show that 289 000 maternal deaths occurred across the world in 2013. a 65% decrease in maternal mortality rate (mmr) has recorded in india from 1990 to 2013, it still contributed the major proportion, (17%; 250000 deaths) of maternal deaths in the world in 2013. the unpredictability of many direct obstetric complications which cause maternal mortality means that they present as 3emergency situations during the intrapartum period. access to interventions targeted at this intrapartum period is crucial to saving maternal lives and reducing mortality. the who, unicef and united nations population fund (unfpa) have classied these interventions into emergency obstetric care (emoc) signal functions—seven basic (bemoc) and two 4,5comprehensive (cemoc). whereas it is recognised that all these emoc functions may be performed by a physician, nurse or midwife, all of whom are dened as skilled birth attendants, the advanced cemoc function of caesarean section (cs) generally lies in the domain of obstetricians.5 in india in particular, bemoc skills have also become largely concentrated in the hands of obstetricians due to the neglect 6of the midwifery cadre over the past many decades. universal health coverage (uhc) for all has been set as one of the sustainable development goals the world needs to attain by 2030.8 universal access to health services, in all its three dimensions, physical accessibility, services accep tability and nancial affordability, is a prerequisite for universal coverage. universal coverage would build on 7access by ensuring actual receipt of services. reduction in the number of maternal deaths requires, besides essential obstetric care, timely access to effective, reasonably priced, and appropriate emergency obstetric care (emoc) services when complications arise. universally, emoc has broadly been categorized into two groups__basic and comprehensivebased on the performance of certain signal 9,11functions. basic emoc includes administration of injectable antibiotics, oxytocics, and sedatives/ anticonvulsants, removal of retained products, performance of 10manual removal of placenta, and assisted vaginal delivery. in addition to these six signal functions, comprehensive emoc also includes blood transfusion and caesarean section. in this context, the present study was conducted in to assess the knowledge regarding emoc services among nursing students at sgt university, gurugram. material and methods a nonexperimental descriptive research design was used. total of 50 nursing studentsstudying in sgt university, gurugram who met the inclusion criteria were selected using convenient sampling technique. the tools for study consist of demographic variables and structured knowledge questio nnaire which consists of 30 multiple choice questions. reliability of the knowledge questionnaire was established by kr 20and it was found to be 0.83. data collection was done in the month of january, 2020. the data was analysed and interpreted in terms of objectives of the study. descriptive and inferential statistics were utilized for the data analysis. a p assess knowledge regarding emergency obstetric care (emoc) : pilot study original research paper sunil kumar dular* research scholar, shri jjt university, jhunjhunu (rajasthan). associate professor, faculty of nursing, sgt university, gurugram *corresponding author x 7gjra global journal for research analysis nursing since immemorial, complications arising from pregnancy, childbirth and postpartum is not exceptional. most health professionals in the hospitals encounter women with obstetric complications or emergencies in their daytoday delivery of health care services. aims and objectives: the objectives of the study were to assess the knowledge regarding emoc services among nursing students and to determine the association of knowledge scores with selected demographic variables. materials and methods: descriptive research design was used to assess knowledge regarding emoc among 50 nursing students studying at sgt university, gurugram who met the inclusion criteria were selected using convenient sampling technique. structured knowledge questionnaire including 30 items was administerd to nursing students. reliability of the knowledge questionnaire was tested by kr20 and it was found to be 0.83 results: the ndings of the study indicated that nearly half (46%) of students were in the age group of 22-24 years, 42% of them were pursuing post basic bsc nursing programme. nearly half (56%) of the students were in second year, majority (86%) of them were following hindu religion. majority (86%) of the students were female, most (70%) of them were residing in urban area and for 42% of them, the source of health information was health professionals. mean knowledge score regarding emoc among nursing students was 15.86± 5.53.44% of them hadmoderate knowledge regarding emoc. study ndings also revealed that the association of knowledge scores with age, educational course, year of study, religion of the student and source of health information was found to be statistically signicant at 0.05 level of signicance. conclusion: demographic variables age, educational course, year of study, religion of the student and source of health information had signicant difference on knowledge score regarding emoc among nursing students. abstract keywords : volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. annu kaushik director-nursing cloudnine hospitals, india jyoti shokeen lecturer, faculty of nursing, sgt university, gurugram 8 x gjra global journal for research analysis value ≤ 0.05 was considered as signicant for the present study. inclusion criteria the participants who were meeting the following criteria were included in study. ÿ present on the day of data collection. ÿ willing to participate in study. exclusion criteria ÿ participants who are not willing to participate in study were excluded from the study. ethical consideration ethical permission was obtained from ethical committee faculty of nursing, sgt university, budhera, gurugram in accordance with the guidelines of icmr 2006. the written informed consent was obtained from each study participants before conducting the study. findings the ndings of the study indicated that nearly half (46%) of students were in the age group of 22-24 years, 42% of them were pursuing post basic bsc nursing programme. nearly half (56%) of the students were in second year, majority (86%) of them were following hindu religion. majority (86%) of the students were female, most (70%) of them were residing in urban area and for 42% of them, the source of health information was health professionals. mean knowledge score regarding emoc among nursing students was 15.86± 5.53. 14% of them were having good knowledge regarding emoc followed by 44% as having moderate knowledge and remaining 42% as having poor knowledge. study ndings also revealed that the association of knowledge scores with age, educational course, year of study, religion of the student and source of health information was found to be statistically signicant at 0.05 level of signicance. discussion findings of the present study revealed that 14% of them were having good knowledge regarding emoc followed by 44% as having moderate knowledge and remaining 42% as having poor knowledge. these ndings are consistent with the ndings of a study conducted by university of medical sciences, ondo, nigeria where it was found that only 13% of the respondents scored high in knowledge of emoc whereas 41% were low in knowledge. findings of the present study revealed that most (70%) of them were residing in urban area. these ndings are consistent with the ndings of a study conducted by ngoran grace bongban in kenya where it was found that 71.7% of them were residing in urban area and remaining 22.3% in rural area of residence. conclusion demographic variables age, educational course, year of study, religion of the student and source of health information had signicant difference on knowledge score regarding emoc among nursing students. source of funding : self nanced limitation the study conned to 50nal year nursing students studying at sgt university, gurugram. nursing implications nursing education the study has a signicant implication in nursing education and other elds. staff nurses and nursing students can give teaching programmes regarding better utilization of emoc services. nursing student can also give teaching programmes regarding availability of emoc services. nursing practice nurses are backbone of health care set up of any country.the nursing knowledge has gone many evolution in recent past .the expanded roles of professional nurse emphasize the implication which include promotive ,preventive, curative and rehabilitative aspects. nursing research a very few interventional studies have been conducted regarding emoc services. new evidences based information becomes available every level on this subjects. it is vital that student researchers update their knowledge constantly and are always willing to examine and alter their practice in the light of new published evidences. nursing administration nursing administrator may use the study nding to improve the utilisation and availability of emoc services. the concept of extended role of nurse offer many opportunities for a nurse administrator to improve the knowledge regardingemoc services among staff nurses in community setting. recommendations ÿ a similar study can be replicated on a larger sample size to validate the ndings and generalisations can be made. ÿ a similar study can be conducted to assess knowledge and skills regarding emoc among staff nurses in selected hospital, gurugram, haryana. ÿ comparative study can be done between staff nurses working in private or government hospital. ÿ interventional study can be done by planning some sort of training program on emoc services. table no.1 frequency and percentage distribution of students in terms of selected demographic variables (n= 50) volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra s.no. demographic variables frequency percentage 1. age in years a) 18-20 b) 20-22 c) 22 – 24 d) >24 5 15 23 07 10 30 46 14 2. educational course a) general nursing midwifery b) b.sc. nursing c) p.b.b.sc. nursing d) m.scnursing 10 09 21 10 20 18 42 20 3. year of study a) first year b) second year c) third year d) fourth year 0 28 15 07 0 56 30 14 4. religion of the student a) hindu b) muslim c) sikh d) others 43 02 03 02 86 04 06 04 5. gender of student a) male b) female 07 43 14 86 6. area of residence a) rural b) urban 15 35 30 70 table 2. frequency and percentage distribution of students in terms of knowledge score maximum score= 30 minimum= 0 figure 1. frequency and percentage distribution of students in terms of knowledge score table no 3. range mean, median, standard deviation and mode of knowledge scores of nursing students table 4. anova and 't' value showing association of knowledge score with selected demographic variables n= 50 table 5. post-hoc test showing mean difference in association of knowledge score and demographic variable (age) n= 50 *the mean difference is signicant at the 0.05 level. table 6. post-hoc test showing mean difference in associ ation of knowledge score and demographic variable (educational course) n=50 *the mean difference is signicant at the 0.05 level. table 7. post-hoc test showing mean difference in associ ation of knowledge score and demographic variable (year of study) n=50 *the mean difference is signicant at the 0.05 level. table 8. post-hoc test showing mean difference in associ ation of knowledge score and demographic variable (religion of the student) n=50 *the mean difference is signicant at the 0.05 level. table 9. post-hoc test showing mean difference in associ ation of knowledge score and demographic variable (source of health information) n=50 x 9gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 7. source of health information a) newspaper/magazine b) radio/ television c) friends/ relatives d) health professionals 13 09 07 21 26 18 14 42 level of knowledge score range f(%) good 24-30 7 (14) moderate 15-23 22 (44) poor 0-14 21 (42) variable n obtained range mean +_ sd median mode knowledge score 50 7-28 15.86 +_ 5.53 15 15 s. no. demographic variable mean +_ sd f/t value df p-value 1. age in years a) 18-20 b) 20-22 c) 22 – 24 d) >24 10.60 ± 4.98 15 ± 2.39 16.43 ± 5.80 19.57 ± 7.39 3.113 3/46 0.035* 2. educational course a) general nursing midwifery b) b.sc. nursing c) p.b.b.sc. nursing d) m.scnursing 12.40 ± 2.87 13.78 ± 4.17 15.14 ± 2.88 22.70 ± 7.33 11.304 3/46 0.000* 3. year of study a) first year b) second year c) third year d) fourth year 0 17.89 ± 6.05 12 ± 3.02 16 ± 2.76 6.859 2/47 0.002* 4. religion of the student a) hindu b) muslim c) sikh d) others 15.67 ± 5.34 26.50 ± 0.707 12.33 ± 4.16 14.50 ± 0.707 3.344 3/46 0.027* 5. gender of student a) male b) female 15.29 ± 2.87 15.95 ± 5.87 0.293 48 0.104ns 6. area of residence a) rural b) urban 14.87 ± 3.83 16.29 ± 6.12 0.828 48 0.081ns 7. source of health information a) newspaper/magazine b) radio/ television c) friends/ relatives d) health professionals 16 ± 4.61 11.78 ± 3.15 13.71 ± 3.72 18.24 ± 6.25 3.846 3/46 0.015* variable category mean difference p-value age 18-20 vs 20-22 -4.40 0.369 18-20 vs 22-24 -5.83 0.120 18-20 vs 24 and above -8.97 0.025* 20-22 vs 22-24 -1.43 0.840 20-22 vs 24 and above -4.57 0.235 2224 vs 24 and above -3.13 0.509 variable category mean difference p-value educational course general nursing midwifery vs bsc nursing -1.37 0.900 general nursing midwifery vs pbbsc nursing -2.74 0.363 general nursing midwifery vs msc nursing -10.30 0.000* bsc nursing vs pbbsc nursing -1.365 0.85 bsc nursing vs msc nursing -8.92 0.000* pbbsc nursing vs msc nursing -7.55 0.000* variable category mean difference pvalue year of study second year vs third year 5.89 0.002* second year vs fourth year 1.89 0.643 third year vs fourth year -4.00 0.195 variable category mean difference p-value religion of the student hindu vs muslim -10.82 0.029* hindu vs sikh 3.34 0.703 hindu vs others 1.17 0.989 muslim vs sikh 14.16 0.022* muslim vs others 12.0 0.109 sikh vs others -2.16 0.968 variable category mean difference p-value *the mean difference is signicant at the 0.05 level. references 1. trends in maternal mortality: 1990 to 2013. estimates by who, unicef, unfpa, the world bank and the united nations population division. world health organisation, 2014. http://apps.who.int/ iris/bitstr eam/ 10665/112682/2/9789241507226_eng.pdf?ua=1 (accessed 25 jan 2016). 2. campbell om, graham wj. strategies for reducing maternal mortality: getting on with what works. lancet 2006;368:1284–99. 10.1016/s 0140–6 736(06)69381-1 [pubmed] [crossref] [google scholar] 3. maine d, wardlaw tm, ward vm et al. guidelines for monitoring the availability and use of obstetric services. geneva: world health organization, 1997. [google scholar] 4. who, unicef, unfpa and amdd. monitoring emergency obstetric care: a handbook. geneva: world health organisation, 2009. [google scholar] 5. who, icm, figo. making pregnancy safer: the critical role of the skilled attendant. geneva: world health organization, 2014. [google scholar] 6. mavalankar d, sankara raman p, vora k. midwives of india: missing in action. midwifery 2011;27:700–6. 10.1016/j.midw.2010.05.010 [pubmed] [crossref] [google scholar] 7. mavalankar dv, roseneld a. maternal mortality in resource-poor settings: policy barriers to care. am j public health 2005;95:200 10.2105/ ajph.2003.036715 [pmc free article] [pubmed] [crossref] [google scholar] 8. who. health in 2015: from mdgs to sdgs: 2015. http://ww w.w ho.in t/gho /pu blications/mdgs-sdgs/mdgs-sdgs2015_chapter1.pdf?ua=1 (accessed 25 jan 2016). 9. evans db, hsu j, boerma t. universal health coverage and universal access. bull world health organ 2013;91:546–546a. 10.2471/blt.13.125450 [pmc free article] [pubmed] [crossref] [google scholar] 10. paxton a, bailey p, lobis s et al. global patterns in availability of emergency obstetric care. int j gynaecolobstet2006;93:300–7. 10.1016/j.ijgo.2016.01.030 [pubmed] [crossref] [google scholar] 11. bailey p, paxton a, lobis s et al. the availability of life-saving obstetric services in developing countries: an in-depth look at the signal functions for emergency obstetric care. int j gynaecolobstet2016;93:285–91. 10.1016/j.ijgo.2006.01.028 [pubmed] [crossref] [google scholar] volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 10 x gjra global journal for research analysis source of health information newspaper/magazine vs radio/ television 4.22 0.240 newspaper/magazine vs friends/ relatives 2.28 0.776 newspaper/magazine vs health professionals -2.23 0.604 radio/ television vs friends/ relatives -1.93 0.875 radio/ television vs health professionals -6.46 0.014* friends/ relatives vs health professionals -4.52 0.192 introduction sepsis is a physiological syndrome, pathology and biochemical abnormalities induced by infection, is a major problem in public health. although the actual incidence is not clearly known, sepsis is a major suspect to cause mortality and critical illness worldwide, especially in low-income countries where infection is still the most frequent disease causing death. in addition, there is an increasing concern in patients recovering from sepsis who experience long-term physical, psychological and cognitive paralysis. these 1patients need special care that can impact their social life. more than 200,000 deaths per year in the united states is caused by sepsis reactions. the incidence of severe sepsis and septic shock has increased in the last 20 years and the annual rate of sepsis cases is currently more than 700,000 2(less than 3 per 1000 populations). however, the global burden of sepsis is greatest in the middle and low-income countries (two-thirds of the world's population). low living standards and poor hygiene along with malnutrition and bacterial infections, parasites and human immunodeciency virus (hiv) increase the burden of sepsis in these countries. according to world bank data, indonesia belongs to the low3middle income country. study conducted in a hospital in bandung, indonesia, 4obtained patients suffering from sepsis were 192 patients. there were 233 sepsis cases in 2015 at the haji adam malik 5central hospital, medan. however bacterial infection in the last decade is the main concern. bacteremia infections are associated with high mortality rates. fast and right treatment can reduce mortality. several biomarkers of bacterial infections have been investigated, such as procalcitonin (pct), the parameters of procalcitonin in the recent years are superior (auc 0.952) use 6as biomarkers of bacterial infections. procalcitonin (pct) is a hormone precursor of calcitonin which is serological marker of acute bacterial infection. in bacterial infections there will be an increase in the expression of the calcitonin-1 (calc-1) gene which causes the release of pct from all parenchymal cells and differentiated cells in the liver and mononuclear cells. the release of pct inammatory mediators can be induced through 2 processes, including: the release of toxins in bacteria (endotoxin) and cellular immunity response mediated by pro-inammatory cytokines such as: il71β, il-6 and tnf-α. one of the factors contributing in sepsis prognosis is vitamin d, which has recently been known to have other functions beyond its classic activity in bone and calcium homeostasis. the new functions are identied in regulation of hormone secretion, immune function, cellular proliferation and differentiation. the potential role of vitamin d and its active metabolite 1,25-dihydroxyvitamin d (1,25 (oh) 2d) in modulating the immune response was rst identied by the discovery of vitamin d receptors in activated inammatory 9cells of humans. vitamin d dysfunction and insufciency conditions are common throughout the world. about 1 billion people worldwide had vitamin d insufciency and/or deciency, which is dened as 25-hydroxyvitamin d (25 (oh) d) <30 ng/ml for insufciency or <20 ng/ml for those with 10deciency. both of these conditions do not have a direct risk to healthy people. however, vitamin d deciency is associated with mortality in critically ill patients, suggesting that deciency or vitamin d insufciency can affect the outcomes in critically ill 9,10patients. septic patients treated in the emergency department (ed) and intensive care unit (icu) have been shown to have lower levels 11,12of 25 (oh) vitamin d compared to the healthy controls. association of 25 (oh) vitamin d levels with increased procalcitonin levels in septic patients at h. adam malik general hospital medan original research paper maruhum nur clinical pathology department, faculty of medicine, university of north sumatra /h. adam malik general hospital medan. x 115gjra global journal for research analysis medicine introduction: sepsis is a complex syndrome caused by an uncontrolled systemic inammatory response, caused infection. one factor that plays a role in the prognosis of sepsis is vitamin d. while procalcitonin (pct), a biomarker response to infection, and pct levels can be increased in septic patients. the purpose of this study was to determine the association of 25 (oh) vitamin d levels with increased pct levels in septic patients. methods: this study was conducted with cross sectional design, from august to december 2016. the subjects of this study were septic patients who admitted to the intensive care unit at h. adam malik general hospital medan, aged >18 years. 25 (oh) vitamin d total and procalcitonin (pct) were measured by means of mini vidas brahms, correlation of 25 (oh) vitamin d and pct levels was tested using spearman correlation test, statistical tests with p values <0.05 were considered signicant. results and discussions: a sample of 33 people consisted of 20 (60.6%) men and 13 (39.4%) women, with an average (sd) age of 53.6 (11.7) years. there were 27 (81.8%) patients reporting hypovitaminosis vitamin d. that was found a signicant negative correlation of total 25 (oh) vitamin d levels with procalcitonin levels (r = 0.434, p = 0.012). conclusions: in this study concluded that 81.8% of patients who treated in the icu had hypovitaminosis vitamin d. there was a negative correlation between 25 (oh) vitamin d levels and increased procalcitonin levels of septic patients who admitted to the icu. abstract keywords : sepsis, vitamin d, procalcitonin volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra adi k. aman* clinical pathology department, faculty of medicine, university of north sumatra /h. adam malik general hospital medan. *corresponding author achsanuddin hanae department of anesthesiology & intensive therapy, faculty of medicine, university of north sumatra /h. adam malik general hospital medan. 116 x gjra global journal for research analysis vitamin d status of patients are divided into 3 groups: deciencies (0.0-19.9 ng / ml), insufciency (20.0-29.9 ng/ml), 12sufciency (≥30ng/ml). based on these data, pct and 25 (oh) vitamin d have a close relationship in patients with critical conditions and those who had sepsis admitted to the intensive care unit (icu). however, there are still few studies that examine the association between levels of 25 (oh) vitamin d and increased pct levels in septic patient, especially at h. adam malik medan general hospital. aim to determine the association of levels 25 (oh) vitamin d with increased pct levels in septic patients at rsup. h. adam malik medan. methods this is observational analytic study with a cross sectional study design, subject are 33 sepsis patients who were treated in the icu ward h. adam malik hospital medan. sampling was collected consecutive on all accessible populations with inclusion criteria from november 2016 january 2017. inclusion criteria: age> 18 years, patients with sepsis who were diagnosed with the criteria of bone et.al who were treated in the icu ward of h.adam malik general hospital medan, willing to follow the research. exclusion criteria: patients with hiv disease, patients with pregnancy, patients with parathyroid disease, patients using drugs that affect 25 (oh) vitamin d total levels, patients who have received vitamin d supplements. vitamin d status of patient was divided into 3 groups: deciency (0.0-19.9 ng / ml), 12 insufciency (20.0-29.9 ng / ml), sufciency (≥ 30ng / ml) . ethical clearance was obtained from the health research committee of the faculty of medicine, university of north sumatra. consent paper was obtained in writing from the patient's family. data and physical examination are written in the status of the study. the sample for this examination are 3 cc patient's blood serum. the sample is taken once for both examinations, that are 25 (oh) vitamin d total and pct. examination of 25 (oh) vitamin d total and pct was using “mini vidas brahms” tool, with sandwich principle using the elfa (enzyme-linked fluorescent assay) method. data analysis was performed using spss software (statistical package for social sciences, chicago, il, usa) for windows. description of the characteristics research subjects are presented in tabulated form and described. the relationship of clinical characteristics with vitamin status was used kruskall wallis test. correlation of levels 25 (oh) vitamin d and pct were tested using spearman rank test. statistical tests with p <0.05 were considered signicant. results this study was conducted to see the association of total 25 (oh) vitamin d levels and increased levels of procalcitonin in septic patients at h. adam malik general hospital medan, was conducted from august to december 2016. samples were collected in accordance with the inclusions criteria in this study. a total of 33 septic patients were performed in icu and then data analysis was carried out. table 1:patient characteristic (n= 33) note: a: data are presented as mean ± sd, b: data are presented as median (min, max) in table 1, the patient characteristics are presented, consists of 20 (60.6%) males and 13 (39.4%) females, with an average age (sd) at 53.6 years (11.7 years) at icu. the mean (sd) value of platelet count is 213363.6/ul1,130550.7 u/l), the mean value (sd) of leukocytes is 16627.5 u/l (8093.2 u/l), and the mean value (sd) of level 25 (oh) total vitamin d is 21.3 ng/ml (11.6 ng/ml), while procalcitonin levels with a median value of 26.2 ng/ml (4.0 ng/ml 252.0 ng/ml). in table 2, among of 33 patients were analyzed there were 18 (54.5%) patients reporting (oh) vitamin d deciencies, 9 (27.3%) patients reporting insufciencies, and 6 (18.2%) patients reporting sufciencies. table 2. clinical characteristics of patients based on vitamin d status note: a: data are presented as mean ± sd, b: data are presented as median (min, max), * signicant value p <0.05 with the kruskall wallis test. table 2 analyzes the associations of vitamin d status and the clinical characteristics of patients. patients with 25 (oh) vitamin d deciency found a signicantly higher procalcitonin level of 47.2 ng/ml (7.0 ng/ml, 252.0 ng/ml) (p = 0.004), and a signicantly lower number of platelets 161666.6 ul ± 87287.8 ul (p = 0.041), 25 (oh) vitamin d levels which are 14.1 ng/ml ± 4.12 ng/ml. in contrast, in the 3 groups of vitamin d status there were no differences in age, sex and leukocyte count. table 3. the correlation coefcient between total 25 (oh) vitamins d and procalcitonin values note: * signicant correlation p <0.05, with spearman correlation test. in table 3 and figure 1, the associations of the levels of 25 (oh) vitamin d and procalcitonin levels, which showed a total 25 (oh) vitamin d level, was signicantly negatively correlated with procalcitonin levels (r = 0.434, p = 0.012). figure 1. correlation between of total 25 (oh) vitamin d and procalcitonin values volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra table 1 patient characteristic (n= 33) variable value age 53.6 ± 11.7 sex, n (%) male female 20 (60.6) 13 (39.4) trombocyte, /ula 213363.6 ± 130550.7 leukocyte, /ula 16627.5 ± 8093.2 pct, ng/mlb 26.2 (4.0, 252.0) 25 (oh) total vit. d, ng/mla 21.3 ± 11.6 status 25 (oh) vitamin d variable sufcient (≥ 30.0 ng/ml insufcient (20.0 – 29.9 ng/ml) decient (0.0 -19.9 ng/ml) p n (% total) 6 (18.2) 9 (27.3) 18 (54.5) agea 50.3 ± 8.1 59.0 ± 10.2 52.0 ± 13.0 .088 sex, n (%) male female 5 (83.3) 1 (16.7) 7 (77.8) 2 (22.2) 8 (44.4) 10 (55.6) .120 trombocyte, /ula 312833.3 ± 165872.7 250444.4 ± 140734.7 161666.6 ± 87287.8 .041* leukocyte, /ula 17050.0 ± 10139.0 15282.2 ± 4039.1 17159.4 ± 9168.5 .964 pct, ng/mlb 11.3 (4.9, 29.7) 10.9 (4.0, 106.0) 47.2 (7.0, 252.0) .004* 25 (oh) vit.d, ng/mla 41.0 ± 12.0 22.7 ± 2.0 14.1 ± 4.12 <.001* variable procalcitonin r p 25 (oh) total vitamin d 0.434 0.012* discussions in this study we present that 81.8% of sepsis patients treated in the icu run into 25 (oh) vitamin d deciency (<20 ng/ml) and 25 (oh) vitamin d insufciency (20.0 30.0 ng/ml). the proportion of patients with hypovitamin d is high in accordance with previous studies in icu-treated adult patients (prevalence range 17% 79%). chen et.al 2015 reported in his study there was 74,1% from 236 adult icu 9,13patients in guangxi hospitals in china had hypovitamin d. the results in this study show that hypovitamin d is generally still obtained in septic patients admitted to the intensive care unit of h. adam malik hospital in medan. this can be explained as a result of lack of sun exposure which results in low amounts of vitamin d synthesis in the skin, malnutrition due to lack of dietary intake containing vitamin d and impaired absorption and/or hydroxylation of vitamin d in the liver. sari dk et.al on research on healthy women in indonesia also reports that the factors that most inuence vitamin d levels are sun exposure, work, and vitamin d 14,15intake. so that monitoring and improving levels of 25 (oh) vitamin d is very important in improving vitamin d status in some patients at risk for sepsis, as in elderly patients and patients who experience long-term care. another factor analyzed in this study was platelet counts in septic patients. the range of normal platelet values in adults is 150000 400000/ul. thrombocytopenia is common in critical patients with an incidence of 20% to 50%, this situation is due to the production of various cytokines, endothelial damage, bone marrow suppression, excessive consumption due to the process of dic (disseminated intravascular coagulation) 16,17and organ dysfunction in septic patients. thrombocytopenia is associated with mortality in patients admitted to the icu. claushuis et.al examined the relationship of thrombocytopenia with sepsis and outcame in 931 septic patients, patients with low platelet counts (<100 x 109/l) had more severe disease, this can be indicated by high apche and sofa scores, more often shocked and organ 16dysfunction. in this study the mean value of platelet count was lower in the 25 (oh) vitamin d deciency group than the other 2 groups (insufciency and efciency), but not yet experienced thrombocytopenia, as well as the total platelet count total of all patients still in the normal range, even though it was found 10 patients with thrombocytopenia. this can be explained by some patients who have not experienced shock or organ dysfunction. the mean number of leukocytes in the study showed leukocytosis (>12000/ul) although it did not show a signicant difference in the 3 groups of vitamin d status, but this corresponds to one of the clinical criteria of sepsis as follows: leukocyte count >12,000 cells/µl or lower from 4000 18cells/µl or >10% immature leukocytes. the importance of vitamin d has been recognized since this compound was discovered. in addition to maintaining optimal calcium levels and physical health, other effects of vitamin d have been widely evaluated at this time. the antiinammatory and regulatory effects of the hormonal system and the immunomodulatory effects on the kidneys, heart, and immune system of vitamin d have been of considerable 19concern. in this study, vitamin d deciency was signicantly negatively correlated with serum pct levels in patients in our icu (figure 4.1) according to chen et al's study that a signicant negative correlation was found (r = -0.780, p = <0.001). increased serum pct levels are reported to be associated with an inammatory response triggered by bacterial infections and have been used as acute phase markers in patients suspected of infection. kibe et al & lopez et al reported that pct levels correlated with disease severity at onset (apache score) and inammatory process (crp). unlike pct, which is regulated by inammatory cytokines, vitamin d actually suppresses nuclear activation factor kappa b (li 2010), thereby reducing proinammatory cytokines such as il-1, il19, 202, il-6, il-8, il-12, interferon -y, and tnf-a. preliminary results of epidemiological and clinical studies also support the potential role of vitamin d in maintaining the balance of the immune system. in one study, supplementation of vitamin d in congestive heart failure patients reduced the proinammatory situation, suggesting that vitamin d supplements could function as a new anti-inammatory agent for the treatment of future congestive heart failure . in addition, 1,25 (oh) 2d can induce monocyte maturation into mature t cells, which immediately decreases the infectious process 21,22which causes an increase in pct. therefore, 25 (oh) vitamin d deciency or insufciency decreases the ability of the host immune system to suppress bacterial infection and inammatory response, which causes increased circulating pct levels. conclusions and suggestions in the study it can be concluded that 81.8% of septic patients treated in the icu had 25 (oh) vitamin d deciency. there was a negative correlation between 25 (oh) vitamin d levels and an increase in procalcitonin levels of septic patients admitted to the icu. so that further 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[online] available at: http://www.who.int/bulletin/volumes/88/11/10-077073/en/ [accessed 10 april2016]. 4. pradipta is, et al. antibiotic resistance in septic patients: evaluation and recommendation of antibiotic use. north american j of med sci. 2013:344-52. 5. medical record rsup haji adam malik. 2015. 6. wacker c, prkno a, brunkhorst fm, schlattmann p. procalcitonin as a diagnostic marker for sepsis: a systematic review and meta-analysis. lancet infectious diseases. 2013;13(5): 426-35. 7. meisner m, dresden-neustadt sk. procalcitonin-biochemistry and clinical analaysis. uni-med science.1st ed. 2010:128. 8. castelli gp, pognani c, meisner m, stuani a, bellomi d, sgarbi l. procalcitonin and c-reactive protein during systemic inamatory response syndrome, sepsis and organ dysfunction. crit care. 2004;8(4):234-42. 9. chen z, luo z, zhao x,et.al. association vitamin d status of septic patients in intensive care units with altered procalcitonin levels and mortality. jclin endocrinol metab. 2015;100(2):516-23. 10. holick mf, binkley nc, bischoff-ferrari ha, gordon cm, hanley da, heaney rp, et al. evaluation, treatment, and prevention of vitamin d deciency: an endocrine society clinical practice guideline. j clin endocrinol metab. 2011; 96:1911-30. 11. ginde aa, camargo ca, shapiro nij. vitamin d insufciency and sepsis severity in emergency department patients with suspected infection. acad emerg med. 2011;18(5):551-4. 12. dellinger rp, levy mm, rhodes a, annane d, gerlach h, opal sm, et.al. surviving sepsis campaign: international guidlines for management of severe sepsis and septic shock. critical care medicine. 2013;41(2):580-637. 13. lucidarme o, messai e, mazzoni t, arcade m, cheyron dd. incidence and risk factors of vitamin d deciency in critical ill patients: result from a prospective observational study.intensive care med. 2010;36:1609-11. 14. zuniga s, firrincieli d, housset c, chignard n. vitamin d and the vitamin d receptor in liver pathophysiology.clin res hepatol gastroenterol. 2011;35:259-302. 15. sari dk, damanik ha, lipoeto ni, lubis z. is micro evolution in tropical country women resulting low 25(oh)d level?: a cross sectional study in indonesia. j nutr food sci. 2013;4:246. 16. claushuis tam, vught lav, scicluna bp, et al.thrombocytopenia is associated with a dysregulated host response in critically ill septic patients.blood. 2016;127(24):3062-72. 17. guclu e, durmaz y,karabay o. effect of severe sepsis on platelet count and their indices.african health sciences. 2013;13(2):333-8. 18. mayr fb, yende s, angus c. epidemiology of severe sepsis. virulence. 2014; 5(1):4-11. x 117gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 19. gynther p, tropainen s, matilainen jm, seuter s, carlberg c. vaisanen s mechanism of 1�,25-dihydroxivitamin d3-dependent repression of interleukin-12b. biochim biophys acta. 2011;1813:810-818. 20. z h a n g y, l e u n g d y, r i c h e r b n , e t a l . v i t a m i n d i n h i b i t monocytes/macrophage proinammatory cytokine production by targeting mapk phosphatase-1. j immunol. 2012;188:2127-35. 21. schleithoff ss, zittermann a, tenderich g, et al. vitamin d suplementation improves cytokines proles in patients with congestive heart failure: a double blind, randomized, placebo controlled trial. am j clin nutr. 2006; 83:754-56. 22. schuezt p, albrich w, mueller b. procalcitonin for diagnosis of infection and guide to antibiotic decision: past, present, and future. bmc medicine. 2011; 9:107. 118 x gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction oral health is an integral part of general health and wellbeing and is a fundamental human right without distinction of race, religion and political belief, economic and social condition. health can be determined by various factors like life style, dietary habits, socio-economic conditions, occupational environment and the quality of life is reduced [1,2]due to loss of teeth and intraoral diseases . the goal of who is that, oral health as one among the healthy life. so who has selected the theme “oral health” for healthy life (2013-14 [3]. in chennai, survey about the oral health status of 5 years school going children reported that decayed missing lled teeth (dmft) of boys was 3.53 ± 3.07, girls was 3.49 ± 2.83 and in a 12 years the dmft for boys was 3.80 ± 3.43, girls was 4.11 [4,5]± 2.98 . a study by moallemi et al in 2008 showed that mother's oral health knowledge and attitudes are positively [6]related to their children's sound dentition . the result of national survey in brazil, conducted in 2003, showed a signicant drop in caries prevalence in 12 year olds from 8.3 to 2.8. dmft index (1991) in french children at the age of 12 was [8,7]2.59 in a similar survey the oral health problems that are . currently most prevalent dental caries, periodontal diseases, and dental traumas can be prevented by measures aimed at [9,10]reducing exposure to risk factors . schools serve as a valuable platform for promoting oral health among school going children. hence the current study was planned to provide the baseline data regarding oral health status and the factor effecting it with the aim of knowing their awareness level regarding oral health. materials and methods after obtaining the ethical clearance from ethical committee of the institution, list of schools containing required age groups of children had been obtained as per division of district by panchayat halquas/tehsil and the written consent for the survey will be taken from the school authorities. the study work was carried out in 8-14 years old school going children in shopian district, jammu and kashmir and meerut district, uttar pradesh. self structured questionnaire used by [5]al-omiri mk, al-wahadni, saeed kn . the questionnaire includes questions without names and is used to evaluate oral health status, knowledge, attitudes and practice. all questionnaires were completed under the supervision of survey staff and subjected for statistical analysis using spss statistical software 21.0 chicago inc. questionnaire q1. what do you use for cleaning your teeth? 1. toothbrush + toothpaste. 2. dental oss. 3. mouthwash. 4. toothpicks. 5. finger q2. what type of tooth brushing methods do you employ? 1. vertical 2. horizontal 3. combined q3. how often do you brush your teeth? 1. o nce per day. 2. twice per day. 3. more than twice per day. q4. for how long do you brush your teeth? 1. less than one minute. 2. one minute. 3. two minutes. 4. more than two minutes. q5. my parents… 1. watch me while brushing my teeth. 2. do not watch but advise me. 3. never cared. 4. only my mother watches me. q6. do you experience gum bleeding while brushing your teeth? 1. yes 2. sometimes 3. never q7. how often do you visit your dentist? 1. regularly every 6-12 months. 2. occasionally. 3. during dental pain. comparision of oral health attitude, knowledge and practice among 8-14 years old, school going children in shopian, jammu & kashmir and meerut, uttar pradesh. a cross sectional study. original research paper dr shakir hussain rather* department of pedodontic and preventive dentistry kdc, meerut. *corresponding author x 43gjra global journal for research analysis dental science aim: to assess the oral health attitude, knowledge and practice among 8-14 years old, school going children in shopian, jammu & kashmir and meerut, uttar pradesh, india. materials and methods: the subjects for this study were randomly selected from ve private and ve government schools in the age group of 8-14 years. a total of 1000 children were selected both males and females through cluster sampling, with age group of 8 to 14 years government and private school going children both male and female had been selected. self structured questionnaire used by al-omiri mk, al-wahadni, saeed kn. the questionnaire includes questions without names and is used to evaluate oral health status, knowledge, attitudes and practice among school going children. results: overall the level of knowledge score was statistically signicant with p = 0.001. conclusion: the overall level of oral health knowledge among the surveyed children was low. abstract keywords : volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr shabir raq department of orthodontics and dentofacial orthopedics, dj dental college , modinagar. dr abhaya agarwal department of pedodontic and preventive dentistry kdc, meerut. dr umer farooq ids dental college, jammu 44 x gjra global journal for research analysis 4. never visited a dentist. q8. the reason for your last visit to the dentist was: 1. dental pain. 2. family & friend advice. 3. a dentist advised me. 4. another reason (specify)…….. results a total of 1000 children in the age group 8-14 years were randomly selected, of these 590 were males (59%) and 410 were females (41%). the schools were categorized as low and high socio-economic school groups based on the government and private schools, of which 500 children were studying in government schools and 500 children were studying in private schools respectively. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 1.what do you use for cleaning your teeth? 2.what type of tooth brushing methods do you employ? toothbrush + toothpaste / vertical method dental floss / horizontal method mouthwash / combined method toothpick finger chi square value p value shopian gp 441 10 2 45 2 103.12 0.001 (signicant)88.2% 2.0% 0.4% 9.0% .4% meerut gp 264 95 67 37 37 52.9% 19.0% 13.2% 7.4% 7.5% 3.how often do you brush your teeth? morning / once per day afternoon / twice per day other times / more than twice chi square value p value shopian gp 244 179 77 32.33 0.001 (signicant)48.8% 35.8% 15.4% meerut gp 168 194 138 33.5% 38.9% 27.6% 4.for how long do you brush your teeth? less than one minute. one minute. two minutes more than two minutes chi square value p value shopian gp 230 112 111 47 16.893 0.001 (signicant)46.0% 22.4% 22.2% 9.4% meerut gp 191 160 120 29 38.1% 32.1% 24.0% 5.8% 5.parental supervision during brushing? watch me while brushing my teeth . do not watch but advise me never care only my mother watches me chi square value p value shopian gp 268 158 45 29 39.994 0.001 (signicant)53.6% 31.6% 9.0% 5.8% meerut gp 190 186 103 21 37.9% 37.3% 20.6% 4.2% 6.do you experience gum bleeding while brushing your teeth yes sometimes never chi square value p value shopian gp 05 57 438 132.641 0.001 (signicant)1.0% 11.4% 87.6% meerut gp 192 212 96 38.3% 42.5% 19.2% 7.how often do you visit your dentist? regularly every 6-12 months occasionally. during dental pain never visited a dentist. chi square value p value shopian gp 98 318 67 17 184.61 0.001 (signicant)19.6% 63.6% 13.4% 3.4% meerut gp 138 124 138 100 27.7% 24.8% 23.0% 24.5% 8.the reason for your last visit to the dentist was: dental pain. family & friend advice dentist advised me another reason chi square value p value shopian gp 325 97 44 34 115.41 0.001 (signicant)65.0% 19.4% 8.8% 6.8% meerut gp 164 134 101 101 32.7% 26.9% 20.2% 20.2% discussion the present study intended to provide information regarding the children aged 8-14 years old in shopian district, j&k and meerut district, up. in the present study regarding the oral health of children, 88.2% in shopian, j&k and 52.9% of the children in meerut, uttar pradesh used to clean their teeth by using tooth brush and tooth paste followed by dental oss and mouthwash. whereas similar results were reported by who (83%) and puntha and sivaprakasam (62.9%), in a rural population in uttaranchal state and kanchipuram district [11],[12]respectively . this results is not in accordance with that of the study by mahesh kumar et al in chennai, where in his study sample some of the children resorted to the use of charcoal as a medium to brush their teeth than the tooth brush [13]. 0% in shopian, j&k and 7.4% of the children in meerut, uttar pradesh of the children used toothpick to clean their teeth and it was seen 5% used wooden sticks and toothpicks to clean their teeth as the study done in 2016 by bashir r et al in [14]pakistan . while 0.4% in shopian, j&k and 7.5% of the participants in meerut, uttar pradesh used ngers to clean their teeth. in case of method of brushing it was seen that 43.4% in shopian, j&k and 30.3% of the children in meerut, x 45gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra uttar pradesh used vertical method to brush their teeth and 35.4% in shopian, j&k and 41.1% of the participants followed horizontal method of tooth brushing. 21.2% in shopian, j&k and 28.6% of the children's in meerut, uttar pradesh followed combined method to clean their teeth while brushing. in this study 48.8% of the participants in shopian, j&k and 38.9% in meerut, uttar pradesh performed the recommended practice of brushing their teeth once a day. it was reported by harikiran ag et al in 2008 and al-omiri et al that 38.5% brushed their [14,15]teeth two or more times a day . in the present study 35.8% in shopian, j&k and 38.9% of the children in meerut, uttar pradesh performed the recommended practice of brushing their teeth twice a day. this is similar to that observed in some [16, 17, 18]industrialized countries of east europe but low when compared to western industrialized countries. prasad et al reported 66.9% children brush once and 30.7% brush twice [19]daily in tamil nadu, india . about 46.0% of the subjects in shopian district j&k and 38.1% in meerut district u.p used to brush for less than one minute, while 22.4% children's in shopian district j&k and 32.1% in meerut district u.p used to brush one minute. in this study it was seen that 22.2% children's in shopian district j&k and 24.0% in meerut district u.p used to brush two minutes and 9.4% children's in shopian district j&k and 5.8% in meerut district u.p used to brush more than two minutes. in 2016 bashir r et al done a study in which 34% of the participants used to brush 2 minutes and 11.7% brushed for even less than a minute which was similar to the [20]present study . in the present study it was reported that 68.6% of the children in shopian district j&k and 40.7% in meerut district u.p used to brush their teeth in morning which was less (81.6%) as compared to the study done by bashir r et al in 2016 karachi, pakistan. 14.0% children in shopian district j&k and 27.5% in meerut district u.p used to brush their teeth in afternoon. while 11.4% in shopian district j&k and 22.0% in meerut district u.p preferred to brush before going to bed and 6% children in shopian district j&k and 9.8% in meerut district u.p used to brush other times. the parental supervision during brushing was found 53.6% in shopian, j&k and 37.9% in meerut, uttar pradesh. in the present study about 19.4% in shopian, j&k and 26.9% in meerut, up of the children visit a dentist due to family advice while 8.8% in shopian, j&k and 20.2% in meerut, up of the children visit a dentist due to dentist advice. barker and horton done a study on pre-school children in calfornia showed that parents played a major role [21]in inuencing their children's oral health and access to care . a similar study was done by al-darwish ms in 2016 reported that parents were the most popular 69.1% source of oral health [22]knowledge information for children . the awareness of periodontal diseases seems to have increased in shopian, j&k and it was seen 1% of children have gum bleeding during brushing their teeth and 38.3% of the children's in meerut, uttar pradesh experiences gum bleeding while brushing their teeth. our observation is similar to linn in which children [23]knew about periodontal diseases . similar study was done by sharma et al in 2013 in which he reported that the overall [24]prevalence of gingivitis among children was 53.4% . in the present study 54.8% in shopian district j&k and 39.9% in meerut district u.p children's stop brushing their teeth during gum bleeding and 40.8% in shopian district j&k and 41.9% in meerut district u.p children's brush slowly during gum bleeding. 4.4% in shopian district j&k and 18.2% in meerut district u.p of the children visit a dentist after gum bleeding [25] while brushing their teeth. nicolas et al reported that frequent exposure to dental experiences might be a positive factor in helping to reduce patient's anxiety levels. the ndings from the present study revealed that the children's visit a dentist due dental pain. according to a study done by zhu et al 73.6% of the children in china knew that regular [26]dental check-ups are necessary . this scenario observed in malaysian, jordanian studies and in study done by mirza ba et al in pakistan 2011 reported 57% of high socio-economic school children were only aware of brushing to prevent dental [27],[28]problems . bharathi mp et al in 2012 reported in her study that the majority of the children had never visited a dentist due socioeconomic backgrounds, including family income, parental education and area of residence along with cost of dental care, which might have inuenced dental service [29]utilization . according to children's opinion 27.8% in shopian, j&k and 36.3% of the participants in meerut, uttar pradesh the major factor that cause dental problem were sweets and the observation was less as done by al-omiri et al (87.4%). 55.0% of the children's in shopian, j&k and 23.5% in meerut, uttar pradesh of the children's don't know the effects of sweets on teeth. abhinav singh who conducted a study to assess the oral health knowledge, attitude and practice among national cadet corps in south india in which 49% of codets reported consumption of sweets very often and 14.4% [30]reported its consumption all the time . conclusion the current study shows that the knowledge, attitude and practice among school going children about oral health was not satisfactory in both the districts due to lack of poor oral hygiene practices, lack of parental guidance, sociodemographics with the lack of knowledge and frequent exposure to cariogenic foods. parents and schools play a key role in providing a knowledge about oral health. oral health education programs could be included in school curriculum for the children to emphasize a positive attitude towards oral health. references 1. bumb ss, bhaskar dj, punia h, singh v, kadtane ss, jain cd. comparison of oral health knowledge, attitude, practice and oral hygiene status of crpf ofcials in srinagar. dent stu res 2014;2(1):32-35. 2. ali ms, hussain t, ara g, zehra n. oral health awareness and practices of school going children aged 11 to 16 years in a squatter settlement of karachi. j dow uni of health sci 2015;9(2):71-75. 3. mumghamba egs, manji kp, michael j. oral hygiene practice, periodontal condition, dentition status and self-reported bad mouth breath among young mothers, tanzania. int j dent hygiene 2006;4:166-173. 4. nayana, umarani j. knowledge of children regarding oral hygiene: a school based descriptive study. j sci innov res 2014;3(2):134-138. 5. priya m, devdas k, amarlal d, venkatachalapthy a. oral health attitude, knowledge and practice among school children in chennai, india. j educ ethics dent 2013;3(1):26-33. 6. bashir r, rizvi k.assessment of levels of oral hygiene awareness, knowledge, attitude and practice among the students of a government school in karachi, pakistan. bjmmr 2016:15(2):1-11. 7. sultan s, ain ts, gowhar o. awareness of mothers regarding oral health of their children in kashmir. int j cont med res 2016;3(7):2168-2171. 8. behal r, lone n, shah af, yousuf a, jan sm. oral health status of 6-12 year old children attending a government hospital in kashmir. int arch integrated med 2016;3(3):139-146. 9. bansal r, sharma s, shukla ak, parashar p, singh d, varshney am et al. prevalence of dental caries among school children in meerut. asian pac. j. health sci 2015;2(1):84-88. 10. sharma s, parashar p, srivastava a, bansal r. oral health status of 9-12 year old school going children in urban meerut. ind j community health 2013;25(1):61-65. 11. bharathi mp, abhinav s. oral health status of 12 year old children with disabilities and controls in southern india. who south-east asia journal of public health 2012;1(3):330-338. 12. priya m, devdas k, amarlal d, venkatachalapathy a. oral health attitudes, knowledge and practice among school children in chennai, india. j educ ethics dent 2013;3:26-33. 13. smyth e, caamaño f, fernández-riveiro p. oral health knowledge, attitudes and practice in 12-year-old schoolchildren. med oral patol oral cir bucal 200712(8):614-20. 14. harikiran ag et al. oral health-related kap among 11-12 year old school children in a government-aided missionary school of bangalore city. indian j dent res 2008; 19:236-42. 15. oral health in rural child population: promotional and interventional strategies. a goi-who collaborative programme 2006-07. 16. mahesh kp, joseph t, varma rb, jayanthi m. oral health status of 5 and 12 years school going children in chennai cityan epidemiological study. j indian soc pedod prev dent 2005;23:17-22. 17. al-omiri mk et al. oral health attitudes, knowledge, and behaviour, among school children in north jordan. journal of dental education 2006;70-(2). 18. king a, wold b, tudor-smith c, harel y. dietary habits, dental care and body image. in: world health organisation. the health of youth: a cross-national survey. copenhagen: who regional ofce for europe; 1995. p. 39-55. 19. petersen pe, danila i, samoila a. oral health behavior, knowledge, and attitudes of children, mothers, and schoolteachers in romania in 1993. acta odontol scand 1995;53:363-8. 20. chen mm, andersen rm, barmes de, leclercq mh, lyttle cs. comparing oral health care systems: a second international collaborative study. geneva: who; 1997. 21. prasad pa, shankar s, sowmya j, priyya cv. oral health knowledge, attitude, practice of school students of k.r matriculation school, thiruchengode. jaids 2010;1:5-1-11. 22. aapd guideline on periodicity of examination, preventive dental services, anticipatory guidance/counselling, and oral treatment for infants, children and adolescents. aapd;2013. 23. barker jc, horton sb. an ethnographic study of latino preschool children’s oral health in rural calfornia: intersections among family, community, provider and regulatory sectors. bmc oral health 2008; 8:8. 24. al-darwish ms. oral health knowledge, behaviour and practices among school children in qatar. dent res j (isfahan) 2016;13(4): 342-353. 25. linn el. teenagers attitudes, knowledge and behaviours related to oral health. j am dent assoc 1976;92:946-51. 26. nicolas e, bersadent m, collado v, carrasco p. factors affecting dental fear in french children aged 5-12 years. int j paediatric dent 2010;20:366-73. 27. taani dq. periodontal awareness and knowledge and pattern of dental attendance among adults in jordan. int dent j.2002;52:94-98. 28. zhu l, petersen pe, wang hy, bian jy, zhang bx. oral health knowledge, attitudes and behaviour of children and adolescents in china. int dent j 2003;53:289-98. 29. lian cw, phing ts, chat cs, shin bc, baharuddin lh, jalil zb. oral health knowledge, attitude and practice among secondary school students in kuching, sarawak. arch orofacial sci 2010;5(1):9-16. 30. mirza ba, syed a, izhar f, ali khan a. oral health attitudes, knowledge, and behavior amongst high and low socioeconomic school going children in lahore, pakistan. pak oral dent j 2011;31:396-401. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 46 x gjra global journal for research analysis 76.shilpa kobragade online.cdr introduction: dietary assessment encompasses food supply and production at the national level, food purchases at the household level, and food consumption at the individual level. this review focuses only on individual-level food intake. it is intended to serve as a resource for those who wish to assess diet in a research study, for example, to describe the intakes of a population, using individual measurements for group level analysis. in order to produce better evidence for formulating effective nutrition projects, policies and programmes, the most appropriate dietary assessment method rst needs to be selected. objectives: to obtain quantitative information on the amounts of energy and nutrients available for metabolism. methods: dietary assessment methods: the common methods to assess dietary intake at various levels are: a) quantitative survey (24 hours dietary and recall method by oral questionnaire). i. in this method of diet survey, a set of standardized cups, utilized by family are used. ii. information on the total amount of each prepared is noted in terms of standardized cups. iii. the intake of each food item by specic individual in family such as preschool child adolsant girl, pregnant lady or lactating mother is assessed by using the cups. iv. we should remember while doing 24 hours recall, each and every ingredient used in cooking of recipe should be involve. v. in case of milk/curd/buttermilk and extend to which these are diluted should be found. vi. in case of bread, the number of slice per loaf should be assessed. vii. in case of chapati, the number should be recored. viii. the important step is to convert the individual cooked intake into raw amount of each food, the formula is : raw intake : b) qualitative survey (food frequency questionnaire method) i. the method consist of asking individual how often specic food is eaten. ii. this can be assessing diet pattern of specic gravid. iii. food frequency method is primary method for measuring dietary intake in epidemiological studies. iv. it consist of two components: food list and frequency response section for subject to report how often each food is taken. c) other methods of dietary intake assessment:a) household diet survey. b) weighment method. c) food record. d) diet history e) institutional diet survey. f) food balance sheet. g) chemical analysis. h) dietary score. i) estimated food records j) weighed food records k) duplicate meal method a) household diet survey:i) it called information an diet consumed at household level. ii) the results are expressed as per capita or per consumption unit. b) weighment method:i. in this method, the food either cooked or raw is actually, weighed using accurate balance. ii. it is conducted for seven consecutive days to know the true picture of diet consumption. iii. every raw food is weighed in morning and evening before actual cooking done by housewife. only edible portion is weighed. iv. survey is not done in festive days. v. this method is time consuming and needs cooperation of housewifes. c) expenditure method:i. in this method, the money spend on food as well as non food items is assessed by administering specially designed questionnaire. ii. the reference period could be either a previous month or dietary assessment methodsa literature review. original research paper dr. khobragade shilpa vasantrao assistant professor, dept of sanskrit samhita siddhant jupiter ayurved medical college, nagpur (maharashtra) ayurveda the goal of dietary assessment is to identify appropriate and actionable areas of change in the patient's diet and lifestyle and to improve patient health and wellbeing. patients with complex dietary concerns should receive a comprehensive assessment by a dietitian. specic dietary and nutritional counseling recommendations will depend on the patient's comorbidities. diet records, diet-history questionnaires, 24-h recalls, or food-frequency questionnaires (ffqs) are the most common methods to get individual dietary intakes. abstract keywords : dietary assessment. dr harsha r. shende* b.a.m.s. m. a.(sanskrit) assistant professor, dept of sanskrit samhita siddhant jupiter ayurved medical college, nagpur (maharashtra) *corresponding author dr suchita shrikhande p g scholar, department of sharir kriya, k d k college, nagpur. 12 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra week. iii. this is simple method than weighing method. d) food diary:i. it involves maintains of diary records of weighed of food consumed by individual or family according to number of days of survey. ii. in this method a large sample can be covered in short time. e) diet history:i. this method is useful for obtaining qualitative details of diet and studying the pattern of food consumption at household level. ii. the process includes assessment of frequency of different categories of food daily or the number of times in a week or fortnight or occasionally. iii. this method is used to assess diet compsution pattern, dietary habits individual food preference and avoidance during pathophysiological conditions like pregnancy, lection, sickness etc. f) institutional diet survey:i. this method is used in survey in hostel, army kitchen and orphanages home for aged etc. ii. the homogenous people take their meals from common kitchen. iii. in this method the amount of food stuff issued to kitchen as per records maintained is taken into consideration. g) food balance sheet method:food balance is employed when information regarding availability of food is needed of macro level country region. per capita availability per day = stocks at beginning – stocks at end of year + stocks at the end of year food + total food exports + seeds + cattle/poultry produced + import. mid year population x 364 days. h) chemical analysis:i. in this method the individual is required to save sample of each type of food eaten by him during day. ii. this sample is taken and sent to laboratory for chemical analysis. iii. this is most accurate method but costly and needs laboratory support. i) dietary score:this method is used where investigator is trying to assess the dietary intake of specic nutrient for example. iron content of diet. depending upon content of iron, a food item is given score. brief dietary assessment instruments: ÿ characterizing a population's median intakes; ÿ discriminating among individuals or populations with regard to higher vs. lower intakes; ÿ examining interrelationships between diet and other variables; and ÿ comparing ndings from a smaller study to a larger population study conclusion: the benets of developing healthy dietary and lifestyle patterns from an early age onwards can positively impact on people's nutrition and health throughout their adult lives, and enhance the productivity of individuals and nations. references: 1. barbara olendzki, rd, mph, ldn, dietary assessment in adults, upto date.com 2. frances e. thompson and amy f. subar, dietary assessment methodology, national cancer institute, bethesda, md, united states. 3. dietary assessment a resource guide to method selection and application in low resource settings food and agriculture organization of the united nations rome, 2018. 4. http://www.fao.org/3/ai004e04.htm 5. http://www.fao.org/3/i9940en/i9940en.pdf x 13gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: in a moving settlement, each exchanging day is considered as an exchanging period and exchanges executed amid the day are settled in view of the net commitments for the day. at nse and bse, exchanges moving settlement are settled on a t+2 premise i.e. on the second working day. for touching base at the settlement day all mediating occasions, which incorporate bank occasions, nse/bse occasions, saturdays and sundays are prohibited. regularly exchanges occurring on monday are settled on wednesday, tuesday's exchanges settled on thursday and so on. dematerialization in short called as 'demat is the process by which an investor can get physical certicates converted into electronic form maintained in an account with the depository participant. the investors can dematerialize only those share certicates that are already registered in their name and belong to the list of securities admitted for dematerialization at the depositories. depository: the organization responsible to maintain investor's securities in the electronic form is called the depository. in other words, a depository can therefore be conceived of as a "bank" for securities. in india there are two such organizations viz. nsdl and cdsl. the depository concept is similar to the banking system with the exception that banks handle funds whereas a depository handles securities of the investors. an investor wishing to utilize the services offered by a depository has to open an account with the depository through a depository participant ordinarily to purchase and offer offers, you need the cash to pay for your buy and offers in your demat record to convey for your deal. however as you don't have everything to make useful for your buys or offers to convey for your deal you need to cover (square) your buy/deal exchange by a deal/buy exchange before the end of the settlement cycle. on the off chance that the cost over the span of the settlement cycle moves to support you (ascended if there should be an occurrence of procurement done before and fallen in the event of a deal done before) you will inuence a benet and you to get the instalment from the trade. in the event that the value development is unfavourable, you will inuence a misfortune and you to should make the instalment to the trade. edges are in this way gathered to defend against any antagonistic value development. edges are cited as a level of the estimation of the exchange purchasing at the correct minute is the best barrier against an unstable market. at the point when the load of a best class organization ascends out of a sound value base on substantial volume, don't pursue it more than ve per penny past its purchase point. awesome stocks can rise 20-25% out of a couple of days or weeks. on the off chance that you buy at those expanded levels, what may end up being an ordinary pull back could shake you out. that hazard ascends with a more unstable stock there are a few signs in money markets that propose alert, despite the fact that they're all extremely bullish. here are some of them and what they may mean, in light of past understanding. to begin with, everyone's bullish. on the off chance that everybody's bullish, that implies they've just purchased their stock and are trusting more individuals will take after their energy. most individual nancial specialists are completely contributed. furthermore, as long as expansive inows are as yet going into value shared assets, everything's ne. watch out when the streams transform into streams. there won't purchase energy to c o n t i n u e b o o s t i n g s t o c k s . s e c o n d , f e a r o f t h e economy/political scenario. this is an initial indicator, which would pull of sporadic selling that could eventually mount into an outright bear market. the bombay stock exchange and the national stock exchange of india ltd are the two primary exchanges in india. in addition, there are 22 regional stock exchanges. however, the bse and nse have established themselves as the two leading exchanges respectively which accounts for 80 per cent of the equity volume. the average daily turnover at the exchanges has increased from rs. 851 crore to rs. 1,284 crore in 1998-99 and moves up to rs. 2,273 crore in 1999-2000 respectively. nse has about 1500 shares listed with a total market capitalization of rs.9,21,500 crore. the bse has 6000 stocks listed and has a market capitalization of around rs. 9,68,000 crore . review of literature: 1. jiang luo and avanidhar subrahmanyam high levels of turnover in nancial markets are consistent with the notion that trading, like gambling, yields direct utility to some agents. the purpose of this paper is to show that the presence of these agents attenuates covariance risk pricing and volatility, and implies a negative relation between volume and future returns. since psychological literature indicates that the desirability of a gamble arises from the ex ante volatility of the outcome, the authors propose that agents derive greater utility from trading more volatile stocks. these stocks earn lower average returns in equilibrium, although the risk premium on the market portfolio is positive. the authors then consider a dynamic setting where agents' utility from trading increases when they make positive prots in earlier rounds (e.g. due to an endowment effect). this leads to “bubbles,” i.e. disproportionate jumps in asset returns as a function of past prices, higher volume in up markets relative to down markets, as well as a leverage effect, wherein down markets are followed by higher volatility than up markets. 2. viktoria dalko the purpose of this paper is to assess the us securities and exchange commission's new regulation, limit up–limit down (luld), against the background of manipulative high-frequency trading (hft). 3. charnwut roongsangmanoon, andrew h. chen, joseph kang and donald lien empirical evidence of the hedging pressure risk premium exists only in the futures contracts the effect of equity investment on non traders and stopped traders – analysis on investors' perception original research paper n. parthiban guest lecturer in management, government arts and science college sathyamangalam 638401 x 131gjra global journal for research analysis management the purpose of this paper is to understand the customer perception towards equity trading and their difculties in accessing the icici direct online portal. to make non trader customer and stopped trader to start trading in equity market. abstract keywords : volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 132 x gjra global journal for research analysis with delivery-related options. since hedging pressure is supposed to exist for all futures contracts, the empirical evidence raises an interesting empirical question: whether the hedging pressure risk premium is in fact the risk premium associated with the delivery-related options. this chapter contains an empirical test of the nonredundancy between the two related but alternative sources of non-market risks. for the test, we employs a futures risk premia model in which the expected futures returns contain the market risk premium (proxied by the equity market risk premium) and two non-market risk premia (proxied by the hedging pressure effect and by the delivery risk premium reected in the returns of futures options, respectively). our main nding is that both the hedging pressure and the delivery risk premia are nonredundant and statistically signicant for futures contracts with delivery-related options. this nding implies a substantial degree of segmentations between these futures markets and the underlying asset markets. methodology: the type of study was “descriptive study”, were done on equity investment on trading of shares through online brokers in icici securities respectively. tools used in this research, tools used was questionnaire method to nd out the problems occurred with the customers in icici securities and data were collected through the questionnaire method. ÿ questionnaire-the instrumentation used to collect data was likert scale (5point scale) ÿ research method-survey method� sources of data the data collection was done by means of phone call is schedule in questionnaires form. each person has approached separately al questions were read out and explained by researcher. the two types of data used for the purposes &the study are ÿ primary data ÿ secondary data primary data was collected from the respondents by using the questionnaire the following types of questions are used in questionnaire ÿ closed ended questions � ÿ open ended questions � secondary data was collected from company website, booklets and records of the organisation. sampling method: sampling method followed was “random sampling” method, were channel manager in icici securities have provided 400 data from that i have randomly choose 150 data for my research. sample size: sample size taken was 150 framework of analysis: the framework of analysis was ÿ survey was taken through questionnaire method and statistical analysis was done through spss tool and nd whether there is signicant relation between cause and he effect respectively assumption: the conclusion of the research has been made by interview over 150 clients who has dmat account in icici with special reference to icici securities ltd. the majority of the employees considered in this research are inactive traders and stopped traders respectively. if the client faces any problem, it will redirect to channel manager in the organization and channel manager came up with feasible solution. limitation: the study has been made on active customers, inactive customer and stopped trader respectively. the limitation of the study was the data provided by the icici securities was limited to 400 and they have not provided data of active customers. analysis and interpretation: table.1 interpretation: the above table shows that about 40% of the clients are investing in equity market. from 150 clients about 40 clients are investing in equity market. figure : 1 interpretation: the above table shows that about 31% of the clients agree that external factor is the reason for stopped trading and 9% of the clients disagree to this factor respectively. figure : 2 interpretation: the above table shows that about 27% of the clients agree that external factor is the reason for stopped trading, 6% of the clients disagree to this factor and 7% of the clients strongly agree to this factor respectively. figure : 3 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra frequency percent valid percent cumulative percent valid yes 40 100.0 100.0 100.0 interpretation: the above table shows that about 29% of the clients agree that loss is the internal factor which is the reason for stopped trading, 5% of the clients disagree to this factor and 6% of the clients strongly agree to this factor respectively. figure : 5 interpretation: the above table shows that about 9% of the clients agree that service is the internal factor which is the reason for stopped trading, 31% of the clients disagree to this factor respectively. figure : 6 interpretation: the above table shows that about 23% of the clients agree that ination is the external factor which is the reason for stopped trading, 16% of the clients disagree to this factor respectively. figure : 7 interpretation: the above table shows that about 11% of the clients agree that volatility is the external factor which is the reason for stopped trading, 25% of the clients disagree to this factor and 3% of the clients strongly agree to this factor respectively. figure : 8 interpretation: the above graph shows that about 16% of the client wants nancial guidance have to be provided, 15% of the client wants to reduce the brokerage cost, 4% of the clients want service to be improved and 5% of the client wants recommendation of companies respectively. figure : 9 interpretation: from the above table shows that 35% of the clients agree that brokerage cost were reason for not started trading and 155 of the clients disagree that brokerage cost is not the reason for start trading. figure: 10 interpretation: from the above table shows that 25% of the clients agree that nancial status were not good and about 35% of the clients disagree with this reason. about 5% of the clients strongly agrees with this factor. figure : 11 interpretation: from the above graph shows that 45% of the clients agrees that they want nancial guidance to start their trading and 15% of the clients strongly agree to this factor respectively figure: 12 x 133gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra interpretation: from the above table shows that most of the client wants nancial advice to start their trading about 32% of the clients wants nancial advice and 28% of the clients want to reduce the brokerage cost and 5% of the people want service to be improvemodelrr squareadjusted r squarestd. error of the estimate1.392a.154.057.374 stopped traders: table 2 the r squared statistics provided that how model tting the actual data. the value should be lies between 0 and 1.here the r square is lies in 0.154, where the r square represent how predicted variable is relationship to target variable. table 3 null hypothesis (ho): the independent variable (loss, service, brokerage and volatility) have impact on equity investors. alternate hypothesis (h1): the independent variable (loss, service, brokerage and volatility) have no impact on equity investors. signicance level= 0.00 calculated value < table value 0.00<0.05 hence, the null hypothesis [ho] is accepted conclusion: in the output above, loss variable is signicant because of their p value is .000 which is less than 0.05, whereas the signicant value of brokerage, service and volatility was .052, .840 and.456 which is >0.05, hence reject null hypothesis. ÿ the above table shows that investors have impact on loss respectively and hence accept ho. ÿ the above table shows that investors have no impact on brokerage respectively and hence reject ho. ÿ the above table shows that investors have no impact on service respectively and hence reject ho. ÿ the above table shows that investors have no impact on volatility respectively and hence reject ho. references: [1] g ramasamy, k sandhya international journal (2013), investor perception towards online trading in chennai. [2] pm dechow (2000), analysts forecasts and brokerage rm trading. [3] jac santos (1999),the relation between analysts' forecasts of longterm earnings [4] www.livemint.com [5] www.icicidirect.com [6] www.moneycontrol.com 134 x gjra global journal for research analysis coefcients: model unstandardized coefcients standardized coefcients t sig. 1 (constant) .469 .388 1.20 .235 loss is the major internal factor that i inoccurred during trading? .347 .175 .326 1.97 5 .000 brokerage is the major internal factor that i .112 .172 .105 .649 .052 service is the major internal factor that i inoccurred during investment .030 .147 .033 .203 .840 volatility is the major external factor that i inoccurred during investment .097 .129 .117 .753 .456 model r r square adjusted r square std. error of the estimate 1 .392a .154 .057 .374 introduction the term chronic spontaneous urticaria (csu) is used to describe those cases in which the cause could not be determined despite of intensive clinical and laboratory investigations. autoimmune mechanisms have been proposed to cause some cases of csu. this was supported by the observation that an intradermal injection of autologous serum (autologous serum skin test) elicited immediate wheal and are response in 60% of patients with csu (1).later igg autoantibodies directed against ige or fceri receptor on ige were demonstrated and were found to be the cause of autoimmune urticaria (2). the autoimmune process in csu overlaps with many other autoimmune diseases, most common amongst them is the autoimmune thyroid disease (3). the incidence of thyroid autoantibodies in patients with cu ranges from 6.5% 57% (4, 5). total ige has been found to be raised in patients with cu. this is because of polyclonal activation of b cells in cu (6).thus, autoimmune markers like antinuclear antibodies (ana), rheumatoid factor (rf), antithyroid peroxidase antibodies (anti-tpo ab), autologous serum skin test (asst) and total ige are important investigations in csu. characterization of inammatory response erythrocyte sedimentation rate (esr) and c reactive protein (crp) are essential for an insight into the pathophysiology of the disease as well as its activity, severity and diagnosis/management of infections and autoimmune diseases in the course of chronic urticaria (7). infections can cause urticaria by inducing molecular mimicry, hence identication and management of infections in patients of cu is essential (8). materials and methods we retrospectively evaluated 134 patients of chronic urticaria seen in allergy clinic of department of dermatology, venereology and leprosy at avbims dr. ram manohar lohia hospital, after taking approval from recent 2 years span instituitional ethical board. patients of acute urticaria (duration of urticaria<6 weeks), physical urticaria (excluded with proper history), urticarial vasculitis, children less than 12 years, pregnant and lactating women were excluded. data were collected regarding, age, sex, disease duration, severity and laboratory parameters. we used urticaria activity score (uas) to assess severity of the disease autologus serum (9). skin test(asst) done for each patients by injecting intradermaly of 0.1 ml each of autologous serum, saline (negative control) on the volar aspect of left forearm with a gap of 5 cm between each injection site. after 30 minutes the wheal formed at each injection site were measured at two perpendicular diameters (d1, d2) and the average of the two was calculated. asst was considered to be positive if seruminduced wheal had a diameter (average of d 1 and d 2) of ≥1.5 mm as compared to the saline-induced wheal at 30 minutes (10). various serologic autoimmune and inammatory markers including, antiassessed by different methods nuclear antibodies (ana), rheumatoid factor (rf), thyroid autoantibodies-thyroperoxidase (antitpo<50iu/ml), serum total ige (female<175, male<250iu/ml) and c-reactive protein (crp) assessed by elisa. thyroid function test (tft) by chemiluminesense (vitros eci, and jhonson and jhonson) anti-streptolysin antibodies (aso) by latex agglutination method . comple te haemogram and e r y th rocy te sedimentation (esr), routine and microscopic examination of urine and stool examination for ova and cyst were done for each participant. statistical analysis for demographic and other clinical variables we use descriptive statistics, using mean ± standard deviation and percentage (frequency). we compared between all clinical with laboratory variables by using anova. pearson correlation was used to nd correlation of these lab and clinical variables. a p value of <0.05 was considered as statically signicant. we used spss soft version 20.0. results of the 134 patients with chronic spontaneous urticaria 92(68.7%) were female, 42(31.3%) male with the average age of 35 year (14yrs-72yrs). the duration of the onset of disease was average 38 months (2 360months). urticaria activity score was found to be of moderate grade among 84(62.7 %), severe grade 31(23.1 %) and mild grade 19(4.2 %). autologus serum skin test (asst) was positive in 40(29.9%). among 40, to evaluate the association between clinical parameters of chronic urticaria and various biomarkers original research paper dr seema rani* associate professor, department of dermatology, abvims, dr rmlh, new delhi *corresponding author dermatology introduction: causes of chronic urticaria (cu) remain obscure. laboratory parameters or biomarkers can be a predictor of duration and severity of urticaria. objective: the aim of this study was to evaluate the association between clinical parameters of chronic urticaria and various biomarkers. methods: a retrospective cross-sectional data of 134 patients of chronic urticaria seen in allergy-clinic, during recent 2 years span were collected. demographic details, duration of the disease, urticaria activity score (uas), autologus serum skin test (asst) and various autoimmune and inammatory laboratory parameters were included. results: we found disease activity (uas) was signicantly associated with biomarkers, asst (.044), crp (.025) and ana (.000). ana positivity was signicantly (.000) associated with duration of the disease. conclusions: the present study found association of chronic urticaria with inammatory and autoimmune markers; hence it is important to monitor certain laboratory testings like, crp, esr, ana, asst, thyroid auto antibodies, ige and routine blood count to predict the disease duration, severity and to manage patients appropriately. abstract keywords : urticaria; biomarkers; autoimmunity; inammatory dr niharika dixit senior resident, department of dermatology, abvims, dr rmlh, new delhi. dr devika choudhry post graduate student, department of dermatology, abvims, dr rmlh,new delhi. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 44 x gjra global journal for research analysis dr p. k. sharma professor, department of dermatology, abvims, dr rmlh, new delhi 26(65%) were female and 14(35%) were male. anti-nuclear antibodies and rheumatoid factors were found to be positive in 20(14.9%) of patients. both ana and rf were raised in only 3 patients (2.2%). out of 20 rheumatoid factor and ana positive patients, 12(60%) were female and 8(40%) male. ana and asst were positive in 10 (7.46%) cases. 31(23.5%) had risen anti thyroid antibodies. serum ige was signicantly raised in 82(61.2%). laboratory inammatory markers aso and crp were positive in 11(8.2%) and 49 (36.6%) respectively. routine stool and urine samples were showed 13(9.7%) and 31(23.1%) positive for cyst of giardia and bacteria respectively. esr was raised among 32(25%) patients as shown in table1, 2. there were no signicant difference of all clinical and lab parameters in both sexes except esr in female (p=.007), comparison to male. we found positive association of age with duration (p=.000), serum ige (p=.025) and esr (.044). the study showed positive association of crp with uas (.025) and raised count of total leucocytes (.025). absolute eosinophil counts (aec) was associated with raised tlc and uas with statistical signicant p value of .025 and .043 respectively. raised esr associated with ana, anti-tpo and positive stool test for giardiasis with signicant p value.026, .024 and .027 respectively. all cu patients with rf positive were associated with raised serum ige (.020) ana positivity was signicantly (.000) associated with duration of the disease, raised esr (0.026) and uas (0.000). positive result of asst was signicantly correlated with uas (.044) as shown in table 3. angioedema was found in only 4(3%) person. discussion the present study has shown 68.7% female preponderance similar to previous studies (11). the mean age of the patients were 35.45 years which was comparable to the study done by george et al (13).average duration of chronic urticaria was 38 months and cu patients with ana positivity had prolonged duration (11). we found, elderly patients had prolonged disease-duration (.000) with raised value of esr (.040) and serum ige (.025). although measuring ana serves as a nonspecic marker of systemic autoimmunity, its relationship with cu is poorly understood. nonetheless, positive ana has been found to have some correlation with ciu severity and was strongly associated with refractoriness to antihistamines (14). was associated whereas in other study cu duration clinical parameters such as severity and angioedema, and presence of both autologous serum test and anti-thyroid antibodies (15). in our study disease duration was associated with age, crp, ana and asst positivity. asst was found to be positive in 40 patients (29.9%), these were associated with moderate to severe grade of urticaria (uas). some studies also showed severe clinical features in asst positive cu than asst negative(16), in contrast to the other study which did not found such association (17). similar to most of the previous studies, our study was found positive correlation between crp and severity of urticaria (17, 18).this indicates that crp levels reect activity of disease and it may serve as a biomarker to monitor csu patients. crp positive individual also had raised total leukocytes counts (tlc). we found association of raised serum ige with positive rf. rf were positive in 20(14.9%) patients all had raised serum ige level. earlier studies also found high titres of ige in serum of rheumatoid arthritis (ra) (19, 20)patients but no increased prevalence of atopy (21, 22) rather decreased prevalence (23). de clerck et al. found elevated ige levels and ige circulating immune complex in ra patients more frequently than in patients with allergic asthma and good correlation between skin ige deposition and extra articular manifestations of ra. in our studies we did not nd any clinical severity in rf positive cu patients with raised serum ige. we also did not found any correlation of thyroid autoantibodies to sex, duration, severity, asst, ana positivity in cu. elevated esr was seen in thyroid auto-antibodies positive patients (p=.024) similar to result found in other study (24), ana positive, female and elderly individuals and patients associated with positive stool test for ova and cyst . raised aec were found to be associated with raised tlc and cu severity. conclusions in our study we found, chronic urticaria was seen more commonly in female. disease duration was prolonged in elderly and patients with autoimmunity. disease severity was found to be associated with inammatory marker-crp positivity, peripheral eosinophilia and ana, asst positivity. hence, it is important to monitor certain laboratory testings like, crp, esr, ana, asst, thyroid auto antibodies, ige and routine blood count to predict the disease duration and severity and to manage patients appropriately. the limitation was that we have not covered the therapeutic part/response in our patients, no comparison with healthy control and also the sample size was not adequate to derive any nal conclusion. acknowledgement: for statistical analysis.dr triptish bhatia, ph.d. senior research scientist, indo-us projects, dept. of psychiatry, center of excellence in mental health, pgimer, dr rmlh, new delhi, india. table1. showing demographic and clinical prole table 2. percentage of patients with positive inammatory and autoimmune markers. esrerythrocyte sedimentation rate, crp-c-reactive protein, asoantistreptolysin o, aecabsolute eosinophil count, total leukocyte count anaantinuclear antibodies, anti-tpoanti thyroid peroxidise, asstautologus serum skin test, rfrheumatoid factor volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra sex males females number of patients (%) (n=134) 42 (31.3%) 92 (68.7%) mean±sd 52.17+83.46 31.20+41.75 age (years) range 14-72 35.45±11.94 duration(months) range 2-360 37.77±58.61 severity of urticaria (uas7) mild moderate severe 19 (14.2%) 84 (62.2%) 31 (23.1%) 27.54±8.364 inammatory markers positive (no. of patients, %) n=134 autoimmune markers positive (no. of patients, %) n=134 esr 32 (25%) ana 20 (14.9%) crp 49 (36.6%) antitpo antibodies 31 (23.5%) aso 11 (8.2%) asst 40 (29.9%) aec 24 (17.9%) rf 20 (14.9%) tlc 7 (5.2%) s. ige 82 (61.2%) table 3. signicant correlation between various clinical and laboratory parameters. inammatory markers with demographic and autoimmune parameters *p value autoimmune markers with demographic and inammatory parameters *p value demographic with autoimmune and inammatory parameters *p value esr stool for ova and cyst 0.027 ana duration 0.000 duration ana 0.000 x 45gjra global journal for research analysis *p value signicant below 0.05 level, esrerythrocyte sedimentation rate, crpc-reactive protein, uasurticaria activity score, tlctotal leukocyte count, aecabsolute eosinophil count, ana-antinuclear antibodies, asstautologus serum skin test, rfrheumatoid factor references 1. sabron ra, grattance,francis dm, barr rm, kobza black a, greaves mw. the autologous serum skin test: a screening test for autoantibodies in chronic idiopathic urticaria. br dermatol 1999; 140:446-52. 2. hide m, francis dm, grattan ceh, hakimi j, kochan jp, greaves mw. auto antibodies against the high afnity ige receptor as a cause of histamine release in chronic urticaria. n eng j med 1993; 328:1599-604. 3. conno cohen r, chodick g, shalev v et al. chronic urticaria and autoimmunity: associations found in a large population study. j allergy clin immunol. 2012; 129(5):1307-13. 4. atta am, rodriguesmza, sousa cp, medeiros junior m, sousa-atta mlb. autoantibodies production in chronic idiopathic urticaria is not associated with helicobacter pylori infection. braz j med biol res 2004;37:13-7. 5. aamir is, tauheed s, majid f, atif a. frequency of autoimmunethyroid disease in chronic urticaria. j coll physicians surg pak 2010;20:158-61. 6. kessel a, helou w,bamberger e, sabo e, nusem d, panassof j, toubi e. elevated serum total igea potential marker for severe chronic urticaria. int arch allergy immunol 2010; 153:288-93. 7. kasperska-zajaca, acute-phase response in chronic urticaria. j eur acad dermatol venereol. 2012; 26:665-72. 8. wedi b, raap u, weickzorek d, kaap a.urticaria and infections. allergy, asthma &clinical immunology. 2009; 5:10. 9. godsekv.urticariameter.indianjdermatol2012; 57:410-1. 10. ghose sk, ghosh s. autologous seum skin test. indian journal of dermatology. 2009;54(1):86-87. 11. irinyi b, sze ĺ es g, gyimesi e, et al. clinical and laboratory examinations in the subgroups of chronic urticaria. int arch allergy immunol 144:217–225, 2007. 12. magen e, waitman da, dickstein y, davidovich v, kahan nr. clinicallaboratory characteristics of ana-positive chronic idiopathic urticaria. allergy asthma proc.2015 mar-apr; 36(2):138-44. 13. george m, ba lachandran c , prabhu s . chron ic id iopa th ic urticaria:comparison of clinical features with positive autologus serum skin test.indian j dermatol venereol leprol 2008;74:105-8 14. viswanathan rk, biagtan mj, and mathur sk. the role of autoimmune testing in chronic idiopathic urticaria. ann allergy asthma immunol 108:337–341.e1, 2012 15. toubi e. kessel a. avshovich n. bamberger e. sabo e. nusem d. panasoff j.clinical and laboratory parameters in predicting chronic urticaria duration: a prospective study of 139 patients.allergy.2004 aug; 59(8):869-73. 16. caproni m, volpi w, giomi b, et al. chronic idiopathic and chronic autoimmune urticaria: clinical and immunopathological features of 68 subjects. acta derm vererol 2004; 84:288–90. 17. rabelo-filardi r.daltro-oliveira r.campos r.a. parameters associated with chronic spontaneous urticaria duration and severity: a systematic review. int arch allergy immunol 2013; 161:197-204. 18. kolkhir p, altrichter s, hawro t, maurer m. c-reactive protein is linked to disease activity, impact, and response to treatment in patients with chronic spontaneous urticaria. allergy.2018 apr; 73(4):940-48. 19. grennan dm, palmer dg. serum ige concentration in rheumatoid arthritis: lack of correlation with gold toxicity. br med j. 1979;2:1477–8. 20. hunder gg, gleich gj. immunoglobulin e (ige) levels in serum and synovial uid in rheumatoid arthritis. arthritis rheum. 1974;17:955–63. 21. o'driscoll br, milburn hj, kemeny dm, cochrane gm, panayi gs. atopy and rheumatoid arthritis. clin allergy. 1985;15:547–53. 22. hasan wu, keaney np, holland cd, kelly ca. bronchial reactivity and airow obstruction in rheumatoid arthritis. ann rheum dis. 1994;53:511–4. 23. allanore y, hilliquin p, coste renoux m, menkès cj. decreased prevalence of atopy in rheumatoid arthritis. lancet. 1998;351:497. 24. kumutnart chanprapaph , wimolsiri iamsumang,penpun wattanakrai, and vasanop vachiramon. thyroid autoimmunity and autoimmunity in chronic spontaneous urticaria linked to disease severity, therapeuticresponse, and time to remission in patients with chronic spontaneous urticaria. hindawi biomed research international volume 2018, 13 pages. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra esr age 0.044 ana uas 0.000 age esr 0.044 esr ana 0.026 ana esr 0.026 age duration 0.000 esr antitpo antibodies 0.024 anti tpo antibod-ies esr 0.024 age s. ige 0.025 esr sex (female) 0.007 asst uas 0.044 sex esr 0.007 crp uas 0.025 rf serum ige 0.020 crp tlc 0.025 aec uas 0.043 aec tlc 0.025 46 x gjra global journal for research analysis introduction: valerius cordus synthesized diethyl ether in 1540 and shortly thereafter theophrastus bombastus von hohenheim (paracelsus) noted that it could diminish pain. priestley synthesized nitrous oxide in 1774, and in 1800, davy found that it decreased pain and suggested its use for surgery. in the 1820s, hickman advanced the notion of anaesthesia, but davy quashed hickman's idea. von liebig synthesized chloroform (1)in 1831 . the recreational use of diethyl ether and nitrous oxide and a desire to eliminate the pain of surgery, initially led to unsuccessful (nitrous oxide) demonstrations or unreported use in patients undergoing surgery. long's experience with ether in 1842 is as famous as his failure to publicize the discovery. anesthesia was born on 16 oct 1846 (ether day) with morton's public demonstration of ether anesthesia. simpson's 1847 discovery of the anesthetic effects of chloroform followed. nitrous oxide (restored to favor in the 1860s) and ether combined with oxygen provided anesthesia for a century, with modest competition in the 1930s to 1950s from divinyl ether, (2)(3) .cyclopropane and trichloroethylene world war ii advances in uorine chemistry enabled development of compounds halogenated with uorine to eliminate ammability. the major advance was suckling's synthesis of halothane in the early 1950s. released for clinical use in the mid-1950s, halothane swept away its pungent, toxic, ammable predecessors, dominating anesthesia for more than a decade. its use in newly developed vaporizers (copper kettle and fluotec) allowed the precise control of anesthetic concentrations, contributing to its safety and popularity. world war ii also gave birth to methods, particularly the infrared analyzer, to continuously analyze inhaled anesthetics. this facilitated the measurement of the minimum alveolar conce ntration (mac) required to eliminate movement in response to (2)noxious stimulation in 50 % of subjects, an anesthetic ec50 . halothane was less than perfect. it caused a rare, immuno logically-based and potentially fatal hepatic injury. this spurred the synthesis of progressively less metabolized, less toxic, and less soluble (faster recovery) anesthetics. enurane came rst, and displaced halothane. however, enurane could cause convulsions and in the 1980s, isourane, a compound less soluble and without convulsant properties, replaced enurane. the rise of ambulatory, day case surgery in the 1980s increased the demand for more rapid awakening from anesthesia, and the 1990s saw the release of the poorly (3),(4),(5)soluble anesthetics, sevourane and desurane . materials and methods: for this prospective, randomized, comparative study 40 patients were randomly allocated by closed envelope method into two groups of 20 each in which group d receives desurane and group s receives sevourane. after approval from the ethical committee and written informed consent from patients, patients were randomized to the desurane or sevourane group. patients with clinically signicant cardiovascular, respiratory, hepatic, renal, neurologic, psychiatric, or metabolic disease were excluded from the study. patients with a history of malignant hyperthermia and pregnant, possibly pregnant, or lactating women also were excluded. atropine, benzodiazepine, and similar drugs were not used as premedications before induction of anesthesia. anaesthesia work station was checked. appropriate size endotracheal tubes, working laryngoscope with medium and large size blades, stylet and working suction apparatus were kept ready before procedure. after shifting the patient to operating room, iv access was obtained with 18g iv cannula and ringer lactate started. all patients were preoxygenated with 100% oxygen for 3 minutes before the induction of anaesthesia with fentanyl 1.5 to 2 μg/kg iv and propofol 2mg/kg iv and vecuronium 0.1mg/kg iv. after loss of consciousness, patient were intu bated. anaesthesia was maintained with either sevourane 1% to 2% or desurane 3% to 6% in n2o:o2 at a ratio of 60:40. during the procedure, the patients were monitored by electro recovery time of desflurane versus sevoflurane in patients undergoing general anaesthesia original research paper dr. omais ali beigh senior resident, department of anaesthesiology, skims medical college bemina x 25gjra global journal for research analysis anaesthesiology objectives: to compare recovery time of desurane versus sevourane in patients undergoing general anaesthesia. methodology: 40 patients of age between 14-50 years, belonging to asa grade i and ii, scheduled for elective surgeries under general anaesthesia were included in the study. patients belonging to asa grade iii and iv, those scheduled for emergency surgeries and patients with anticipated difcult airway were excluded from the study. the patients were randomised into two groups of 20 each, group-s and group-d. patients in group-s received sevourane as inhalation agent. patients in group-d received desurane as inhalation agent recovery time which included time to verbal response, eye opening, name stating, nger sequencing, limb lift was assessed. results: comparison of the parameters of recovery time which included verbal response, eye opening, name stating, nger sequencing and limb lift between the two groups were higher in sevourane group with a t value of between -22.899 and -19.808 which is statistically signicant with a p value of <0.001. conclusion: in comparison of both desurane and sevourane we found that there was early recovery with desurane. abstract keywords : volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. aatif nabi shah* senior resident, department of anaesthesiology, sheri kashmir institute of medical sciences(skims) soura, j&k, india-190011. *corresponding author 26 x gjra global journal for research analysis ÿ comparison of the verbal response(in sec) between the two groups shows that verbal response(in sec) is higher in sevourane group with a t value of -22.166 and is statistically signicant with a p value of <0.001 ÿ comparison of the eye opening(in sec) between the two groups shows that eye opening(in sec) is higher in sevourane group with a t value of -22.899 and is statistically signicant with a p value of <0.001 ÿ comparison of the name stating(in sec) between the two groups shows that name stating(in sec) is higher in sevourane group with a t value of -20.442 and is statistically signicant with a p value of <0.001 ÿ comparison of the finger sequencing(in sec) between the two groups shows that finger sequencing(in sec) is higher in sevourane group with a t value of -19.808 and is statistically signicant with a p value of <0.001 ÿ comparison of the limb lift(in sec) between the two groups shows that limb lift(in sec) is higher in sevourane group with a t value of -20.831 and is statistically signif icant with a p value of <0.001 graph 1 graph1 we can see that, ÿ comparison of the verbal response(in sec) between the two groups shows mean of 141secs in desurane vs 327.75 secs in sevourane and is statistically signicant with a p value of <0.001 ÿ comparison of the eye opening(in sec) between the two groups shows mean of 178.75secs in desurane vs 388.25 secs in sevourane and is statistically signicant with a p value of <0.001 ÿ comparison of the name stating(in sec) between the two groups shows mean of 261secs in desurane vs 456.75secs in sevourane and is statistically signicant with a p value of <0.001 ÿ comparison of the finger sequencing(in sec) between the two groups shows mean of 309.5secs in desurane vs 562.25secs in sevourane and is statistically signicant with a p value of <0.001 ÿ comparison of the limb lift(in sec) between the two groups shows mean of 327.75secs in desurane vs 586.5secs in sevourane and is statistically signicant with a p value of <0.001 discussion: in our study we compared the recovery time between the two groups which included the following parameters, 1. verbal response 2. eye opening 3. name stating 4. finger sequencing 5. limb lift 1. verbal response: following desurane anaesthesia the ver bal response was 141.5 seconds as compared to 327.75 seconds in sevourane group. this is a signicant difference in time both clinically as well as statistically. this can be attributed to the lower blood gas coefcient of (4) desurane as compared to sevourane . 2. eye opening: in patients receiving desurane anaesth e sia the time for eye opening was 178.75 seconds as compared to sevourane receiving patients which was more in duration at 388.25 seconds. this is clinically as well as statistically signicant difference in time. 3. name stating: patients receiving desurane anaesthesia stated their names earlier at a mean of 261 seconds as compared to patients receiving sevourane anaesthesia with a mean of 456.75 seconds. 4. finger sequencing: mean time for nger sequencing was 309.5 seconds in desurane group as compared to 562.25 seconds in sevourane group. this is a signicant difference clinically and statistically. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra group n mean std. deviation t df p value verbal response(in sec) desurane 20 141.5 26.512 -22.17 38 <0.001 sevourane 20 327.75 26.63 eye opening(in sec) desurane 20 178.75 27.714 -22.9 38 <0.001 sevourane 20 388.25 30.1 name stating(in sec) desurane 20 261 32.265 -20.44 38 <0.001 sevourane 20 456.75 28.157 finger sequencing(in sec) desurane 20 309.5 29.015 -19.81 38 <0.001 sevourane 20 562.25 49.137 limb lift(in sec) desurane 20 327.75 26.63 -20.83 38 <0.001 sevourane 20 586.5 48.75 table 8: independent t test: comparison of the durations cardiography, pulse oxymetry, and noninvasive arterial blood pressure measurement. volatile concentrations of sevourane and desurane were determined using a multigas analyzer. sevourane was administered using ohmeda sevotec-5 and desurane was administered using drager d vapourizer. the inspired concentration of the volatile anesthetic was adjusted to maintain mean arterial pressure within 20% of baseline values. during the maintenance period, ventilation was controlled to maintain normocarbia with a fresh gas ow (4.0 l/min) using a semiclosed circular system. muscle relaxation was maint ained by incremental doses of vecuronium. fluid was admin istered at a rate of 10 to 15 ml/kg/hr.at the end of surgery, inhaled anaesthetics were discontinued. the lungs were ventilated with 100% oxygen at a fresh gas ow rate of 8 l/min. residual neuromuscular blockade reversed with inj. neosti gmine 0.05 mg/kg and inj. glycopyrrolate 0.01 mg/kg. emergence quality was measured from the time of termination of anaesthetic gas. parameters evaluated: recovery time which included time to verbal response, eye opening, name stating, nger sequencing and limb lift. results: 40 patients randomly divided into two groups with 20 patients in group d (desurane) and 20patients in group s (sevo urane) scheduled for surgery under general anaesthesia was undertaken to assess the recovery time of the two volatile anaesthetic agents. 5. limb lift: return of muscle power can be assessed by limb lift. in our study patients in desurane group lifted their limbs earlier at 327.75 seconds as compared to sevourane group at 586.5 seconds. the pharmacokinetic properties of desurane and sevo ur ane favour better intraoperative control of anaesthesia and a (6),(7),(8)rapid postoperative recovery . they have signicantly lower blood/gas partition coefcients (0.45 and 0.65 respe ctiv ely) than isourane (1.4) or halothane (2.4). the lower fat/blood partition coefcient of desurane, 27 v/s 48 for sevourane, should favour its early elimination from the body (8),(9),(10)resulting in early recovery . references: 1. robert k. stoelting, simon c. hiller; pharmacology & physiology in anaesthetic practice. lippincott williams & wilkins. fourth edition. inhaled 2006, page 41-42anesthetics. 2. kent cd and domino kb. depth of anaesthesia. current opinion in anaesthesiology 2009, 22:782-787 3. robert k. stoelting, simon c. hiller; pharmacology & physiology in anesthetic practice. lippincott williams & wilkins. fourth edition 2006, page no: 62-63 4. eger ei. desurane (suprane): a compendium and reference. nutley, nj:anaquest, 1993,1-119. 5. weiskopf r., cahalan m., eger e. i., yasuda n., rampil i., onescu p., lockhart s., johnson b., friere b., and kelley, s. cardiovascular actions of desurane in normocarbic volunteers. anesth. analg1991, 73:143-156. 6. ebert t. and muzi m. sympathetic hyperactivity during desurane anesthesia in healthy volunteers: a comparison with isourane. anesthesiology 1993,79:444-453. 7. cahalan mk. haemodynamic effects of inhaled anesthetics.cl evelan d:in ternational anesthesia research society,1996:14-18. 8. caldwell j., laster m., magorian t., heier t., yasuda n., lynam d., eger e. i., and weiskopf r. the neuromuscular effects of desurane, alone and combined with pancuronium or succinylcholine in humans. anesthesiology 1991,74:412-418. 9. rampil i., lockhart s., eger e. i., yasuda n., weiskopf r., and cahalan m. the electroencephalographic effects of desurane in humans. anesthesiology 1991,74:434-439. 10. lutz l., milde j., and milde l. the cerebral functional, metabolic, and hemodynamic effects of desurane in dogs. anesthesiology 1990, 73:125-131. x 27gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: valproic acid (valproate) is a branched chain organic acid, used for treatment of epilepsy, migraine headache prophylaxis, bipolar disorders and is a renowned cause of several distinctive forms of acute and chronic liver injury. valproate acts by increasing levels of gamma amino butyric acid(gaba),a major inhibitory neuro-transmitter in human brain. valproate has multiple side effects and clinically signicant drug interactions; common side effects include headache, insomnia, nervousness, somnolence, tremor, blurred vision, nausea, weight gain and rash. more serious side-effect includes fatal liver damage . valproate induced hepato-toxicity can occur in following three : valproate can cause hepatotoxicity by 3 mechanisms 1: hyperammonemia with minimal or no evidence of hepatic injury. this syndrome presents with progressive and episodic confusion followed by obtundation and coma. diagnosis can be made by elevation in serum ammonia with normal serum amino-transferases and bilirubin levels. this syndrome resolves within few days with stopping of drug and more rapidly with carnitidine supplementation. 2:acute hepatocellular injury with jaundice and mixed pattern enzyme elevation. onset is usually within 1-6 months of starting valproate. mixed pattern or hepato-cellular pattern of enzyme elevation may be seen . fever, rash, eosinophilia are rare. liver histology s/o microvesicular steatosis with central lobular necrosis, mild to moderate inammation and steatosis. intravenous carnitine can be useful if given soon after presentation. 3:acute hepatic injury with reye like syndrome usually occurs in children on aspirin like agent following inuenza or varicella infection. child on valproate develops fever, lethargy followed by confusion, stupor and coma. laboratory nding s/o raised in ammonia level with marked alt elevation with normal bilirubin level. incidence of valproate induced hepatotoxicity in united states in 2016 was 3060 single exposures. the international frequency of valproate toxicity is unknown. retrospective studies indicate that patients under 2 years of age, those receiving multiple anticonvulsants, and children with underlying developmental disorders and inborn errors of metabolism may be at increased risk clinical features of valproate induced hepato-toxicity: symptoms are accounted to hepatocyte damage, biliary stasis, hyperammonemia. usually occur within 1-6 months of starting drug. clinical presentation usually begins in form of lethargy, nausea, vomiting. soon, jaundice, fever, rash, itching, abdominal pain may occur. symptoms depend on form of hepato-toxicity which has varied manifestations in different patients. patients with hyperammonemia as predominant form of injury present with altered sensorium, coma, features of hepatic encephalopathy. while those with hepatocellular or mixed pattern present with symptoms of obstructive jaundice like pruritus, right hypochondrial pain, pale stools, dark urine and sclera. children with features of hepatic injury like rye syndrome present with fever, lethargy, confusion, coma. ii. case report: a 22 year old male, presented to the emergency room of civil hospital ahmedabad on 6/1/2019 with chief complaints of: yellowish urine and sclera, anorexia, generalized weakness and easy fatiguability and rash since 10 days patient had no history of nausea, vomiting, fever ,abdominal pain, loose stools. patient was a known case of seizure disorder since 2010 and a rare case of valproate induced hepato-toxicity original research paper dr. v. c. singel professor, head of department & head of unit, department of medicine, b. j. medical college, ahmedabad. medicine drug induced liver injury(dili) can occur owing to a dose dependent or idiosyncratic reaction to a drug. valproate induced hepato-toxicity can lead to acute hepatic failure, occasionally can progress to fulminant hepatic failure and may require liver transplantation. valproate being a commonly used drug, most physicians need to exert a cautious approach for judicious use of the drug. hereby, we aim to discuss different manifestations of valproate induced hepato-toxicity and it's medical management. abstract keywords : valproate hepato-toxicity, hyperammonemia, l-carnitine, reye like syndrome, hy's law. dr. kartikeya parmar assistant professor, department of medicine, b. j. medical college, ahmedabad. dr. khanjan patel* third year resident, department of medicine, b. j. medical college, ahmedabad. *corresponding author dr. vijay dhalavaniya third year resident, department of medicine, b. j. medical college, ahmedabad. dr. swansu batra third year resident, department of medicine, b. j. medical college, ahmedabad. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 32 x gjra global journal for research analysis was on tab. phenytoin (300mg) since two years, which he stopped in 2012. he had 3-4 episodes of seizures for which he was started on tablet valproate (500mg) in october 2018. within 2 months of initiation of tab. valproate patient started developing generalized weakness, yellow discoloration of urine and sclera, skin rash. he was admitted for the same at some local hospital in december 2018 and was later on referred to civil hospital ahmedabad for further evaluation and management in january 2019. examination on examination patient was conscious, oriented. temperature-normal pulse-82/min blood pressure-112/70 mmhg tonguepale nail-pale bulbar conjunctiva, scleraicterus present respiratory system-bilateral air entry present cardiovascular system-first and second heart sounds present abdominal examination-no palpable hepato-splenomegaly no obvious enlargement or swelling central nervous systemconscious, oriented. tone, reexes, power, sensations wnl image 1: icteric sclera and under-surface of tongue image 2: rashes in palms and soles secondary to vaproate exposure volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra laboratory investigations hb (gm/dl) total wbc count (/cumm) bilirubin(mg/dl) sgot (u/l) sgpt (u/l) alp (u/l) albumin (gm/dl) inr creatinine (mg/dl) platelet (lacs) sodium (meq/l)direct indirect total 10.3 18,100 12 3 15 1745 2150 2.2.72 5 25,500 14 2.1 16.1 704 1550 5.3 3.8 7 4100 18 8 26 232 876 125 2.26 1.6 0.8 2.6 139 10 4600 28 8 36 163 312 766 3.1 2.32 1.2 2.8 141 8.5 5200 18 4 22 164 165 1141 2.8 1 1.24 2.6 128 tests for hbsag, hcv, hiv, hav, hev were negative. tests for autoantibodies asma, igg, ana, ama were negative. serum ceruloplasmin was normal serum ammonia – 58 µmol/l imaging studies and other investigations ecg, chest xray-normal usg abdomen and pelvis-nad, with no signs of biliary obstruction cect abdomen and pelvis, mrcp-nad slit lamp examination -no evidence of kayser fleischer ring. 2d echo-nad liver biopsy-lobular architecture of hepatic tissue with extensive sinusoidal dilation, intrahepatic cholestasis and mild hepatic steatosis. no granulomatous lesion or sclerotic changes seen. course in hospital patient was admitted at civil hospital ahmedabad on 6/1/2019.routine investigations were suggestive of obstructive jaundice. tab. valproate was stopped and tab. levetiracetam was started in its place. initially supportive treatment was given in form of tab ursetor( ursodeoxycholic acid) 300mg thrice a day, liquid lactulose 30cc thrice a day, lactulose enema, intravenous uids containing dextrose over a period of 5 days. intravenous n-acetylcysteine over 21 hours was given in form of divided doses ie 50mg/kg over 1 hr, 150 mg/kg over 4 hrs,100mg/kg over 16 hrs. during this period, complete workup was done. all other causes of jaundice ie infectious, metabolic, genetic ;mainly of obstructive variety were ruled out. a nal diagnosis of valproate induced hepato-toxicity was established post liver biopsy. patient was started on carnitine and other antioxidants. carnitine was given intravenously in the loading dose of 100mg/kg over 30 minutes and 15mg/kg every 4 hours till 3 days. as patient's liver function test was not improving signicantly and had developed dilin grade 4 (severe) acute hepatic failure, patient was referred to ikdrc at civil hospital ahmedabad for liver transplantation. i. discussion regarding treatment of valproate induced hepato-toxicity the offending drug i.e. valproate is to be stopped rstly. importantly, carnitine appears to be a specic antidote for valproate hepatotoxicity. l-carnitine, a water soluble amino acid, is indicated in the management of patients that develop hyperammonemia (serum ammonia concentrations >80 µg/dl) and hepatic toxicity associated with both therapeutic dosing and acute overdose of valproic acid. valproic acid is commonly used in the management of seizure and psychiatric mood disorders. deciencies in dietary intake and endogenous production of l-carnitine increase the risk of developing hyperammonemia fol lowing valproic acid exposure. high ammonia concentrations may produce encephalopathy characterized by altered mental status or seizures and possibly death if not recognized. prompt administration of carnitine (particularly when given intravenously) improves survival in acute valproate hepatotoxicity. the typically recommended dose is 100 mg/kg intravenously over 30 minutes (but less than 6 grams), followed by 15 mg/kg every four hours until clinical improvement. other supportive management for liver failure includes intravenous dextrose containing uids, syrup lactulose, ursodeoxycholic acid. n-acetylcysteine an antioxidant commonly used in paracetamol poisoning , can be used in acute hepatic failure due to it's hepato-protective x 33gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra effect. patients not improving with medical management and progressing towards acute hepatic failure may require liver transplantation at the earliest. iv. key message valproate induced hepato-toxicity is a diagnosis of exclusion. only after ruling out all other causes, should a patient be diagnosed as a case of valproate toxicity. dosage of valproate should be appropriate to age, condition and other factors. liver function tests mainly amino-transferase levels should be frequently monitored in all patients. valproate should be avoided in patients with known liver diseases, alcoholism, enzyme defect disorders. according to hy's law, patients with drug induced hepato-toxicity, have 10% or more chance of progressing towards hepatic failure may require liver transplant. thus, early diagnosis may aid in improving prognosis. references: 1 bethesda (md): national institute of diabetes and digestive and kidney diseases; 2012 .livertox: clinical and research information on druginduced liver injury https://www.ncbi.nlm.nih.gov/books/nbk548284/ 2. zimmerman hj, ishak kg. valproate-induced hepatic injury: analysis of 23 fatal cases. hepatology 1982; 2: 592-597 3. sherlock’s diseases of the liver and biliary system chapter 24: drug induced liver injury 4. university of maryland school of pharmacy; july 2012 34 x gjra global journal for research analysis introduction “it is impossible to think about the welfare of the world unless the condition of women is improved. it is impossible for a bird to �y on only one wing.” — swami vivekananda the worth of a civilization can be judged from the position that it gives to women. of the several factors that justify the greatness of india's ancient culture, one of the greatest is the honoured place ascribed to women. manu, the great law-giver, said long ago, 'where women are honoured there reside the gods'. according to ancient hindu scriptures no religious rite can be performed with perfection by a man without the participation of his wife. wife's participation is essential to any religious rite. married men along with their wives are allowed to perform sacred rites on the occasion of various important festivals. but in the later period the position of women went on deteriorating. according india's constitution, women are legal citizens of the country and have equal rights with men . because of lack of acceptance from the male dominant society, indian women suffer immensely. women are responsible for baring children, yet they are malnourished and in poor health. women are also overworked in the �eld and complete the all of the domestic work. most indian women are uneducated. although the country's constitution says women have equal status to men, women are powerless and are mistreated inside and outside the home. india is a society where the male is greatly revered. therefore women, especially the young girls, get very little respect and standing in this country. as per the latest census carried out by the government of india, there are 933 females for every 1000 males in our country. male dominance is everywhere. we can �nd superiority of men in every phase of our lives. when we are born, we have our fathers to look after us, our brothers then share the responsibilities of the father when we enter our teenage years, then we have our life partners who decide everything in our married lives, lastly our sons enter the bandwagon in our old age days. to a very large extent, lives of women in our country are decided and controlled by the men in their lives. this scenario is slowly changing in recent years. we can see a slow and steady rise of women in all �elds of importance. women of today are not just restricted to cooking and taking care of their households, they have stepped out of their comfort zones to create their own images in the outside world as well. this in short, can be termed as women empowerment. society has now changed its stand and the way it looks at women, due to the progress achieved by women in all spheres of life. men of today are more understanding towards the women in their lives, yet we hear many cases of harassment against women. let us look deeper into the topic perspective by perspective. women in the traditional times traditionally, women were considered to be care takers of the home. they had to look after the running of the family smoothly, they had to manage the expenses in the most economical way possible, they had to look after aged in-laws, nurture the children etc. they were judiciously kept out of decision making matters as the primary role of women was not that of ruling the family. they were expected to obey orders of the husband, the elders of the family but kept in isolation when it came to major decisions related to the family. women were not too educated in the bygone eras. they would be married off one day to their in-laws place and hence would not need too much of knowledge was the previous thinking. women, who were still part of families that thought otherwise, saw some respite in this narrow minded approach. there were women in olden days too, who were well educated and led paths of success in many spheres of life because of support from their families. it is these women who led paths of change and brought about a transformation in the way people viewed women in the society. modern indian women the status of women in modern india is a sort of a paradox. if on one hand she is at the peak of ladder of success, on the other hand she is mutely suffering the violence afflicted on her by her own family members. as compared with past women in modern times have achieved a lot but in reality they have to still travel a long way. their path is full of roadblocks. the women have left the secured domain of their home and are now in the battle�eld of life, fully armored with their talent. they had proven themselves. but in india they are yet to get their dues. the sex ratio of india shows that the indian society is still prejudiced against female. there are 933 females per thousand males in india according to the census of 2001, which is much below the world average of 990 females. there are many problems which women in india have to go through daily. these problems have become the part and parcel of life of indian women and some of them have accepted them as their fate. women education in india education is the one and most powerful instrument of social change and social development. every and all sectors of social development is largely depends on its human capitals. as an independent group in india, women constitute nearly (48.72%) of the total population. they not only constitute valuable human resources of the country but their development in the education and socio-economic arena also set pace for sustainable growth of the economy. if the society neglect or not nurture properly of the women population, the complete development of the society remain dream forever. therefore, the education of the women in india plays a signi�cant role in improving the living standard in the country. a higher women literacy rate improve the quality o�ife both at home and outside home, by encouraging and promoting education of children, especially female children and in reduce the infant mortality rate and so on. in spite of the forceful intervention by a bastion of female privilege, feminist critics, constitutional guarantees, protecting laws and sincere efforts by the state governments and central government through various schemes and programmes over the last 69 years and above all, the united nation's enormous pressure with regard to the uplift of the plight of women in terms of education is still in the status of women in indian society original research paper b. venkateswaran part time ph.d, scholar, bharathiar university, coimbatore. political science keywords : dr. s. saravanakumar* assistant professor of political science, gobi arts & science college , gobichettipalayam, tamilnadu, india *corresponding author x 1gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 state of an enigma in india for several reasons. the 2011 census report indicates that literacy among the women as only 65.46 percent. it is virtually disheartening to observe that the literacy rate of women in india is even much lower to the national average, i.e., 74.04. the growth of women's education in rural areas is very slow. this obviously means that still large womenfolk of our country are still illiterate, the weak, backward and exploited. moreover education is also not available to all equally. gender inequality is reinforced in education which is proved by the fact that the literacy rate for the women is only 65.46% against82.14 of men as per (census, 2011). according to government data, more than 24,000 cases of rape were reported in 2011. most are never reported because of the stigma surrounding rape, but after the gang rape what was a taboo subject in india is now on the front pages and leading tv news. indian women, in some ways, have also made some strides. literacy rates have gone up, maternal mortality rates have gone down, and millions of women have joined the workforce. leaders like the president of the national advisory council and the widow of the late prime minister rajiv gandhi, sonia gandhi are role models who show that women can rise to great heights. but they are the exception. authorities acknowledge that action is needed and say they are taking steps to try to better protect women. the home minister said india plans to recruit more female police officers. currently only 7% of the indian police force is female. helplines have been set up and at least one state, haryana, is soon putting up a website naming and shaming convicted rapists. a government task force has been set up to look into what more can be done to make delhi safer. a number of fast track courts have also been established because of the december 16 gangrape, exclusively for cases of sexual assault and rape. but women's rights activists say that when discrimination begins even before birth, change will not come easily. constitutional provisions for empowering women in india 1equality before law for all persons (article-14) 2prohibition of discrimination on grounds of religion, race, caste, sex or place of birth (article 15(i) 3however, special provisions may be made by the state in favors of women and children article 15(3). 4equality of opportunity for all citizens relating to employment or appointment to any office under the state (article 16) 5state policy to be directed to securing for men and women equally the right to an adequate means of livelihood (article 39(a); (v) equal pay for equal work for both men and women (article 39(d). 6provisions to be made by the state for securing just and humane conditions of work and maternity relief (article 42). 7promotion of harmony by every citizen of india and renouncement of such practices which are derogatory to the dignity of women article 51a(e). 8reservation of not less than one -third of total seats for women in direct election to local bodies, viz; panchayats and municipalities (articles 343(d). conclusion women play many roles in their lives, that of a daughter, sister, wife, daughter-in-law, mother, friend, colleague, professional and the list is never ending. with addition of roles, comes addition of responsibilities and women have to handle everything in a very digni�ed manner. the modern day woman is more aware of the society around her and believes in her strengths, handles her weaknesses with grace, identi�es the goodness in things and is socially responsible towards her duties. women don many roles and handle them with grace. there is no profession that does not have women enrolment. the government has put together many schemes especially for the empowerment of women. many seats are reserved in parliament to encourage women participation. education of girls is made free and compulsory in government schools to encourage women to join different institutions and render their valuable services. our armed forces have seen a rise in women enrolment and it's a matter of pride for the nation to have great daughters in the country. references:1s.k.pamdit, women in society, rajat publications, delhi, 1998, p.39-40. 2maya majumdar, social status of women in india, dominant publishers and distributors: new delhi-110002. p.292. 3idem., p.63. 4idem. p.247. 5 a.r.gupta, women in hindu society, p.7. 6the times of india, new delhi: wednesday, october 17, 2012, p.8. 7idem.,p.9. and danik jagran, new delhi, 17 october 2012, p.15. 8the hindu, tuesday, october 16, 2012, p. 6 9ibid. 10james stuart mill in the subjection of women. 11lisa haydon, the huffington post (e-newspaper), friday, 16, june 2016. 12quoted from the times of india, new delhi, wednesday, september 14, 2016. p-28. 13indonesia's 'orgasm lady' uses sexual empowerment to champion women's rights,’ quoted in reuters | sep 13, 2016, 11.17 am ist. 14 (aristophanes, “lysistrata”, (trans.) alan h. sommerstein, penguin classics, penguin books, london, england, 2002. 2 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 introduction: proximal tibia involvement is one of the most common intra articular fracture and difcult to manage. this fractures result from strong varus/valgus forces with or without axial loading. fractures range from simple lateral condyle fracture to severe 1comminuted metaphyseal fractures . complex biomechanics of its weight bearing position and complex ligamentous stability and articular congruency are the main reason why these fractures are of concern to surgeon. in current scenario new surgical techniques, various xation methods and implant, surgical management is mainstay treatment for these complex fractures. open reduction and stable internal xation helps in maintaining the articular surface anatomy, repair of soft tissue injury, rigid internal xation, and restoration of the mechanical alignment and stable knee joint which allows early mobilization of knee with 2full range of movement . we have studied 55cases of proximal tibia intra-articular fractures and operative functional outcome at our institute. material and method: in this series, 70 cases of proximal tibia intra-articular fractures were treated in our institute, 15 patients were excluded from study due to lost to follow up. so 55 adult patients having closed fracture were followed up for a minimum period of 12 months. primary management: all patients were managed according to atls protocol to start with. hemo-dynamically stabilized, thoroughly examined for other major associated injury in head, thorax, abdomen or spine along with local limb examination including distal neurovascular status. prophylactic doses of tetanus toxoid and antibiotics were given. the limb was immobilized by above knee slab and elevation with or without st pin insertion. radiological investigations were done. x ray and c t scan done to know the extent and dimension of fracture degree of comminution and extent of articular depression. line of treatment was decided according to the type of fracture, degree of displacement and depression, and general condition of the patient. 3surgical indication : ÿ fracture of lateral condyle tibia. lateral tilting of plateau >5º step off > 3mm condylar widening > 5mm ÿ fracture of medial condyle tibia except ssures ÿ articular depression > 4 mm ÿ lateral tilted bicondylar fracture ÿ when medial condyle is undisplaced see criteria for lateral condyle. ÿ when medial condyle is displaced, operation is always recommended ÿ metaphyseal-diaphyseal translation of >1 cm ÿ medially tilted bicondylar fracture ÿ angular deformity of >10° in the coronal (varus-valgus) or sagittal plane ÿ open fracture ÿ associated compartment syndrome ÿ associated ligament injury requiring repair. the approaches used commonly are: 1] anterolateral approach 2] medial approach 3] postero medial approach 4] postero lateral approach one of our case has been shown below: post operative care: above knee slab or removable knee brace with leg elevation is given to reduce the pain and oedema. static knee quadriceps exercise and ankle toe mobilisation exercise is started on second day. the patients with stable xation were allowed intermittent knee mobilization once the pain subside on cpm machine to achieve exion up to 90 degree as early (within 3 to 7 days) depending upon comminution of fracture and xation. stitches are removed at round 2 weeks and progressive muscle strengthening exercises along with passive exercises instituted. non weight bearing walker walking was allowed after 2 to 3 days. operative results of intra articular fractures of proximal tibia in adults original research paper ejajahmed ansari* senior resident, department of orthopedics, s c l general hospital, ahmedabad *corresponding author x 5gjra global journal for research analysis orthopedics objective: the aim of our study was to evaluate the functional outcome of intraarticular tibia fractures. material and methods: 55 adult patients having closed fracture were followed up for a minimum period of 12 months. mean age was 40 years and 85% male and 15% female. road trafc accident was most common mode of injury. most of our patients were labourer. average time interval from injury to operation was 3-4 days. after proper pre operative planning open reduction and internal xation was done using tibial locking plate. average time of partial weight bearing was 10 weeks and full weight beariung was 12 weeks. average time of fracture union in our study is 12.07 weeks. results: average knee exion 134 degree and knee extention was 2.27 degree. radiologically medial tibial plateu angle was 86.3 degree and posterior slope was 6.94 degree. functional outcome according to tegner lysholm score system shows 76 % execellent and 18% of good outcome. abstract keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra tirthesh rana resident, department of orthopedics, s c l general hospital, ahmedabad raghav suthar assistant professor, department of orthopedics, l g general hospital, ahmedabad 6 x gjra global journal for research analysis follow up protocol: the patient was followed up at the interval off 1,3,6,9,12 month and then 2 years. full range of motion is expected at 8-10 weeks after discharge. weight bearing: non weight bearing continued for approximately 10-12 weeks.partial weight bearing was started from 1014 weeks depending upon the fracture conguration and correlation with the x-ray.complete weight bearing was started after 14-16 weeks. the course of healing was documented radiologically (ap and lateral) and clinically. ÿ complete healing was dened as follows: radiologically complete bone regeneration at the fracture site and a patient capable of pain-free, full weight bearing on the injured limb. ÿ the angular deformity was measured radiologically and use of goniometer by comparative x-ray of normal limb. ÿ angle in a varus and valgus direction as measured on the ap projection perpendicular to the long axis of the tibia. normal medial tibia plateau angle range from 85 to 90 degree. ÿ tibia plateau makes the angle with a line perpendicular to the long axis of the tibia on lateral projection. normal posterior slope range from 50 to 150. ÿ final assessment done with tegner lysholm knee 4functional score and rasmussen clinical functional 5score . results: in our study there were 85% of male and 15% of female patients with a mean age of 40 (21 – 70 years). the high incidence of fracture associated due to motor vehicle accident which accounts for (63%).average time interval of injury and operation in our study is 34 days. high incidence of fractures seen in occupation involved high level activity like labourer (45%) and employees (36%) which is around (81%). average time of knee mobilization was 5.5 days. average time for partial weight bearing was 10 weeks and full weight bearing without support was 12 weeks. average time of fracture union in our study is 12.07 weeks. one patient had longer time of union (16 weeks) due to early deep wound infection. we used ao classication for this fracture. 4 1 b 1.1 (9 patients), b 1.2 ( 3 patients ), b 1.3 (8 patients), b2.1 (1 patient), b2.2(1 patient),b2.3(1 patient), b3.1( 7 patients), b 3.2 (0 patients), b 3.3(1 patients). 4 1 c 1 (13 patients), c 2(10 patients) and c 3( 1 patient). early wound infection was present in 2 cases which were treated with antibiotic coverage debridement. one patient had late infection in form of osteomyelitis treated with implant removal, wound debridement and long term antibiotics. average knee exion at nal follow up was 134 degree( normal range 10-140). average knee extension was 2.27 degree. one patient had knee stiffness with 60 to 110 degree range of movement. average medial tibial platue angle was 86.3 degrees( normal side 87.7). average posterior tibial slope was 6.94 degrees ( normal side 7.25). functional out come according to tegner lysholm score 4system is 76 % excellent and 18 % good results are achieved. 2 pateints had fair and 1 patient had poor outcome. discussion: proximal tibia intra-articular fractures, one of the most common intra articular fractures, are major traumatic injuries occurring as result of motor vehicle accident, fall from height, domestic fall etc. and sometime associated with other bony injuries. treatment strategies and specic indications for surgery of tibia intra-articular fractures continue to be different. 6rademakers et al in 2006 study shows that motor vehicle accident was account for 39% of fractures which accounts for 69% of type b fractures and 31% of type c fractures compare to our study which shows increasing in numbers 63% with 56.3% type b fractures and 43.61% type c fractures. this suggests that mva is the major cause and emerging factor now a day for this type of fractures due to increase numbers of population and vehicles. we found that type of high velocity injury predisposed to severity of comminution is also increasing. 6rademakers et al found the mean functional range of motion was 1300 with 5.4% of infection rate and 5% patients had 9nonunion of fracture at nal follow up. f. biggi et al had studied internal xation with locking plates and mipo technique for tibia fractures in 44 patients with excellent functional outcome. mean age was 43 years with wound 8complication was 9.09 %. in mardian et al study they found 6% of complication rate with good functional outcome. in our study wound complications were less (3.63%) in compare to other studies with average range of functional movements of 1340. this suggest improvements in surgical techniques, proper timing of surgery and precise tissue handling with minimization in implantation, and sterilization are key points in lessening the infection rate. acceptable functional result of different study are shown below in this series we achieved nal outcome with satisfactory result of 94.56% (excellent 76.38% and good 18.18%) according to tegner lysholm and rasmussen functional scoring system. overall complication rate was 14.52% which involves the earlylate infection, and knee stiffness. no signicant angular deformity was noted in our study. we believe that future studies with better randomization with similar fracture pattern are needed to better understand the xation techniques and possible strategies aimed at reducing and avoiding adverse events it the treatment of proximal tibia intra-articular fracture. references: 1. watson jj and wiss ad. rockwood and green,s fractures in adults: fractures volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra f. biggi et al. 2012 94% mardian et al.2015 73.3% jain et al 2016. 84% our study 94.56% of the proximal tibia and bula. bucholz rw and heckman jd edi. 8th philadelphia: li-pincott williams and wilkins;2001;2:1799-1839 2. yu z, zhang y , li j, ma b. functional and radiological evaluation oh high energy tibial plateau fractures treated with double buttress plate xation. eur j med res. 2009;14(5):200-05 3. prat-fabregat s, camachocarrasco p. treatment stratergy for tibial plateau fractures: an update. efort open rev 2016,1:225-232. 4. tegner y and lysholm j: rating systems in the evaluation of knee ligament injuries. clin orthop relat res: 43-49, 1985. 5. rasmussen ps. tibial condylar fractures. impairment of knee joint stability as an indication for surgical treatment. j bone joint surg am. 1973;55:1331-50. 6. rademakers mv, kerkhoffs gm, sierevelt in, raaymakers el, marti rk. operative treatment of 109 tibial plateau fractures: ve-to 27-year followup results. j orthop trauma. 2007;21:5-10. 7. jain rk, shukla r, baxi m, agarwal u, yadav s. evaluation of functional outcome of tibial plateau fractures managed by different surgical modalities.int j res orthop. 2016 mar 21;2(1):5-12. 8. märdian s, landmann f, wichlas f, haas np, schaser kd, schwabe p. outcome of angular stable locking plate xation of tibial plateau fractures midterm results in 101 patients. indian j orthop 2015; 49: 620-9. 9. biggi f, di fabio s, d’antimo c, trevisani s. tibial plateau fractures: internal xation with locking plates and the mipo technique. 10. tegner y and lysholm j: rating systems in the evaluation of knee ligament injuries. clin orthop relat res: 43-49, 1985. x 7gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 2.1 development of production planning system the idea was to develop a system which works automatically with the input of demand & cutting data in the cutting section. the primary requirement is that the system should be simple to apply and cater to the dynamic environment. for this ms excel is used. 2.2 using ms excel for production planning ms excel spreadsheet has been used for production planning. this approach is sometimes the practical solution for a small project in a big organization. microsoft excel is available as a part of the popular ms ofce package. it has an add-in module for solving problems, called – solver, that can be used for tasks solving. as ms ofce excel is a widespread and used software system it has the advantage to be well known, thus making sense to use is as a tool for production planning. 2.3 mathematical model & logic used a) the batch size “column l in the sheet in gure 4.1” is calculated as below : =round((if(b7/50*4/3<=10,if(b7/50*4/3<=4,(b7/50*4/3)* 4,(b7/50*4/3)*2),(b7/50*4/3))),0) where, b7 denotes the annual demand of the item. to keep some buffer we have decided to do the work of one month in three weeks. b) the frequency “column m in the sheet in gure 4.1” of each item i.e. whether it should be taken weekly (w), fortnight (f) or monthly for cutting, is calculated as below : =if(b7/50*4/3<=10,if(b7/50*4/3<=4,"m","f"),"w") where, b7 denotes the annual demand of the item. c) the time required “column n in the sheet in gure 4.1” by each item in one month cutting to meet the monthly demand, is calculated as below : =((k7*if(m7="m",l7,if(m7="f",l7*2,l7*4)))+(if(m7="m",j7, if(m7="f",j7*2,j7*4))))/60*(l7/if(l7>0,l7,1)) where, k7 denotes the machine time. j7 denotes the setup time. l7 denotes the batch size. m7 denotes the frequency of the batch in a month. d) the net cutting “column v in the sheet in gure 4.1” in any month is calculated as below :=(p7+q7+r7+s7+t7+u7) where, p7,……..,u7 denotes the quantity cut at each time in one month. e) the cumulative cutting “column w in the sheet in gure 4.1” for any item from the starting of the year, is calculated as =w7+ah7 where, w7 is cumulative cut in previous month. ah7 is net cut in this month. f) the time taken by each item “column x in the sheet in gure 4.1” in one month i.e. job hours booked in the month for each item, is calculated as below :=((k7*p7)+(j7*p7/if(p7>0,p7,1))+(k7*q7)+(j7*q7/if(q7>0 ,q7,1))+(k7*r7)+(j7*r7/if(r7>0,r7,1))+(k7*s7)+(j7*s7/if( s7>0,s7,1))+(k7*t7)+(j7*t7/if(t7>0,t7,1))+(k7*u7)+(j7* u7/if(u7>0,u7,1)))/60 in this, the time taken has been calculated on the basis of no. of setups taken, no. of quantity cut each time and the machining time. g) the inventory “column ff in the sheet in gure 4.1” in the line of any item, is calculated as below :=if((-fd82 +v82+ ah82+ at82+ bf82+ br82+ cd82+ cp82+ d b 8 2 + d n 8 2 + c z 8 2 + e l 8 2 + e x 8 2 + f e 8 2 ) > = 0 , ( fd82+v82+ah82+at82+bf82+br82+cd82+cp82+db82 +dn82+cz82+el82+ex82+fe82),0) development of production planning system in a manufacturing organisation original research paper vinod kumar iimt college of engineering, greater noida, u.p., india x 115gjra global journal for research analysis mechanical engineering production planning, scheduling, monitoring & controlling plays an important role in accomplishment of the organizational objectives of manufacturing companies. a well designed rule, with an information system that keeps track of the current situation of the shop in a real time manner, is a very effective tool for exercising management control over the job-shop. these are especially necessary in very large job shops. a practitioner would like a production plan meeting all the due dates while keeping overtimes and sub contracting costs to minimum, because failure to meet due dates may result into customer dissatisfaction, bad reputation and such other undesirable consequences. in production planning the jobs that exist on the job shop at the time of scheduling are considered and a schedule is prepared. in real situation, these schedules become obsolete as new jobs arrive. to manage such a changing environment, a rolling schedule is required. most of the productions planning problems are dynamic in nature, i.e. new orders are received continuously during the production process. the created production schedule may be changed to cope the changes of production orders and manufacturing conditions during production process. for production planning i have used microsoft excel spreadsheet. this approach is sometimes the practical solution for a small project in a big organization. i've experimented here using the excel spreadsheet format. i have used lot of logic and formulas to make the production planning excel sheet which is of great use in the shop oor production environment. i've tried to keep it simple and have not used any macros or vb, so it should be straight forward. abstract keywords : kapil kumar jss academy of technical education ,noida, india*corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 116 x gjra global journal for research analysis in this, the logic used is by keeping an eye on the input taken and output gone in the form of nal product. h) the difference in cutting pattern of two machines “column o in the sheet in gure 4.1”is calculated as below :=if(or(a7="a",a7="n"),if(and(40<=f7,f7<=60),n7/3,(if( and(60<f7,f7<=100),n7/2,n7))),n7) kaltan : at one time only one bar or tube can be taken irrespective of the dimension of the tube. amada:this machine is dependent upon the dimensions of the tubes. if the outer diameter of the tube is in between range 40-60, three pieces can be cut at one time. range 60-100, two pieces can be cut simultaneously. range > 100, only one piece can be cut. this logic is taking into account itself these considerations depending upon we are sending an item to the machine. 3.1 production planning excel sheet the nal excel sheet (figure 4.1) which i have made have all the required features. the excel sheet is looking very small but all the features are present. different buttons are there to make it compact in size. if we will click on these buttons the full size excel sheet will be opened. this excel sheet is like small software doing all the work which is required in shop oor production planning. this sheet is able to cope up the changes of production orders and manufacturing conditions during production process. only jobs that are existing on the job shop at that time are considered and a schedule is prepared. these previous schedules become obsolete as new jobs arrive or production environment changes and new schedule is prepared it self. figure 3.1:production planning excel sheet 3.2 features of proposed production planning system production planning sheet is a tentative plan showing how much production will occur in the next several time periods. production planning sheet also determines expected inventory levels, as well as the workforce and other resources necessary to implement the production plans. production planning is done using an aggregate view of the production facility, the demand for products, and even of time (using monthly time periods). 3.3 scheduling in terms of batch size & frequency the current system is far away from the concept of scheduling. monthly and yearly target is projected by marketing peoples . these targets are lled in left hand side under the column quantity required and automatic scheduling is done showing the batch size, frequency in one month. the proposed system can reschedule itself if there is any change in the demand of the product. it is very much exible and easy to use. just our work is to ll the daily entry of cutting under the column cutting pattern. it will automatically keep accountability of different sub items, job card hours booked by employees, inventory in the shop oor for various sub items. the schedule will repeat itself if everything goes according to the plan. now, the excel sheet shown below in gure 4.2 is showing the schedule in the form of batch size and frequency of the batch in a month. figure 3.2 – auto planning for april month 3.4 re-planning re-planning is an important activity in dynamic situation. this feature has been included in the current system. in a certain month if the work is not done as scheduled then this will be automatically reected in the next month plan as shown in gure 4.3. further if new orders are received during the production process, the created schedule will be changed to cope the changes of production orders and manufacturing conditions. production order changes include removal of an order that is canceled by a customer and insertion of an order that has to be completed within a short period of time. manufacturing condition changes include disturbance events of resources such as breakdowns of machines and sickness of workers. figure 3.3 – auto re-planning for may month 3.5 tracking the existing system is having lot of inventory at the input stage as well as in the form of wip (work in progress). the proposed system is tracking the inventory level and is focused towards reducing the inventory in line based upon the priority rule which and aimed at rolling the items as soon as possible. 3.6 prioritization to give the priority we can see the inventory level of the various items in the sheet. the sheet shown in gure 4.4 is showing the wip in the shop oor for various items. it will help to cut only those items, which are scarce. priority rule is focused towards reducing the inventory and aimed at rolling the items as soon volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra as possible. figure 3.4 – inventory level for sub items of projects 3.7 load calculation for sub contracting in the existing planning system also, the mangers are trying to cut each and everything on the machine without having any idea of how much can be given outside for sub contracting. if they are giving more items outside then the machines will be idle and the company will lose the costly machine hours and if they are giving lesser amount outside, then they will not be able to meet the target resulting in banging's from the corporate management. in such a situation it is important to know the current loading in the shop as shown in the gure 3.6 the total loading on the two machines can be calculated by this sheet. figure 3.5 – load to be given for subcontracting the available hours for a machine in one month are 20*24 = 480 hours. it is showing which machine has more loads as shown in gure 4.7 so we can redistribute the load also. the load which we should give outside for sub contracting is shown by “n”. figure 3.6load distribution the production planning sheet is showing the exact load which should be given outside to meet the demand. further, it is showing we should give those items outside having lesser dimensions, because it will reduce the transportation cost. also, the employees are taking advantage of putting more than one item on “amada” machine and doing the work for very less time. it is because there is xed timing for each piece whether it is small or large and after doing three pieces in a single pass employees are not doing anything and taking advantage of the situation. so, we can give tubes, rods of lower outer diameter and only the tubes of large outer diameter should be cut in the section. this will improve the production and reduce the idle machine hours. 3.8 expected benefits of the proposed system the proposed system is expected to have following benets with respect to improved efciency and effective decision making ÿ increased efciency & effective decision making ÿ eliminate hours spent scheduling and calling staff on the phone — managers will have more time to manage. ÿ instant visibility of schedules, risk areas and budget/cost impacts — do more with less staff. ÿ minimized make span. ÿ minimized work in process. 4. conclusion 4.1 summary basically the production planning and control system provide information to efciently manage the ow of materials, effectively utilize people and equipment, coordinate internal activities with those of suppliers, and communicate with customers about the market requirements. the ppc system does not make decisions or manage the operations-manager perform those activities. the system provides the support for them to do so wisely. current study was done in the cutting section of the plant. the cutting section was chosen for the study because there are lots of problems in the cutting section which affect the performance and immediate attention was required. since there is no systematic planning and control in the cutting section further improvement with respect to e.g. quality etc is difcult to implement. the proposed methodology of production planning by means of the ms excel spreadsheet is like small software doing all the work required in shop oor production. the proposed planning system uses the advantage of the popularity of the ms excel and can be easily applied, modied and extended to other sections also. by following the production planning excel sheet, the cutting section will be under full control. after having full control over the section, the other aspects of manufacturing like six sigma, quality improvement etc can be implemented. 4.2 resistance faced the main resistance faced is human nature of accepting any change. any change whether it is good or bad is opposed. the production planning excel sheet is of great use but nobody wants to use it and still people want to keep sticking to the existing system. in the proposed planning system employees will not be able to exploit the situation, so after some time they also started ignoring this work. nobody has shown any type of interest in knowing the importance of this planning excel sheet. only, the cutting shop in charge is using this production planning excel sheet for keeping the track of items leaving behind other aspects of this sheet. 4.3 recommendation maintaining this production planning excel sheet must be an integral part of the activities of the shop. like quality, customer service, and plant safety, this work must be promoted throughout the organization as everyone's responsibility. this attitude must start at the top levels. x 117gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 4.4 limitations using ms excel for the production planning purpose has two limitations. first, it is not having gui and hence do not appeal to the user. second, the complex logics used in the system may not be understandable to workers. 4.5 future work with good information system and aided by simulation as tool, we can expand our work to the other section also i.e. next stages of operations. then a manager can know where exactly the problem lies and come up with some alternate solutions to eliminate the problem. thus, the congested atmosphere of a typical shop oor production can be systematically reduced, by effective controls on operations through proper scheduling, aided by simulation and a well designed information system. references 1) vollmann t.e., whybark d.c and berry w.l. “manufacturing planning and control system”, 5th edition. boston: mcgrawhill (2005). 2) corke d.k. “production control in engineering”, 4th edition (1997). 3) subashbabu a (coordinator), “workshop on production management” iit bombay, april 24-28, 2007. 4) bauer, bowden, browne, duggan and lyons, “shop oor control systems” publisherchapman & hall (1998). 5) king j.r., “production planning and control” pergamon press oxford (1975). 6) chase r.b., aquilano n.j. and jacobs f.r., “production and operation mangement”, tmh, 8th edition (1999). 7) goodwin, cardillo j. and bergmann e., “implementing erp in big way” apicsthe performance advantage, june (1996) 8) abumaizar r.j. and svestka j.a. (1997), “rescheduling job shops under random disruptions, international journal of production research”, pp. 20652082. 9) lee c.y., liman s.d. (1993), “capacitated two-parallel machines scheduling to minimize sum of job completion times”− discrete appl. math, pp. 211–222. 10) mula j., poler r., garcia-sabater j.p., lario f.c. (2006), “models for production planning under uncertainty: a review” int. j. production economics, pp.271–285. 11) sanmarti e., huercio a., espuna a., puigjaner l. (1996), “a combined scheduling/reactive scheduling strategy to minimize the effect of process operations uncertainty in batch plants.” 12) fylstra, lasdon d.l., watson j., waren a. (1998), “design and use of the microsoft excel solver”, pp. 29-55. 118 x gjra global journal for research analysis 1. background type 2 diabetes mellitus is an escalating public health problem in india that is associated with genetic susceptibility, dietary shift, and rapid lifestyle changes. historically diabetes was considered to be a disease of the urban elite. quantitative studies had conrmed rising prevalence rates among marginalized populations in rural india.(matthew little et al. 2016).dietary habits and sedentary lifestyle were the major factors for rapidly rising incidence of type 2 diabetes mellitus among developing countries (waqas sami et al. 2017).the presence of the public distribution system that subsidized rice, sugar, and cooking oil had inuenced food intake in recent years. commercialization of agriculture and improved access to packed foods reduced the local availability of healthy traditional staples that lead to increased consumption of high-fat and high-sugar foods (matthew little et al. 2016). diabetes is a chronic disease which requires a multipronged approach for its management, wherein the individuals has an important role to play ( raithatha sj et al. 2014). they are required to follow certain self-care practices to achieve an optimal glycemic control and prevent complications. these practices include regular physical activity, appropriate dietary practices, daily foot care practice, compliance with treatment regimen and tackling complications such as hypoglycemic episodes (american diabetes asssociation. standards of medical care in diabetes 2013). studies have concluded that decreased physical activity was observed among the south asians when compared to other ethnic groups (hayes l et al. 2002, khunti k et al . 2007). several studies have focused on the risk factors and lifestyle modications on the individuals residing in urban area. only few studies have focused about the dietary practices, food perceptions, and physical activity on the rural population especially among the southern part of tamil nadu. thus it is essential to have awareness about self care practices among the diabetic individuals residing in rural area to improve the quality of life and prevent complications. based on this background, the objective was designed to assess the practices of diet and physical exercise among type 2 diabetic patients residing in selected rural area. 2. objective to assess the self care practices in terms of diet and physical activity among the subjects with type 2 diabetes residing in selected rural area 3. materials and methods a cross-sectional community-based study was conducted for a period of 3 months. the study was conducted in a village named methigudi that is situated in cuddalore district at chidambaram taluk . methigudi village is situated 2 km away from chidambaram town and has the total population coverage around 2,700 and the particular village was selected due to limited access to health services. around 90% of the subjects with type 2 diabetes mellitus receive their treatment either from chidambaram govt hospital or from phc. regardless of ethnicity, a total of 90 participants with diabetes were selected by using purposive sampling. the subjects with type 2 diabetes were tracked from the non communicable disease register maintained by the village health nurse and the subjects attending ncd clinic at chidambaram govt hospital. subjects of both gender with poor glycemic control and taking oral hypoglycaemic agents were identied and included in the study. individuals with signicant complications related to diabetes and systemic illness were excluded from the study. before data collection, each participant was given a full explanation of the research project and its purpose and was then given to sign an informed consent form. pilot study was carried out to nd out the reliability and validity of the questionnaire. the structured questionnaire was pretested on a sample of 30 subjects to nd out difculties in understanding the meaning of the questions and to estimate the amount of time to answer all the questions. a face-to-face interview was carried out for approximately 10–15 min and was conducted at place comfortable for the participant. when it was necessary, appropriate probing self care practices on diet and physical activity among the type 2 diabetic subjects residing in rural area at chidambaram taluk in cuddalore district original research paper mrs. r. praveena m.sc (n) nursing ph.d (n),tutor in community health nursing, rani meyyammai college of nursing, annamalai university,chidambaram x 7gjra global journal for research analysis nursing background: increased prevalence of diabetes in india is due genetic susceptibility, dietary shift and rapid lifestyle changes. self care practices in terms of diet, physical activity and medication adherence reduce the risk of complications related to diabetes. objective: the objective of this study is to assess the self care practice on diet and physical activity among type 2 diabetic patients residing in selected rural area at chidambaram taluk in cuddalore district. materials and methods: the cross-sectional study was conducted using structured interview guide among 90 subjects with type 2 diabetes residing at selected rural area. baseline characteristics of the study participants were elucidated and their practice regarding the diet and physical activity were assessed. in this study international physical activity questionnaire -short form (version 2.0.april 2004) was used to assess the physical activity of the subjects with diabetes. results: the mean age of the study population was found between 55-65years. the study results reveal that 55(61.11%) of subjects had inadequate dietary practices. whereas 35(38.89%) respondents with diabetes had moderately adequate practice and none of them had adequate dietary practices. only about 5(11.36 %) among males and 2(4.34%) among females are physically active and exercise apart from their normal work duties. conclusion: during the past few years, there have been signicant advances in medications, insulin delivery and glucose monitoring technologies. despite the advances, individuals with diabetes in rural areas have limited access health-care resources and education on importance of physical activity and adherence to dietary regimen. this highlight the need to address structural inequities and empower individuals to pursue health and well-being on their own. abstract keywords : self care practice, physical activity , dietary practice volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. mrs. karaline karunagari* m.sc (n) ph.d(n), principal,rani meyyammai college of nursing, annamalai university,chidambaram *corresponding author 8 x gjra global journal for research analysis questions were asked and the participants were given freedom to express additional views on the topic at the end of the interview session to ensure completeness in data collection. the feedback revealed that the questionnaires were easy to understand and quite convenient for the respondents the study had been approved by the human ethical committee of rajah muthiah institute of health science for conducting the study. permission was obtained from the concerned authorities of the selected communities. the data collected were entered in microsoft excel ofce 2007 and spss statistics version 20 was used for statistical analysis. description of the data collection instrument interview schedule to assess the dietary practices a structured interview guide which was prepared in vernacular language were utilized to assess the self care practice on diabetes .the questions were organized under two domains namely, dietary practices and adherence to physical activity to make the tool complete. a. dietary practices domain: it consist of questions of dietary intake practice were ascertained by 10 questions about the intake of complex carbohydrate and processed foods, inclusion of antioxidant, habit of reading food labels intermittent fasting. the subjects had to recall the dietary practices in the preceding week to assess the dietary practices, 'the answers were scored in three levels 'always' was given 2 marks sometimes' was given 1 marks and 'never' was given 0 mark in positive stated questions and vice versa in negatively stated questions. scoring interpretation b. physical activity questionnaire in physical activity domain, international physical activity questionnaire short form was used as a measure to evaluate the physical activity of the individuals with diabetes. it consist of seven open ended questions surrounding individuals 7-day recall of physical activity to assess the intensity of physical activity and sitting time that individuals do as part of their daily lives are considered to estimate total physical activity in metmin/week. vigorous intensity physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. the samples should think about those physical activities that they did for at least 10 minutes at a time for the past 7 days. moderate intensity activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. the individuals with diabetes should think about those physical activities that they did for at least 10 minutes at a time for the past 7 days. continuous score expressed as met-min per week: met level x minutes of activity x events per week categorical score operational denition self care practice: the pattern and regularity of practices of the subjects with diabetes in terms of eating and physical activity that helps to maintain optimal glycemic levels. physical activity: physical activity is dened as any bodily movement produced by skeletal muscles that require energy expenditure. dietary practices : the dietary measures taken by the subjects with diabetes in order to maintain glycemic control that includes intake of bre rich foods and vegetables and fruits with low glycemic index and use of complex carbohydrate and unrened foods. analysis table 1: distribution of socio demographic characteristics of the subjects ns= not signicant p>0.05 not signicant table 1 denotes distribution of the subjects based on sociodemographic variables in two groups. nearly one third of the participants 50 (55.55) belonged to the age group of 5565 years and fewer subjects 6 (6.67%) were in the age group of 35-45 years among the subjects with t2dm .the data on distribution of subjects according to their gender revealed that 44(48.89 %) were male and 46 (51.11%) were female. with regard to education, majority of the subjects 28 (31.12%) and eleven (12.22%) of the participants were illiterate respectively. with reference to occupation, majority of the subjects, 42(46.67%) were skilled labours, and fourteen (15.55%) of them are unemployed. majority of the subjects 36(40%) had income between rs.9,7 87-19,574 and fewer subjects 4(4.44%) volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra level of practices range of score no of questions perce ntage adequate diet practices 16-20 8-10 >75 moderately adequate diet practices 12-14 6-7 50-75 inadequate diet practices <10 5 <50 activity met levels walking 3.3 mets moderate intensity 4.0 mets vigorous intensity 8.0 mets no activity is reported or some activity is reported but not enough to meet categories 2 or 3. activities achieving a minimum of at least 600 1500 met-min/week.activities achieving a minimum of at least 15003000 met-minutes/week inactive category 1 minimally active category 2 health enhancing physical activity category 3 demographic variables chi square test group1(n=90) n % age 35 – 45 years 6 6.67% 45 – 55 years 34 37.78% 55 – 65 years 50 55.55% sex male 44 48.89% female 46 51.11% marital status married 65 72.22% unmarried 6 6.67% others (divorcee/widow) 19 21.11% education illiterate 11 12.22% primary school 18 20.00% middle school 28 31.12% high school 22 24.44% diploma 8 8.89% graduate 3 3.33% family income > rs.19,575 16 17.78% rs.9,787-19,574 36 40.00% rs.4,8949,786 34 37.78% rs.2,9364,893 4 4.44% <rs.2,936 0 0.00% occupation professional 0 0.00% clerical 9 10.00% skilled 42 46.67% unskilled 25 27.78% unemployed 14 15.55% socio-economic status upper 9 10.00% middle 67 74.44% low 14 15.56% had income lesser than rs,2936 respectively. among 90 subjects 9(10%)of subjects belong to upper income group, 67(74.44%) of them belonged to middle income group and 14(1 3.56%) of subjects belonged to low income group. x 9gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 2: self care practices regarding diet among the subjects sno items life style practice score never sometimes always n % n % n % 1 take diet rich in complex carbohydrate & bre 10 11.11% 70 77.78% 10 11.11% 2 include foods rich in antioxidants 13 14.44% 60 66.67% 17 19.89% 3 take processed foods ,soft drinks and maida products 36 40.00% 51 56.67% 3 3.33% 4 take saturated fats like meat, coconut oil often etc 20 22.22% 63 70.00% 7 7.78% 5 consume unrened rice 31 34.44% 42 46.67% 17 18.89% 6 consume at least 3 portions of fruits or vegetables with low glycemic index 23 25.56% 49 54.44% 18 20.00% 7 have the habit of reading the food labels 55 61.11% 16 17.77% 19 22.22% 8 eat meals at regular timings 13 14.44% 48 53.33% 29 32.22% 9 i compensate over eating by total fasting 13 14.44% 69 76.67% 8 8.89% 10 3 meals spaced over the day with intermittent spacing 45 50.00% 42 46.67% 3 3.33% table 2 displays the recall of dietary practices over the preceding week among the subjects .out of 90 subjects, only few 10 (11.11%) exercised dietary control by largely by avoiding sweet items and reduce their intake of rened carbohydrates. on the other hand 10(11.11%) of the participants never had the habit of taking complex carbohydrate and bre like legumes, whole grains and plant bres as they were not able to relate complex carbohydrate with glycemic response . only 1(19.89%) had the habit of taking foods rich in antioxidant and the majority of them were unaware that glucose metabolism leads to oxidative stress in the diabetic subjects that leads to complications. around 51(56.67%) sometimes take processed foods, soft drinks and maida product because fast food hotels are now available in their village and food products are affordable. a total of 63(70%) of the respondents sometimes had the habit of taking saturated fats often especially meat, dalda etc. about 19(22.22%) of the participants always had the habit of reading food labels regarding added sugar and dietary bre. nearly two fourth of the participants 50(55.56%) in our study were skilled labourers and they expressed their opinion that it was not convenient for them to maintain every time a routine eating schedule. around 69(76.67%) of them compensate overeating by total fasting that spike the blood sugar level. about 45 (50%) of the diabetic subjects never had the habit of gazing food items that make them more resistive to insulin and spike their post prandial blood glucose . only18 (20%) of subjects had the regular habit of consuming fruits and vegetables with low glycemic index. during sorting exercises of foods based on the glycemic index most participants acknowledged the health benets of vegetables, although dietary recall data suggest that the consumption of these items was low, averaging less than one serving per day. in addition, very few participants avoided high-fat items. in regard to oil consumption, usually groundnut oil or palm oil was readily consumed by respondents and were identied as 'healthy' during the sorting exercise. the subjects also believe that wheat products contain negligible carbohydrates and can be taken in any amount. table 3 : distribution of subjects based dietary practice score table 3 highlights that among the subjects, 61.11% of them had inadequate dietary practice, 38.89% of them had moderately adequate practice and none of them had adequate practice. table 4: adherence to physical activity based on ipaq among the participants n=90 table 4 species that most participants residing in selected rural area admitted that diet and medication adherence is important in management of diabetes than physical activity. only very few 5 (11.36%) among males and 2(4.34%) among females are physically active and exercise apart from their normal work duties. around 17 (38.63%) of males and 26( 56.52%) of females are minimally active as they are involved in only moderate household activity and spent less time for vigorous physical activity that take hard physical effort. about 22(50%) of males and 18(39.13)% of females are sedentary as they spent more time in watching television and carrying out light house hold work. most commonly females they regarded themselves as very busy and cited that they lack free of time to make vigorous activity atleast for 10 min in a day. since the χ2 value is 3.53 lesser than the table value and p value greater than 0.05 indicates no signicant difference between the groups in terms of physical activity. overall adherence to physical activity was also found to be poor. only a few subjects accumulate activity for a healthy lifestyle. the following are the statements regarding activity among the subjects . “my family members and neighbours will make fun if i do exercise in this age” “i wake up and make food for my family members, there is no time for other activities ” “where is the time for activit ies, i must full my responsibilities. …” “i feel tired to exercise” these quotes also suggest that exercise is perceived to detract from work and family duties and is considered selsh, over smart or irresponsible. particularly elderly participants viewed themselves as incapacitated by diabetes and therefore unable to exercise. some recognized this as a level of diet practice score group i n % inadequate diet practices 55 61.11% moderately adequate diet practices 35 38.89% adequate diet practices 0 0.00% total 90 100.0% category male (44) female(46) chi square test number of respondents perce ntage number of respond ents perce ntage χ2= 3.53p value 0.17 (ns) inactive 22 50.00 18 39.13 minimally active 17 38.63 26 56.52 health enhancing physical activity 5 11.36 2 4.34 negative cycle. during data collection it became apparent that exercise for health or leisure had little cultural importance or acceptance, and was often met with fears of appearing 'abnormal.' discussion table 2 displays the results of dietary practices that were recalled over previous week by the subjects in selected rural area. about 70 (77.78 %) of the subjects sometimes take complex carbohydrate and only 10 (11.11%) had the habit of taking complex carbohydrate food regularly like whole grains and legumes .the ndings of study conducted by khattab etal .,( 2010) stated that whole grains and legumes full the four dietary objectives for people with diabetes specically high complex carbohydrates, high bre, low fat and rened sugar. the type of fats consumed is more important than total amount of fat when looking at metabolic goals and cvd risk. shashank r joshi et al., (2014) concluded that t2dm participants belonging to any part of india consume high c h o i n t h e i r d i e t i f w e c o m p a r e w i t h d i e t a r y recommendations. the ndings of our study pointed out that almost 51( 56.67%) of individuals with diabetes sometimes take processed foods ,soft drinks and maida product because fast food hotels are now available in their village and food products are available at cost they can afford. similarly the ndings of marcy et al., (2011) have identied that high cost of healthy food and inability to resist the temptation to eat unhealthy as barriers in adopting new dietary habits among type 2 diabetes patients belonging to low-income group. the ndings of the present study reveal that 63(70%) of the study subjects sometimes had the habit of taking saturated fats. whereas multiple randomized controlled trials including patients with type 2 diabetes have reported that a mediterranean-style eating pattern (brehm bj, shai i brunerova l bloomeld he) rich in monounsaturated fats can improve both glycemic control and blood lipids. mufa improves insulin responsiveness in insulin-resistant and type 2 diabetic subjects. approximately 49(54.44%) of the subjects sometimes consume fruits and vegetables because of the nancial inability and lack of market facility that they consistently do not eat a healthy diet. where as a study done by gopichandran et al., (2012) and rajasekharan et al., (2015) also showed only 26% consume fruits and vegetables regularly in their diet this low consumption in our study could be due lack of awareness about the importance of fruits and vegetable intake and also due to their misperception that fruit intake will increase blood sugar levels. the signicant nding is that 55 (61.11%) never had the habit of reading food labels and the study ndings were in accordance to the study conducted by jumma al-kaabi et al., (2008) explained that among a sample of 409 diabetic patients was recruited, 50% of whom were illiterate. only 24% read food labeling. 76% reported being unable to distinguish clearly between low and high carbohydrate index food items and no one reported to count calorie intake. table 4 present that around 17 (38.63 %) of males and 26( 56.52%) of females are minimally active as they are involved in only moderate household activity and spent less time for vigorous physical activity that take hard physical effort. about 22(50%) of males and 18(39.13) % of females are sedentary as they spent more time in watching television and carrying out light house hold work. the study ndings were in agreement of the study conducted by gracy paulin and rama (subramanian 2019) to address the levels of activity among the subject with diabetes residing in urban area. most of the physical activities done by the diabetic patients were moderate intensity physical activity like brisk walking or cycling. the proportion of study population involved in vigorous intensity physical activity was very low (1.5%). nearly 15% of them engaged in moderate physical activity in the transport domain. on an average, the study population spent only 18 minutes per week on physical activity in transport. the present study ndings indicate that females they regarded themselves as very busy and cited that they lack free of time to make vigorous activity atleast for 10 min in a day. since the χ2 value is 3.53 lesser than the table value and p value greater than 0.05 indicates no signicant difference between the groups in terms of physical activity. the study ndings were not similar to the study conducted by carol susan devamani et al., (2018) revealed that women had a higher prevalence of insufcient physical activity compared to men in rural (44.5% vs. 35.6%) areas. rural participants had higher work and travel related physical activity. the high prevalence of insufcient activity found in present study shows that targeted interventions are needed to reduce insufcient physical activity especially for rural populations. currently, there is a pressing need to better understand the physiology and health outcomes specically derived from replacing sedentary time with non fatiguing types of light activity. it can be potentially achievable in more types of people and thereby provide high impact at the population level. limitations: 1. social desirability bias may be existed in this study while this is questionnaire based interview study 2. recall bias: bias in recall occur when the study participant had a poorer recall in general. other factors that inuence recall include age and education recommendation 1. nurse should inuence policymakers to combat the nutrition transition and the diabetes epidemic in rural regions of india by promoting foods with higher ber c o n t e n t a n d l o w e r g l y c e m i c i n d i c e s . h e n c e simultaneously reducing availability and consumption of 'hyperpalatable' foods. 2. dietary recommendations need to be individualized as 'one size does not ts all' and accepted by the subjects with diabetes. it's important to note that the nutrition goals for diabvetes individuals should incorporate into their lifestyle. 3. a special focus must be given by community health nurse for subjects with diabetes and other related comorbidity by providing them with additional information on dietary adherence. 4. nurses can organize “move program” in community for the subjects with diabetes to encourage physical activity conclusion diabetes mellitus (dm) is an incurable but controllable disease. self-knowledge about the physical exercise is very important to enhance the insulin sensitivity. hence, this study provides the valuable data on diet, physical activity and medication adherence. according to our ndings, nonadherence to physical activity is high among t2dm is high as evidenced by 74.3% of the study participants reporting nonadherence. lack of knowledge on complications, presence of co-morbidities, lack of motivation, socio-cultural factors, family inuences were the most signicant barriers responsible for non-adherence. therefore, health professionals must become proactive in identifying and addressing these barriers and health care decision and policymakers should design effective practice guideline for people with t2dm especially in rural areas. references 1. matthew little, sally humphries, kirit patel, and cate dewey (2017). decoding the type 2 diabetes epidemic in rural india : med anthropology 36(2): 96–110 volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 10 x gjra global journal for research analysis 2. waqas sami, tahir ansari, nadeem shaque butt and mohd rashid ab hamid (2017). effect of diet on type 2 diabetes mellitus: a review int j health sci (qassim). apr-jun; 11(2): 65 71 3. raithatha sj, shankar su, dinesh k. (2014).self-care practices among diabetic patients in anand district of gujarat. isrn family med 2014. :743791. 4. american diabetes association. standards of medical care in diabetes mellitus. diabetes care 2013;36 suppl 1:s11-s66. 5. hayes l, white m, unwin n, bhopal r, fischbacher c, harland j, et al. (2002).patterns of physical activity and relationship with risk markers for cardiovascular disease and diabetes in indian, pakistani, bangladeshi and european adults in a uk population. j public health med;24:170-8. 11. 6. juma al-kaabi., al-maskari, f., saadi, h., afandi, b., parkar, h., & nagelkerke, n. (2008). assessment of dietary practice among diabetic patients in the united arab emirates. the review of diabetic studies : rds, 5(2), 110–115. doi:10.1900/rds.2008.5.110 7. gracy paulin1* and rama subramanianphysical inactivity among diabetic patients in urban tamilnadu: a community-based study j community med health educ 9: 649, vol 9(2) 8. carolsusan devamani oommen, anu & mini, gk & abraham, vinodjoseph & george, kuryan. (2019). levels of physical inactivity in rural and urban tamil nadu, india: a cross-sectional study. journal of clinical and preventive cardiology. 8. 13. 10.4103/jcpc.jcpc_32_18. 9. marcy tr, britton ml, harrison d. (2011).identication of barriers to appropriate dietary behavior in low-income patients with type 2 diabetes mellitus. diabetes ther;2:9-19. 10. hempler nf, nicic s, ewers b, willaing i. (2015). dietary education must t into everyday life: a qualitative study of people with a pakistani background and type 2 .diabetes. patient prefer adherence;9:347-54 11. bloomeldhe, koellere,greern,macdonald r,kaner,wilttj. (2016).effects on health outcomes of a mediterranean diet with no restriction on fat intake: a systematic review and meta-analysis. ann intern med;165:491–500 12. brehm bj, lattin bl, summer ss, et al. (2009). one year comparison of a highmonounsaturated fat diet with a high-carbohydrate diet in type 2 diabetes. diabetes care;32:215–220 13. shai i, schwarzfuchs d, henkin y, et al. ( 2008).dietary intervention randomized controlled trial (direct) group. weight loss with a low carbohydrate, mediterranean, or low-fat diet. n engl j med 359:229–241 14. gopichandran sv, lyndon mk, angel pb, manayalil bp, blessy kr, alex rg, et al. diabetes self-care activities: a community-based survey in urban southern india. natl med j india. 2012;25(1):1-14. 8. 15. rajasekharan d, kulkarni v, unnikrishnan b, kumar n, holla r, thapar r. self-care activities among patients with diabetes attending a tertiary care hospital in mangalore karnataka. india. ann med health sci res. 2015;5(1):59–64. 16. hamilton, m. t., healy, g. n., dunstan, d. w., zderic, t. w., & owen, n. (2008). too little exercise and too much sitting: inactivity physiology and tshe need for new recommendations on sedentary behavior. current cardiovascular risk reports, 2(4), 292–298. doi:10.1007/12170-008-0054-8 17. joshi, s. r., bhansali, a., bajaj, s., banzal, s. s., dharmalingam, m., gupta, s.,joshi, s. s. (2014). results from a dietary survey in an indian t2dm population: a starch study. bmj open, 4(10), e005138. doi:10.1136/bmjopen2014-005138. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 11gjra global journal for research analysis introduction: pituitary gland is responsible for the production and secretion of various hormones that play a vital role in the normal growth and development of a child. it consist of anterior and posterior lobe. anterior lobe produces growth hormone(gh),thyroid stimulating hormone(tsh),luteinizing hormone(lh),follicle s t i m u l a t i n g h o r m o n e ( f s h ) , a d r e n o c o r t i c o t r o p i c hormone(acth),prolactin whereas posterior lobe produce antidiuretic hormone(adh) and oxytocin. they are in turn regulated by the hypothalamus that either stimulate or inhibit the production of different pituitary hormones. hypopitui tar ism is a condit ion in which there is underproduction of growth hormone alone or in combination with other pituitary hormones. multiple pituitary hormone deciency(mphd) has 2 types .one is genetic in which sequentially expressed transcription, activation factor direct differentiation & proliferation of pituitary cell type. mutation in this leads to different mphd. in acquired variety any lesion that damage hypothalamus , pituitary stalk or anterior pituitary. examples : craniophar yngioma, cnsgerminoma, eosinophillic, granuloma, tb, sarcoidosis, toxoplasmosis, meningitis. growth hormone (gh) promotes linear growth in children by stimulating cartilage growth, particularly at the epiphyseal plate. in addition, gh increases lean body mass and bone mass and reduces fat mass, while increasing plasma and liver lipid content. case report: a 1 year old male child with weight of 4.9 kg admitted at tertiary care hospital for chief complain of not gaining weight and developmental delay. the patient has an uneventful birth history with birth weight of 2300 gm. at the time of admission patient was not able to stand with support, with immature pincer grasp , speaks only monosyllable words, smiles at mirror image. on genital examination small phallus, hypo pigmented scrotum was there. x ray wrist was done which shows bone age of 4 months. 2d echo and mri brain were done which was normal. hormonal evaluation was done , tabulated below. endocrinologist opinion was taken and they diagnosed it as partial congenital hypopituitarism and advised to start injection gh 0.5 iu subcutaneous on daily basis. patient had taken this treatment for 6 months till now. patient is in regular follow up for growth and development monitoring. after 6 months of treatment patient is now able to run,feed himself with spillage, speaks 3-4 words with meaning showing improvement over growth and development. a case report of partial congenital hypopituitarism original research paper dr. deepa banker professor, department of pediatrics, nhl municipal medical college, ahmedabad. dr. kavita rathod* rd3 year resident, department of pediatrics, nhl municipal medical college, ahmedabad. *corresponding author x 79gjra global journal for research analysis pediatrics where hypopituitarism is common but congenital hypopituitarism is rare. severe prenatal deciency of gh as occur in congenital hypopituitarism has little effect on fetal growth. prenatal and congenital deciency can reduce the size of male penis especially when gonadotropins are also decient. severe gh deciency in early childhood also result in slower muscular development so that gross motor mile stone such as standing ,walking and jumping may be delayed. bone age is helpful as it is usually delayed in patient with congenital growth hormone deciency. incidence: between 1 in 4000 and 1 in 10000 live births. abstract keywords : congenital panhypopituitarism, growth hormone deciency, development delay dr. bijal shah associate professor, department of pediatrics, nhl municipal medical college, ahmedabad. dr. almin mansuri nd2 year resident, department of pediatrics, nhl municipal medical college, ahmedabad. dr. shachi ganatra associate professor, department of pediatrics, nhl municipal medical college, ahmedabad. dr. margav ambani st1 year resident, department of pediatrics, nhl municipal medical college, ahmedabad. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra investigations normal value before treatment at 1 year of age after treatment at 1.5 years of age human growth hormone 0-3 ng/ml <0.05 0.12 acth 3.6-60 pg/ml 7.03 9.32 insulin like growth factor-1 55-327 ng/ml <15 <15 prolactin 2.1-17.7 ng/ml <0.32 1.1 cortisol(random) 3.7-19.4 ug/dl 17.85 3.96 fsh 1.4-18.1miu/ml 1.25 0.54 lh 1.14-8.75miu/ml <0.07 <0.07 t3 0.6-1.81ng/ml 0.68 0.82 t4 4.5-12.6 ug/dl 1.4 1.9 tsh 0.35-5.5 uiu/ml <0.01 0.40 before treatment at 1 year of age after treatment at 1.5 years of age height 54cm 58cm weight 4.9 kg 9.2kg head circumference 41 cm 43cm 80 x gjra global journal for research analysis ÿ height velocity is monitored at threeto six-month intervals (algorithm 1); the goal for treatment is to attain the 75th percentile for height velocity for age during catch-up growth. we also monitor igf-1 levels every 6 to 12 months conclusion: raising awareness about the cause and early initiation of treatment is important because unrecognized pituitary dysfunct ion signicantly af fect the physical and psychological well-being. high index of suspicion coupled with timely and appropriate hormonal assay are essential for the management. it needs to be diagnosed and treated early to prevent associated paediatric mortality and morbidity. supervision, care and regular growth monitoring by paediatrician is crucial along with endocrinologist support. x ray wrist ap and lateral view suggestive of bone age of 4 months at 1 year of age at 1.5 yr of age volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction in 2001, the stages-of-reproductive-aging-workshop (straw) dened 'perimenopause' as the period beginning with menopausal transition and ending 12 months after the 1last menstrual period . this may last for 4-8 years. during this period, the endocrinological, biological and clinical features of approaching menopause commence. in perimenopause, volume and frequency of menses vary due to uctuating estrogen levels, which is unpredictable and unique for each woman. abnormal uterine bleeding accounts for more than 50% of all gynaecologist's consultation in the perimenopausal years, which causes nancial and emotional burden on the quality of the woman's life. prolonged unopposed estrogen stimulation in anovulatory cycles causes endometrial hyperplasia, thus increasing the risk of endometrial cancers. therefore, diagnosing the proper cause of aub in perimenopausal women become essential, so that proper intervention can be initiated at the earliest possible time. the tvs is a simple, non-invasive, easily available and cheap diagnostic modality to assess the organic cause of aub. it permits better visualization of uterus, endometrium and adnexa. so we planned to assess the diagnostic accuracy of tvs in various uterine causes of aub by correlating it with histopathology. aims and objective: to evaluate the accuracy of tvs to diagnose organic uterine pathology causing abnormal uterine bleeding in perimenopausal women with histopathological correlation. materials and methods this prospective study was done in the department of radiodiagnosis of mahatma gandhi memorial medical college & m. y. hospital, indore, madhya pradesh, india after getting approval by institutional scientic review board. a total of 152 perimenopausal patients between 39 to 51 years of age, who were referred to our department with clinical symptom of bleeding per vagina underwent transvaginal ultrasound using siemens usg machine. out of 152 patients, 18 patients were lost during the course of study and in 34 patients histopathological correlation was not established. therefore, the nal study group comprised of 100 perimenopausal patients. women excluded: age <39 or > 51 years, menopausal women, women on hormonal treatment, iucd in situ, endocrine disorders, bleeding disorders, cervical or vaginal cause of bleeding, pregnancy, traumatic bleeding and unmarried. results: out of 100 perimenopausal women in our study, the mean age of women was 46 years and majority (39%) of them belonged to the age group 48-51 years. majority of the women were multiparous (79%). common clinical presentation of aub in perimenopausal women in our study was menorrhagia (51%) followed by menometrorrhagia (19%). (table 1)in our study, 35% women had et>16mm on tvs followed by 21% of women having et between 4-8mm range. on histopathological analysis of the endometrial biopsy in 100 perimenopausal women in our study, the most common hpe nding was proliferative endometrium (34%) followed by secretory endometrium (17%). the role of transvaginal ultrasound in abnormal uterine bleeding in perimenopausal women and its histopathological correlation original research paper dr. (prof.) alka agrawal professor & hod department of radiodiagnosis, mgm medical college & m. y. hospital radiodiagnosis background: abnormal uterine bleeding accounts for more than 50% of all gynaecologist's consultation in the perimenopausal years. aims and objective: to evaluate the accuracy of tvs to diagnose organic uterine pathology causing abnormal uterine bleeding in perimenopausal women with histopathological correlation. results: total 100 perimenopausal women were included, the most common age group was 48-51 years,51% patients presented with menorrhagia. 79% patients were multiparous. uterine broid was the commonest uterine pathology (42%). 35% of patients had et>16mm.on tvs, et>8mm had signicantly higher chance to be abnormal histopathologically.7% and 10%patients revealed endometrial malignancy on tvs and hpe respectively. the sensitivity, specicity, ppv, npv of tvs for benign lesions was 99%, 60%, 96% and 86% respectively and sensitivity, specicity, ppv, npv of tvs for malignant lesion was 60%, 99%, 86% and 96% respectively. conclusion: perimenopausal women with et>8 mm on tvs, should undergo histopathological evaluation. abstract keywords : aub, tvs, et, perimenopausal. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr aakanksha verma pg resident, radiodiagnosis. mgmmc, indore dr jaipal singh pg resident, radiodiagnosis. mgmmc, indore dr rajkumar patidar pg resident, radiodiagnosis. mgmmc, indore dr gaurav bhandari* assistant professor, radiodiagnosis, mgm medical college, indore *corresponding author table 1: comparing et on tvs with endometrial histopathology. et (in mm) on tvs no. of cases on tvs endometrial histopathology 48 x gjra global journal for research analysis on retrospectively comparing et on tvs with nal hpe of endometrium (table 1), in 34(97%) out of 35 patients with et>16mm on tvs, had pathological endometrial histopathology. similarly, in 10(66%) out of 15 patients with et between 12-16mm on tvs and 2(18%) out of 11 patients with et between 8-12 mm on tvs, had pathological endometrial histopathology respectively. while, only 3 (14%) out of 21 patients with et between 4-8mm on tvs, had pathological endometrial histopathology and all the cases with et<4 mm on tvs had normal endometrial histopathology. in our study, statistical analysis for relation of et with probability of abnormal endometrial ndings on histopathology revealed that et> 8 mm on tvs had statistically signicant higher 2chance to be abnormal histopathologically (x -value=43.65, p <0.001). finally, 156 pelvic lesions were diagnosed in 100 perimenopausal women on tvs. out of these 156 pelvic lesions, 124 lesions were conrmed by histopathology.7 out of these 124, were diagnosed malignant (endometrial carcinoma) and rest 117 as benign lesions on tvs (table 3). the most common diagnosed benign lesion on tvs was uterine broids (42%) followed by adenomyosis (23%). other benign lesions found were endometrial hyperplasia (15%), polyp (15%) and endometritis (8%). the nal hpe reported 10 cases of endometrial carcinoma and rest 114 cases as benign in nature. table 3: distribution of nal tvs diagnosis in 100 perimenopausal women presenting with abnormal uterine bleeding compared with nal hpe. discussion: aub is the most common gynaecological complaint among women in perimenopausal age group. in our study, analysis of patients according to bleeding pattern, the most common aub pattern was menorrhagia (51%) which was comparable to the 2study conducted by acharya et al , who observed that 50% patients with menstrual complaints were of menorrhagia. majority of the women were multiparous (79%) followed by primipara (16%). this distribution of parity is similar to the 3study by shobhita gl et al in 2015 . in our study most of the cases (35%) had et in >16 mm followed by 4-8 mm range. all the cases of endometrial hyperplasia (10%) and endometrial carcinoma (7%) had et of >16 mm on tvs. these ndings were in accordance with 4study done by aliya a. et al in 2009, in which all the cases of endometrial hyperplasia and endometrial carcinoma had et above 15 mm. in 34 (97%) patients out of 35 patients with et>16mm on tvs, had pathological endometrium on histopathology and 10 (66%) out of 15 patients with et between 12-16 mm on tvs, had pathological endometrium on histopathology. while among 8-12 mm and 4-8 mm et on tvs, only 18% and 14% of cases showed pathological thickening on hpe respectively. however, patients with et<4 mm revealed normal 5histopathology. a study by machado et al in 2005 concluded that et less than 5 mm did not need d&c as none of these patients had atypia or malignancy, which was also corroborated in the present study. there is no clear denition of what constitutes an abnormal et in the still menstruating perimenopausal woman. the upper limit for normal et remains controversial, but most studies, 6 like that of chatapavit et al have reported transvaginal sonographic et 8 mm as the abnormal cut off value, necessitating further investigations. in our study, 49 patients had abnormal endometrial on hpe. 46 patients out of 49 patients, had et >8mm and only 3 patients had et < 8 mm. patients with et > 8 mm on tvs has signicant higher chance 2of having abnormal endometrium (x -value=43.65, p <0.001). in our study the most common benign and overall pathology diagnosed on tvs was uterine broids found in 43% of the cases. among these 12 women had multiple uterine broids and 19 women had other associated pelvic pathologies along with uterine broids. the most common type of broid on tvs was intramural followed by submucosal. this is in accordance 2with a study conducted by archana et al in 2018 which revealed broids in 41% of cases. in our study, tvs diagnosed 7 cases of endometrial carcinoma (7%) and 10 cases of endometrial hyperplasia (10%). all these cases were having et>16 mm on tvs and were present in late perimenopausal age group. this is in accordance with the previous population-based study by 7susan dr et al in 2009, which revealed that the incidence of endometrial hyperplasia with and without atypia peaks in the late perimenopausal and postmenopausal years. our study on 100 perimenopausal women presenting with aub revealed a total of 153 lesions on tvs examination. out of these, 124 lesions were correlated histopathologically. tvs diagnosed 7 lesions as malignant and 117 cases as benign. on histopathology 10 cases were identied as malignant and 114 cases were diagnosed as benign. (table 4) our study revealed that tvs has excellent statistical results in detecting and characterizing various pelvic pathologies. table4: the sensitivity, specicity, ppv and npv of tvs for various pelvic pathologies. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra normal endometrium abnormal endometrium proliferative secretor y endometrial hyperplasia atrophic endometrium polyp endometritis endometrial carcinomas <4 18 18 0 0 0 0 0 0 4-8 21 11 7 1 2 0 0 0 8-12 11 5 4 1 1 0 0 0 12-16 15 0 5 4 0 5 1 0 >16 35 0 1 11 0 8 5 10 total 100 34 17 17 3 13 6 10 tvs diagnosis/modaility on tvs on hpe intramural broid 31 30 submucosal broid 16 16 subserosal broid 9 9 adenomyosis 23 26 polyp 15 13 hyperplasia 15 14 endometritis 8 6 endometrial carcinoma 7 10 total no. of lesion in 100 perimenopausal 124 124 tvs diagnosis sensitivity (%) specicity (%) ppv (%) npv (%) benign lesion 99 60 96 86 malignant lesion 60 99 86 96 x 49gjra global journal for research analysis the sensitivity, specicity, ppv and npv of tvs in our study is 8in agreement with previous studies of urvashi et al , acharya 2 9et al and ritu et al . therefore, tvs can be practically used as initial and one of the best diagnostic modalities to assess the pelvic pathologies. conclusion: aub is a common and debilitating condition with high direct and indirect costs. the data from our study on statistical analysis for relation of et with probability of abnormal endometrial ndings on histopathology revealed that et> 8 mm on tvs had statistically signicant higher chance to be abnormal. therefore, et>8 mm on tvs in perimenopausal women, irrespective of phase of menstrual cycle, echogenicity of the endometrium, its margin or any added abnormality should be subjected to histopathology. in our study, the diagnostic value of tvs turned out to be excellent for almost all uterine pathologies. the sensitivity, specicity, ppv, npv of tvs for benign lesions was 99%, 60%, 96% and 86% respectively and sensitivity, specicity, ppv, npv of tvs for malignant lesion was 60%, 99%, 86% and 96% respectively. references 1. soules mr, sherman s, parrott e. stages of reproductive aging workshop (straw). j. womens health, gender based med. 2001;10:843-8. 2. choudhary, jaya et al. “evaluation of abnormal uterine bleeding with transvaginal sonography and hysteroscopy in perimenopausal women.” (2017). 3. shobhitha gl et al. endometrial study by tvs and it’s correlation with histopathology in abnormal uterine bleeding. j dental med sci. 2015;14(4):21-32. 4. aliya aslam, gazala. role of tvs in cases of abnormal uterine bleeding. professional med j. 2009;(16)1:127-34. 5. machado ls et al. correlation of et, cycle day and histopathology in women with abnormal uterine bleeding. saudi med j. 2005;26(2):260-3. 6. getpook c et al. et screening in premenopausal women with abnormal uterine bleeding. journal of obstetrics and gynaecology research. 2006;32:588-92. 7. reed sdet al. incidence of endometrial hyperplasia. am j obstet gynecol. 2009;200(6):678.e1–678.e6786. doi:10.1016/j.ajog.2009.02.032 8. verma u et al. diagnostic approach in perimenopausal women with abnormal uterine bleeding. j safoms. 2014;2(1):12. 9. mishra r et al. to compare the result of tvs and sis with hysteroscopy and histopathological examination in perimenopausal and postmenopausal bleeding. j evol med dental sci. 2015;4(7):1230-7. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra uterine broid 91 91 89 92 adenomyosis 71 96 86 92 endometrial hyperplasia 76 98 86 94 50 x gjra global journal for research analysis introduction cancer is a major public health problem worldwide and is the second leading cause of death globally, and was responsible for 8.8 million deaths in 2015. globally, nearly 1 in 6 deaths is 1due to cancer . urological cancers are one of the most common type of cancers in the world. in indonesia, the morbidity and mortality rates are mostly happened in the middle and lower socioeconomic population. urological cancer is a disease with multifactor causes that formed over a long period of time and progressed through different stages2,3 according to globocan 2012, prostate, bladder and kidney cancer are among 20 most common cancers in both sexes in indonesia. they ranked sixth, twelfth and eight-tenth 3,4respectively some of our colleagues have already studied the prole and characteristic of urology cancer in indonesia like studies which had already done by zulkar y et al in 2010, wahidin et 3,5,6al in 2012, umbas et al in 2015. , and also from the other nations, japan hideyuki akaza in 2015, china cheng pang et 8,12,35al in 2016, taiwan chi-feng hung et al in 2016. therefore, in this study we would like to describe the prole of urological cancer based on our medical record data in our institution. methods we conduct this study in haji adam malik general hospital in medan. data were collected retrospectively from the medical records of all the patients with urologic cancer in 2013-2017 (5 years). the patients whose data were collected are patients with prostate cancer, kidney tumor, bladder cancer, testicular tumor, penile cancer, and adrenal tumor. we classify the data based on year when patient was admitted and organ that were exposed by cancer. we collected age, gender, pathological examination, diagnosis, type of treatment the patient would have. result from the collected data we found 446 urologic cancer cases from 2013-2017 in haji adam malik general hospital medan. from the data we found that from 446 cases, 364 are male patients (81.6%), followed by woman with 82 patients (18,3%). for the target organ statistic, the data showed that prostate cancer is the highest cancer incidence across the last 5 years with 167 cases (37,4%), followed by bladder cancer with 133 cases (29.9%) in second place, and penile cancer with 72 cases (16.1%) in third place. the lowest cancer incidence in this study is adrenal cancer with 1 case from 2013-2017 (0.1%), followed by renal 43 cases (9.6%) and testicular 30 cases (6.7%). table 1. characteristic table discussion cancer incidence raised annually up to 8% within the last decade whereas the cancer morbidity was raised from 3.4% in 1980 to 5.7% in 2007 and it became the seventh leading reason 5for death in indonesia . according to report of national basic health research these raising trends may be thanks to many factors cherish exposure to matter of carcinogen, chronic 7infection and longer lifetime expectancy . unhealthy diet and fewer physical activity result in 19% overall fatness in the urologic cancer in adam malik general hospital original research paper frendy wihono* urology department of general surgery, h. adam malik hospital, medan, indonesia *corresponding author x 51gjra global journal for research analysis oncology introduction:urological cancers are one of the most common type of cancers worldwide. we would like to describe the prole of urological cancer in indonesia. materials and methods:data collected retrospectively from in 2013 – 2017 in haji adam malik general hospital, with prostate cancer, kidney tumor, bladder cancer, testicular tumor, penile cancer, and adrenal tumor. we classify the data based on the year, age, gender, pathological examination, diagnosis, treatment. results:a total of 446 urologic cancer cases included (364 males (81.6%) and 82 females (18,3%)). prostate cancer is the highest cancer incidence (167 cases (37,4%)), bladder cancer 133 cases (29.9%), and penile cancer 72 cases (16.1%). the lowest incidence is adrenal cancer 1 case (0.1%), renal 43 cases (9.6%) and testicular 30 cases (6.7%). conclusion:indonesian urologists, other healthcare providers, government and non-government organizations must collaborate to promote health education to minimize the incidences of urologic cancer in medan. abstract keywords : urologic cancer, prostate cancer, bladder cancer, penile cancer, adrenal cancer volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra ginanda putra siregar urology department of general surgery, h. adam malik hospital, medan, indonesia syah mirsya warli urology department of general surgery, h. adam malik hospital, medan, indonesia variable (n =446) n (%) age 59 (±16.907) sex ÿ man 364 (81.6%) ÿ woman 82 (18.3%) organ ÿ prostate 167 (37.4%) ÿ bladder 133 (29.9%) ÿ penile 72 (16.1%) ÿ renal 43 (9.6%) ÿ testicular 30 (6.7%) ÿ adrenal 1 (0.2%) 52 x gjra global journal for research analysis population older than fteen years old, that are risk factors for malignant diseases. therefore, in this article we would like to highlight these urologic cancers based on our institution. prostate cancer prostate cancer is the second leading cause of cancer-related death in men in the western world, second to lung cancer. although there is a noticable difference in the incidence rates 13,17,18in asian and western country . however, cancer in asia is expected to dramatically increase and cause burden to 38human development index in asia . growth of the prostate gland is initially dependent on androgen and the tumor marker to diagnose prostate cancer is known as prostate13,18specic antigen or psa . many of treatment that can be utilize in prostate, such as; bilateral adrenalectomy and androgen deprivation therapy, and some still an ongoing research, that includes; abiraterone acetate pluse prednisone chemotherapy, and enza lu tamide usage be fore 14,16chemotherapy. in indonesia itself the incidence of prostate cancer compared with the reports from western countries was relatively low, 4according to ferlay et al (2013) . however, based on report from akaza, et al (2013), prostate cancer patients in indonesia increased within the last decade and it becomes the third 9commonest cancer in men . iau guideline suggests performing a digital rectal examination (dre) and prostate specic antigen (psa) measurement in men older than 50 years, or 40 years in patients with family history of prostate 11cancer, who came with lower urinary tract symptoms (luts) . a recent survey of the indonesian urologists reported that dre was done in all patients with luts and in 83% of patients with 10elevated psa . in jakarta and surabaya study proposed a psa cutoff of 8 ng/ml and 10 ng/ml. in our study we have found that prostate cancer in the highest urologic cancer cases with 167 cases (37.4%), with psa cutoff was 4 ng/ml, 56.6 % was positive prostate cancer. according to iau guidelines, the treatment option depends on risk factors and patient's age; however, many factors such as co-morbidity, compliance, patient's residence and preference are also considered. in our region, radical treatment by radical prostatectomy (rp) was no been considered because of the refusal from the patient, androgen deprivated therapy (adt) was the most options. adt that we perform in our institution was total androgen blockage (53 cases, 31.7%) and sub-capsular orchiectomy bilateral (114 cases, 68.2%). bladder cancer bladder cancer (bc) is one of the common cancers of both 4sexes in indonesia . bladder cancer is an international public health problem that commonly occurs in developing country. bc need to be taken seriously in developing country due to lower survival rate in developing country than those from the 37,39usa . as it was reported by umbas et al (2007), the incidence increased ~15% per year in the last decade with transitional cell carcinoma (tcc) as the most histological type (78.8%), followed by squamous cell carcinoma (scc) 20(10.2%), adenocarcinoma (8.6%) and sarcoma (2.4%) . most of the patients with scc type had concomitant bladder stone at diagnosis (37.1%) or history of bladder stone operation 20performed between 1 and 25 years . in our study we found that bladder cancer is the second most common urologic cancer (133 cases) in haji adam malik general hospital from 20132017 in medan. compared to china as one of the largest countries in asia with the highest population on earth, bladder cancer was one of the most common urologic mali 21,28gnancies . for bc diagnosis, we screened all patients with hematuria 23,24using urine cytology . as a rule, an underlying ultrasound examination will be performed. a further radiologic examination, in examples iv contrast abdominal ct-scan, was performed to assess the tumor invasion, regional lymph node 25,26and metastasis site . in china, cystoscopy can be used in terms of diagnosing, giving follow up, and giving a prognosis 22to the patient, according to na et al . according to supit et al (2011), our guideline in indonesia, we performed cystoscopy and transurethral resection of bladder tumor (turbt) as the gold standard for bc diagnostic and denitive treatment in 27non-muscle-invasive bladder cancer (nmibc) . early intravesical chemotherapy installation, for the most part with mitomycin-c, will be given inside 24 h after turbt when all of the tumors are effectively expelled and there is no suspicious of bladder puncturing. in our institution 3 nmibc have done mitomycin-c instillation for 8 times and for 3 years follow-up 1 patient has recurrent bc, has done re-turbt. table 2. clinicopathological characteristics of bladder cancer patients in medan mibc, muscle-invasive bladder cancer; nmibc, non-muscleinvasive bladder cancer. a report of 133 bc treated from 2013-2017, heterogeneous treatment was summarized in table 2. in common, the issue of treatment refusal signicantly hinders cancer treatment in indonesia. the underlying cause is not only due to socioeconomic and nancial issues, but also due to the lack of knowledge. table 3. treatment options between nmibc and mibc penile cancer penile cancer is urologic cancer affecting about one in 100,000 men worldwide in a year, thus penile cancer classied as one 40,41of the so-called 'rare malignancies' . it's prevalence highest in developing country such as; thailand and lead into high 45,48morbidity and mortality . study from national taiwan 19university hospital there were 71 cases within 20 years . it is estimated that at least 40% of penile cancers cases are 43attributable to human papillomavirus (hpv) . in our institution penile cancer was the third most cases of urologic cancer, 72 cases within 5 years. on the other hand, there are 283 new cases of penile cancer in brazil ranging from 20062006 that predominantly affecting; low income, living in the north or northeast side of the country, white, and 44uncircumcised patients . in uganda, penile cancer are more 46rarely to be nd than prostate cancer . numbers of cases in our region was affected by culture and religion, that has no circumcision, lack of education and knowledge. according to larke et al, childhood/adolescent circumcision elicit a strong 42protective effect from an invasive penile cancer . is is due to phimosis that associated with risk of balanitis that can lead 147into penile cancer, removing the foreskin can reduce it . from 72 cases, almost al l came with advanced stage, chemotherapy and total penectomy was done (see table 4). volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra characteristics number of patients (%) muscle-invasion ÿ nmibc (stage 0, 1) ÿ mibc (stage ii, iii, iv) 3 (2.25%) 130 (97,7%) treatments nmibc (%) mibc (%) radical cystectomy 20 (15%) chemoradiation 11 (8.2%) ebrt 7 (5.2%) intravesical mitomycin c with turbt 3 (2.2%) turbt only 24 (18%) patient refusal of treatment 68 (51.1%) table 4. treatment option in penile cancer kidney cancer in our study, kidney cancer is in fourth place 43 (9,6%) as the highest urologic cancer behind prostate, bladder, and penile cancer. according to ferlay et al (2012), in indonesia, the overall incidence of kidney cancer is estimated to be 2.4–3 cases/100 000 population. this is an increase from an earlier estimate, which calculated the overall incidence to be 1.4–1.8 4cases/ 100 000 population. due to lack of follow-up data, hamiseno, et al., (2011) could not estimate the survival rate of 30our kidney cancer patients . another research which specically looked for rcc cases in cipto mangunkusumo hospital from 1995 to 2009 found 99 cases, which is 33% of all kidney cancer cases. that study also reveals an increase in the hospital incidence of 1.5to 2-fold for every 5 years period. metastatic disease on the rst presentation was found in 37% 30of all rcc cases . there are quite a signicant number of squamous cell and transitional cell carcinoma (tcc) of the 6,29kidney caused by kidney stones . the essential treatment of kidney malignancy cases incorporates careful resection of the inuenced kidney. for the most part, the treatment was done as open radical nephrectomy, with just a couple of focuses doing it 34laparoscopically . in addition, nephroctomy also alleviates 31,32the response rate of chemotherapy in metastasized rcc . in our institution we have done 43 nephrectomy several cases done in laparoscopy. partial nephrectomy is rarely performed because the tumor stage at presentation is mostly t2 or more. just two institutions ('cipto mangunkusumo' and 'hasan sadikin' hospital) are doing laparoscopic partial nephrectomy. according to naito et al, the median survival time of rcc patient that already metastasized was 21.4 33months . conclusion there are increasing incidences of urologic cancer in medan, especially prostate, bladder, penile, and kidney cancer. nevertheless, treatment refusal is still common and advanced stage is the common incidences, due to patient ignorance. as a result, it is important for the indonesian urologists especially in medan, other healthcare providers, government and nongovernment organization to work together in community health education to minimize these problems. from this data our institution can complete the national data for urologic cancer in indonesia. references 1. jeanne held-warmkessel, msn, rn, aocn, acns-bc. chapter 1: introduction to genitourinary cancers. genitourinary cancers. site-specic cancer series. oncology nursing society. 2011 2. josh gottlieb, bs, cory higley, bs, mph, roman sosnowski, md, phd, et al. smoking-related genitourinary cancers: a global call to action in smoking cessation. vol 18 no. 4. 2016. reviews in urology 3. rainy umbas, ferry safriadi, chaidir a mochtar, et al. urologic cancer in indonesia. 2015. japanese joural of clinical oncology, 2015, 45(8) 708-712. 4. ferlay j, soerjomataram i, ervik m, et al. globocan 2012 v1.0, cancer incidence and mortality worldwide: iarc cancer base no. 11 [internet]. lyon, france: internat ional agency for research on cancer, 2013. http://globocan.iarc.fr 5. wahidin m, noviani r, hermawan s, andriani v, ardian a, djarir h. population-based cancer registration in indonesia. asian pacic j cancer prev 2012;13:1709–10. 6. zulkar y, umbas r, mochtar ca, santoso rb, hamid ar. renal pelvis and ureter carcinoma in jakarta: characteristic and risk factors. indones j cancer 2010;4:55–60 7. report of national basic health research (riskesdas) 2007. indonesia: the national institute of health research and development, ministry of health, republic of indonesia; 2008. http://labdata.litbang.depkes.go.id/menudownload/menu-download laporan (25 january 2015, date last accessed). 8. hideyuki akaza. urologic cancer in japan: role of japan at the frontier of issue in asia. japanese journal of clinical oncology, 2016, 46(1) 23-30. 9. akaza h, hinotsu s, cooperberg mr, et al. sixth joint meeting of j-cap and capsure—a multinational perspective on prostate cancer management and patient outcomes. jpn j clin oncol 2013;43:56–66. 10. umbas r, hardjowijoto s, mochtar ca, et al. guidelines on prostate cancer management of the indonesian urological association. jakarta: indonesian urological association, 2011. isbn: 978-979-25-4288-2 (in indonesian). 11. monoarfa ra, hamid ar, mochtar ac, umbas r. perspective of the indonesian urologists in prostate cancer diagnosis. indones j cancer 2012; 6:97–104 (in indonesian). 12. chi-feung hung, cheng-kuang yang, and yen-chuan ou. urologic cancer in taiwan. japanese journal of clinical oncology, 2016, 46(7) 605-609. 13. katsogiannou m, ziouziou h, karaki s, andrieu c, henry de villeneuve m, rocchi p. the hallmarks of castration-resistant prostate cancers. cancer treat rev 2015 may 9. doi: 10.1016/j.ctrv.2015.05.003. [epub ahead of print]. 14. ryan cj, smith mr, fizazi k, et al. abiraterone acetate plus prednisone versus placebo plus prednisone in chemotherapy-naive men with metastatic castration-resistant prostate cancer (cou-aa-302): nal overall survival analysis of a randomised, double-blind, placebo-controlled phase 3 study. lancet oncol 2015;16:152–60. 15. beer tm, armstrong aj, rathkopf de, et al. enzalutamide in metastatic prostate cancer before chemotherapy. n engl j med 2014;371:424–33. 16. huggins c, scott ww. bilateral adrenalectomy in prostatic cancer: clinical features and urinary excretion of 17-ketosteroids and estrogen. ann surg 1945;122:1031–41. 17. globocan 2012 v2.0, cancer incidence and mortality worldwide: iarc. http://globocan.iarc.fr (may 2018, date last accessed). 18. akaza h. prostate cancer chemoprevention by soy isoavones: role of intestinal bacteria as the “second human genome”. cancer sci 2012;103:969–75. 19. taiwan cancer registry annual report, 2012. department of health and welfare t, 2015. 20. umbas r. bladder cancer: 10 years experiences from two tertiary care hospitals in indonesia. indones j surgery 2007;35:17–22. 21. chenw, zheng r, zeng h, zhang s, he j. annual report on status of cancer in china, 2011. chin j cancer res 2015;27:2–12. 22. na yq, ye zq, sun yh, sun g editors. guidelines on urology in china. 2014 ed. beijing: people’s medical publishing house 2014. 23. arif mi, santoso a, djatisoesanto w, notosoehardjo ise, joewarini e, widodo jp. detection of transitional cell carcinoma of the bladder with nmp test and urine sitology. indones j urol 2007;14:1–4 (in indonesian). 24. tiera h, umbas r. rapid urinary bladder cancer antigen test for the detection of transitional cell carcinoma of the bladder in indonesian population (a preliminary study). indones j cancer 2013;7:41–6 (in indonesian). 25. aschorijanto a, djatisoesanto w, soebadi dm, hermantha c, soemarno t,widodo jp. comparison on staging accuracy in bladder cancer between mri, trans-abdominal ultrasound, and tur-bt in soetomo hospital, surabaya. indones j urol 2006;13:1–4 (in indonesian). 26. umbas r, hardjowijoto s, mochtar ca, et al. guidelines on urothelial bladder cancer of the indonesian urological association. indonesian urological association, 2014. isbn: 978-602-18283-2-8 (in indonesian). 27. supit w, mochtar ca, sugiono m, umbas r. survival of patients with transitional cell carcinoma of the urinary bladder in indonesia: a single institution review. asian pac j cancer prev 2011;12:549–53. 28. chenw, zheng r, zeng h, zhang s, he j. annual report on status of cancer in china, 2011. chin j cancer res 2015;27:2–12. 29. li m, he z, gao j, sun y, li c, huang y, et al. analysis of clinical characteristics of renal cell carcinoma in multi-centers. chin j urol 2010;31:77–80; (in chinese). 30. hamiseno d, mochtar ca, umbas r. current systemic therapy in metastatic renal cell carcinoma. indones j cancer 2011;5:105–12. 31. kinouchi t, saiki s, maeda o, kuroda m, usami m, kotake t. treatment of advanced renal cell carcinoma with a combination of human lymphoidblastoid interferon-alpha and cimetidine. j urol 1997;157:1604–7. 32. akaza h, tsukamoto t, onishi t, miki t, kinouchi t, naito s. a low-dose combination therapy of interleukin-2 and interferon-alpha is effective for lung metastasis of renal cell carcinoma; a multicenter open study. int j clin oncol 2006;11:434–40. 33. naito s, yamamoto n, takayama t, et al. prognosis of japanese metastatic renal cell carcinoma patients in the cytokine era: a cooperative group report of 1463 patients. eur urol 2010;57:317–25. 34. umbas r, hardjowijoto s, safriadi f, et al. guidelines on renal malignant tumor of the indonesian urological association. jakarta: indonesian urological association, 2012. isbn: 978-979-25-4289-9 (in indonesian). 35. cheng pang, youan guan, hongbo li, et al. urologic cancer in china. japanese journal of clinical oncology, 2016, 46(6) 497-501. 36. la vecchia c, bosetti c, lucchini f, bertuccio p, negri e, boyle p, et al. cancer mortality in europe, 2000-2004, and an overview of trends since 1975. ann oncol 2010;21:1323–60. 37. sankaranarayanan r, swaminathan r, black r (1996). global variations in cancer survival. cancer, 78, 2461-4. 38. pakzad r, mohammadian-hafshejani a, ghoncheh m, et al (2015b). the incidence and mortality of prostate cancer and its relationship with development in asia. prostate int, 3, 135-40. 39. mahdavifar n, ghoncheh m, pakzad r, et al (2016). epidemiology, incidence and mortality of bladder cancer and their relationship with the development index in the world. asian pac j cancer prev, 17, 381-6. 40. eslick gd. what is a rare cancer? hematol oncol clin north am. 2012 dec;26(6): 1137–41. 41. greenlee rt, goodman mt, lynch cf, platz ce, havener la, howe hl. the occurrence of rare cancers in u.s. adults, 1995–2004. public health rep. 125(1):28–43. 42. larke nl, thomas sl, dos santos silva i, weiss ha. male circumcision and penile cancer: a systematic review and meta-analysis. cancer causes control. 2011;22(8): 1097–110. 43. hernandez by, barnholtz-sloan j, german rr, giuliano a, goodman mt, king jb, et al. burden of invasive squamous cell carcinoma of the penis in the united states, 1998-2003. cancer. 2008;113(november):2883–91 x 53gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra treatment number of patients (%) penectomy 35 (48.6%) chemotherapy 12 (16.6%) refusal of treatment 25 (34.7%) 44. favorito la, nardi ac, ronalsa m, zequi sc, sampaio fjb, glina s. epidemiologic study on penile cancer in brazil. int braz j urol. 2008 sepoct;34(5):587–93. 45. vatanasapt v, sriamporn s, martin n, sriplung h, chindavijak k, sontipong s, et al. cancer incidence in thailand, 1988–1991.cancer epidemiol biomarkers prev. 1995 jul-aug;4(5):475–83. 46. wabinga hr, parkin dm, wabwire-mangen f, nambooze s. trends in cancer incidence in kyadondo county, uganda, 1960–1997. br j cancer. 2000;82(9): 1585–92. 47. morris bj. the strong protective effect of circumcision against cancer of the penis. adv urol. 2011;2011:812368. doi: 10.1155/2011/812368. epub 2011 may 22. 48. bleeker mc, heideman da, snijders pj, et al. penile cancer: epidemiology, pathogenesis and prevention. world j urol 2009; 27:141-50. 54 x gjra global journal for research analysis volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction forensic science is an integrated part of judiciary system. the collection, sampling, preservation and analysis of evidences are important aspects of forensic investigations. forensic evidences may be biological, physical or audio-visual and generally involve detection or comparison method. most of the cases submitted in forensic science laboratories (fsl's) need comparison between articles collected from crime scene and from accuse or victim. analysis of those evidences requires specic method and technique to reach nal conclusion. analytical instrumental techniques are valuable and integrated part in forensic investigations. the physical evidences that are commonly submitted to fsl are earth, metals, glass, bre and polymer etc. in a rare case cardboard has become an important linking evidence in murder case. thermal analysis of card board box has become imperative and is been done using simultaneous thermal analysis. corrugated cardboard is stiff, strong and lightweight and hence mainly due to its strength, cardboard boxes are generally used for packaging and transportation. cardboard boxes are generally made from pine tree's bark. the bark mainly composed of cellulose, hemicelluloses and lignin. the pine bark chips are treated in a pressurised tank containing sodium hydroxide to remove its glue like material called lignin which holds wood bres together. the process is called kraft process. in this process wood chips breaks down in to brous pulp and used for making cardboard. the cardboard has two at liner sheets on either side of the corrugated sheet (medium) in the middle, bound together with corn starch glue. thermal properties of cardboard have been extensively studied with relevance to its recycle, reuse, safety purposes in [1] [2] [3] storehouses and environmental impact . the present case gives emphasis on comparison of two cardboard boxes found at crime scene and from accuse, using simultaneous thermal analysis. in present case accused used a cardboard box to dispose off a body in murder case. a cardboard piece along with label sticked to it was seized from riverside. the cardboard box piece thrown in river to dispose the body has company label sticked on it. the same label was observed on the cardboard boxes seized from the export company ofce. thermal properties of cardboard boxes at crime scene and from suspected site were found to be different. the peak observed 0at about 357 c was of opposite nature. a study for this difference was performed using different conditions and using different cellulose based materials. the results of analysis revealed that the cardboard used to dispose the body was obtained from the same ofce. 2.0 experimental 2.1 preliminary analysis: label examinationdetails of printed words such as hue, font size, background colour and words printed on labels were compared on intact cardboard box in exhibit no. 1 and piece of cardboard in exhibit no. 2. similarly colours of words were also observed under uv cabinet. thermal properties of label were studied using sta. cardboard examinationthree layers of each corrugated cardboard (outer layer -liner, middle layer -medium /ute, and iner layer –liner) in exhibit no. 1 and exhibit no.2 were separated and assigned as (a) (b) and (c) respectively. each layer was observed under motic smz-168 series stereomicroscope. physical parameters such as thickness and weight of known dimensions were studied using digimatic vernier calliper and digital balance (metter toledo) respectively for comparison. the thermal properties of each layer was studied using sta. 2.2 simultaneous thermal analysis: the sta measurements were performed using netzcsh sta 449, aluminium crucible with pierced lid and nitrogen as purge gas at a ow rate of 40 ml/min about 4-5 mg samples used in this study were heated in the range of 50 °c to 600°c at the rate of 20k/min. data was analyzed using netzcsh sta comparison of cardboard pieces as physical evidence in murder case using simultaneous thermal analysis original research paper keshav s. kapgate* regional forensic science laboratory, nagpur, maharashtra, india. *corresponding author x 1gjra global journal for research analysis forensic science physical evidence obtained at crime scene is important basic evidence in forensic science. in such examination along with classical methods, instrumental analysis plays a major role. very few studies have been performed for cardboard comparison as physical evidence with reference to forensic examination. examination and comparison of cardboard found in murder case was successfully performed using thermal methods of analysis. the results were also matched with control samples. the analysis is found to be helpful in identication and linking of physical evidences at crime scene. the results obtained from the simultaneous thermal analysis of cardboard seized at crime scene and company ofce showed that all the three layers in cardboard show similar thermal properties and differences found in the thermal properties were due to their treatment in making originating from binder in cardboard making. the adhesive material used in preparation of corrugated card board box results in exothermic degradation peak while endothermic peak was observed for corrugated card board box without adhesive material. the differences in results are found out with help of control sample as well as simulated study. abstract keywords : tg, dsc, cardboard comparision, cellulose volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra renuka v. phadke regional forensic science laboratory, amravati, maharashtra, india. charansing b. ghoti regional forensic science laboratory, nagpur, maharashtra, india. shivangi s. apte regional forensic science laboratory, nagpur, maharashtra, india. vijay j. thakre regional forensic science laboratory, nagpur, maharashtra, india. 2 x gjra global journal for research analysis 449 protease software. 3.0 results and discussions label sticked on both cardboard in exhibit no 1 and 2 have same hue, wordings and physical appearances as shown in g.1, similarly sta analysis of label found on ex 1 and 2 also show similar tg as well as dsc curves as shown in g.2. thus labels on cardboard box from company ofce in ex 1 and cardboard piece seized from riverside tally with each other in morphological and thermal characteristics. each layer of cardboard as described in section 2.1 was studied for hue and microscopic appearance. all layers of cardboard in exhibit no. 1 and 2 resembles with each other on the basis of hue. the images under stereomicroscope of each layer are shown in g3.the results of physical parameters indicate that the width and weight of known dimensions of cardboard piece are same. thus on the basis of preliminary examinations the pieces of cardboard on ex 1 and 2 appears to be same. thermogravimetric analysisthe thermal stability of cardboard is determined by testing the onset of degradation temperatures. tg curve for all the layers for ex no. 1 and 2 (g 04 to fig 6) show decrease in the curve at about 300 c. cellulose absorbs moisture and this moisture loss generally found in the range 75 °c 127 °c. cardboard generally consist of cellulose bres. the decrease in weight of the cellulosic bres was observed at 206 – 400 °c with the maximum decrease in weight loss about 60-65% in these temperatures. literature on thermal degradation study of cellulose bre reveals that decomposition of major components of the [4]cellulose bres and the depolymerization of hemicellulose occurs between 180 and 350 °c [5 ] and the random cleavage of the glycosidic linkage of cellulose between 275 and 350 °c [6]. the cellulose molecule is a very long polymer of glucose units, and its crystalline regions improve the thermal stability [6] [7].of bres higher thermal stability of celluloses is attributed to the hydrogen bonds between cellulose chains that can lead to more ordered and packed cellulose regions, and hence increasing the thermal decomposition temperature of cellulose [8]. the cardboard piece obtained from river side was wet and sta was performed on drying the exhibit. the dsc analysis of each layer of cardboard box namely a, b and c obtained from 0river side show endothermic peak at 354-357 c, however the exothermic peak was observed at same temperature from cardboard box seized from ofce. the discrepancy in the dsc results was found for both exhibits. hence similar control samples were used from fresh cardboard box. the piece of cardboard was kept in water for 24 hours and then dried. the results are presented in fig 7 to g 9. the dsc of the control sample was performed and it was found that the nature of 0peak at 357 c was endothermic. thus it was found that 0cardboard box show exothermic peak at 357 c while after getting moistened followed by drying, it shows endothermic peak. the water extract of the residue of cardboard box was tested. water extract was alkaline (ph 9) along with sulphate and traces chloride. the probable reason for the phenomenon is hidden in formation of cardboard box. when cardboard piece get moistened with water, the glue used to stick the medium or corrugated sheet get dissolved in water and only cellulose left behind show endothermic peak instead of exothermic peak for the same cellulose without glue. the phenomenon was again conrmed using cotton and lter paper as control sample. whatman lter paper is made up of high quality cotton linters which have been treated to achieve a minimum alpha cellulose content of about 98%. the dsc of pure whatman 0paper show endothermic peak at 358 c in absence of glue and when the glue is sticked to it an exothermic peak is observed at 0388 c. the same experiment was performed using cotton and the similar results obtained are shown in table 1. the decrease in temperature at endothermic peak with respect to exothermic peak is due to loosening cellulose carbon hydrogen bond and less energy is absorbed to break the bond. the present study successfully interprets the cause of differences in thermal properties during analysis and thus helpful in forensic investigations of comparison of exhibits to come to the nal conclusion. tg results-generally decomposition temperature of any material is found to be low due to less moisture content in dry condition and it shifts to higher value. conclusion: in a murder case cardbard box was used to dispose the body. the results of comparison of cardboard box obtained in the present study show similar sta results for label. in exhibit but show discrepancy in cardboard box results. dsc results show rst endothermic peak for moisture loss and second degradation peak show opposite nature. the adhesive material used in preparation of corrugated cardboard box results in exothermic peak while endothermic peak was observed for the corrugated cardboard box without adhesive material. the differences in results were found out with the help of control samples as well as simulated study. hence the observations are further useful in solving and establishing evidence of cardboard box in similar type of medicolegal case.. figure no. 1: images of label on cardboard paper in exhibit no. 1 and 2 lable in exhibit no. 1 lable in exhibit no. 2 figure no. 2: sta analysis of label in exhibit no. 1 and 2 of cardboard box figure no.3: images of three layers of cardboard paper in exhibit no. 1 and 2 in stereo microscope exhibit no. 1 a exhibit no. 2a volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra ex. no. 1 b ex. no. 2 b ex. no. 1 c ex. no. 2 c figure 4) sta analysis of layer 1a and 2a of cardboard box figure 5) sta analysis of layer 1b and 2b of cardboard box figure 6) sta analysis of layer 1c and 2c of cardboard box figure 7) sta analysis of layer 1a and 2a of cardboard box after treatment figure 8) sta analysis of layer 1b and 2b of cardboard box after treatment figure 9) sta analysis of layer 1c and 2c of cardboard box after treatment table 1: summery of sta results acknowledgement the authors are thankful to director, directorate of forensic science laboratories and director general (legal and technical) mumbai, government of maharashtra, for their valuable guidelines and encouragement for the preparation of this paper. references 1. determination of reaction scheme of cardboard thermal degradation using thermal gravimetric analysis, c. david, s. salvador, j.l. dirion, m. quintard journal of analytical and applied pyrolysis vol. 67, issue 2 pages 307-323, 2003 2. cardboard based packaging materials as renewable thermal insulation of buildings: thermal and life cycle performance, m.cekon, k. struhala and r. slavik, journal of renew material 2017 page 84-93 3. pyrolysis and oxidation of cardboard gaurav agraval , ganu liu and brian lattimer124-re safty science scince and proceeding of the eleventh international symposium pp 124-137, 4. jonoobi m., niska k. o., harun j., misra m. chemical composition, crystallinity, and thermal degradation of bleached and unbleached kenaf bast (hibiscus cannabinus) pulp and nanobers. bioresources. 2009, 4(2), pp. 626-639. 5. kim h.s., kim s., kim h. j., yang h. s. thermal properties of bio-our-lled polyolen composites with different compatibilizing agent type and content. thermochimica acta, 2006, 451(1), 181-188. 6. poletto m., zattera a. j., forte m. m., santana r. m. thermal decomposition of wood: inuence of wood components and cellulose crystallite size. bioresource technology. 2012, 109, 148-153. 7. alemdar a., sain m. biocomposites from wheat straw nanobers: morphology, thermal and mechanical properties. composites science and technology. 2008, 68(2), 557-565. 8. sahari j., sapuan s. m., zainudin e. s., maleque m. a. mechanical and thermal properties of environmentally friendly composites derived from sugar palm tree. materials & design. 2013, 49, 285-289. x 3gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra exhibit weight taken for analysis (mg) dsc mass change (tg %)t1 (°c) t2 (°c) label in ex. no. 1 2.7 162.1 469.2 -87.65 label in ex. no. 2 2.7 162.3 461.7 -89.53 exhibit no. 1a 5 116.6 362.4 -59.55 exhibit no. 1b 5 133.7 364.3 -62.19 exhibit no. 1c 5.3 117.7 365.0 -56.62 exhibit no. 2a 4.3 117.2 359.7 -66.18 exhibit no. 2b 5.0 118.9 354.4 -62.31 exhibit no. 2c 5.4 119.7 359.7 -58.56 ex. 1a (after treatment) 4.3 115.2 357.7 -66.61 ex. 1b (after treatment 5.0 122.0 353.6 -64.77 ex. 1c (after treatment 5.3 114.3 355.0 -54.0 whatman lter paper 3.9 110.6 358.9 -84.0 whatman lte paper with gum 4.6 130.05 388.0 -61.33 cotton 5.0 104.5 357.0 -74.86 cotton with gum 4.3 107.6 358 -70.26 introduction there is need to improve productivity and this calls for application of modern technology. modern technology in turn calls for heavy dose of capital investment in these areas. but the capital formation is a difficult task and depends upon the people's willingness and their capacity to save. thus prosperity of the economy is closely linked with the ability of the public to save and invest in productive assets for an uninterrupted supply of capital. dearth of capital is not felt if the much needed capital is available within. to survive and develop in this competitive business world, capital must be made available at a reasonable rate without conditions attached to it. investment climate must attract the people to save from their income at times even by foregoing the enjoyment of comforts and luxuries. if enough savings are accumulated, the next important thing is to invest them in constructive assets so as to generate further value. actually, �nancial intermediaries undertake the work of channelizing the savings of public into productive assets. banks, non-banking �nancial institutions, post-offices, share markets and governments are some of the important �nancial intermediaries. despite the effort of all these intermediaries, current savings is not up to the regular level. further, the entire savings are not at fully diverted into industry for productive purposes. in the wake of paucity of funds, the process of industrial development has not been activated. mainly due to the �nancial crunch, industrial sector, has stagnated its activities. supply of fund would normalize the process and the supply mainly depends upon individual investors. in recent times, the contribution of individuals alone have contributed to about two-third of total capital. personal savings or savings of individuals are called household sector's savings. if properly guided and motivated, an active and vibrant participation of individuals will lend �nancial support internally to the industrial enterprises. in any country, the investment climate should not encourage public to hoard cash and postpone investments. on the other hand, government and other institutions must evolve new systems to induce more and more public savings. the present study aimed to know the attitude of investors on various investment avenues in erode district. materials and methods brahmabhatta et.al. (2018) in their article entitled “a study of investor behavior on investment avenues in mumbai fenil” stated that investor's perception will provide a way to accurately measure how the investors think about the products and services provided by the company. the main objective of the study is to �nd out the need of the current and future investors and to study on investor behavior. 100 investors were taken for the study. most are making conservative decisions that re�ect a survival mode in the business operation. during these difficult times, understanding what investors on an ongoing basis is critical for survival. therefore, the study is identi�ed that people like to invest in stock market as compared to any other markets, even if they face huge losses. sanjay kanti das (2018) in his article entitled “middle class household's investment behaviour: an empirical analysis” the study reveals to know whether there has been any increase in their savings and if so, the reasons for the same. the present study is based on primary sources of data which are collected by distribution of a close ended questionnaire to 180 respondents out of which 150 respondents have replied and the data has been analyzed using simple statistical tools and to access the signi�cance/ association between dependent variables. it is also observed that most of the respondents show their keen interest towards the insurance products so as to get tax bene�ts, life protection and average pro�table investment avenues. further, it is observed that the level of income also in�uences the investment decisions. higher income group shows relatively high preference towards investment in share market conversely lower and average income group shows keen preference towards insurance and banks as the most preferred investment avenues. this study has used both primary data and secondary data. for collecting primary data �eld survey technique was undertaken in the study. the researcher has collected 1000 samples from erode district by means of questionnaire. the research design adopted for this study is descriptive research. descriptive method was adopted because it deals with description of the state of affairs as it exists at present. if the population from which a sample is to be drawn does not constitute a homogenous group, then strati�ed sampling technique is applied so as to obtain a representative sample. factor analysis was used for further analysis. results and discussions for the purpose of present research work, 21 self-explanatory attitudinal statements comprising the areas such as importance of saving, habit of saving, principles of saving, investment decisions etc. are identi�ed. the statements are framed and arranged in such a way that one statement has no relevance or resemblance to other. the inferences from the attitude statements are made by applying the factor analysis test. the selected variables are 1. con�dent of my ability 2. i take full responsibility for the result 3. i am convinced to manage my investment 4. i know all the features of avenues 5. betterment of services is much essential 6. family play a vital role in making investment 7. i usually invest in companies which i know and trust. 8. i use past price movement to predict future price. 9. i make investment decision on the basis of company's dividend ratio. 10. i make investment decision based on my experience 11. i prefer to invest in pro�table investment avenues 12. i am getting more returns because i have taken right investment decision 13. my investment decision has changed over period of time attitude of investors on making investment in various avenues original research paper k.krishnamoorthi research scholar in commerce, chikkaiah naicker college, erode commerce the practice of savings and investment differs from person to person and place to place as the savers have varying objectives embracing safety, pro�tability and liquidity. similarly, the motive behind such practice equally varies due to the in�uence of internal and external factors of savers. as such, there is no single motivating factor applicable to all investors on all occasions. in the indian context, savings from all quarters are the need of the hour. though 70 percent of our population lives in villages and mainly depend on agriculture, the savings from agricultural sector is not enough due to uneconomic operations of the farms and same is the situation of public undertakings. further, the savings of businessmen and self-employed are not stable and not assured because it is subject to the conditions of business. the present study aimed to know the attitude of investors on various investment avenues in erode district. abstract keywords : savings, investment, pro�tability, liquidity, uneconomic. x 37gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 14. once i decide about my investment option i will choose that option again and again 15. when i invest is based on the market position 16. irrespective of in�ation i will put money in �xed income securities 17. i will invest for tax exemption 18. i receives good quality advice from distributors/broker. 19. attending investor educational programme is bene�cial for my investment. 20. household investment will help me in betterment. 21. i desire to reserve for unforeseen contingencies factor analysis tries to summarise the information contained in a number of original variables into a smaller set of new composite dimensions. hence, correlation matrix for the variables (21 statements) is calculated in order to establish the relationship between them. generally, a correlation value of 0.3 (absolute value) is taken as sufficient to explain the relationship between variables. correlation matrix value has been given in table the following table. further, two tests are applied to the resultant correlation matrix to test whether the relationship among the variables is signi�cant or not. firstly, bartlett's test of sphericity is used to test whether the correlation matrix is an identity matrix i.e. all the diagonal terms in the matrix were 1 and the offdiagonal terms in the matrix are 0. the calculated test value is 786.684. it shows that the correlation matrix is not an identity matrix i.e., correlation exists between the variables. another test of kaiser-meyer-olkin (kmo) measure is used to test the sampling adequacy. the test is based on the correlation and partial correlation of the variables. if kmo measure is closer to 1, it is good to use factor analysis and if kmo is closer to 0, then the factor analysis is not a good idea for variables and the data. the value of test statistics is 0.69083 which means the factor analysis for the selected variables is good. next, pca used to extract factors from the statements. the pca extracted 6 factors and these are all co-efficients used to express a standardized variable in terms of the factors. these co-efficients are called factor loading since they indicate how much weight is assigned to each factor. thus, factors with large co-efficients (in absolute value) for a variable are closely related to that variable. the following table shows the factor loading to each variable. 21 attitude statements are denoted as variables and the statements could be seen from questionnaire in annexure part. it could be seen from the following table that factor 1 is with largest loading (0.61684) for x1 variable and factor 2 for variable x17 (0.70915). factor 3 is highly loaded for variable x5 (0.61140) and factor 4 for variable x11 (0.40065). factor 5 has largest loading for variable x20 (0.64507) and factor 6 is largely loaded for variable x13 (0.50622). table 1 principal component extracted factor matrix for six factors then communalities for each variable are calculated from the factor matrix. the proportion of variance explained by the common factors is called commonality of the variable. eigen values are also calculated which give the proportion of total variance explained by all the factors. the calculated value of “percentage of variance” explains how much variance is attributed to each factor. cumulative percentage is calculated to explain the total variance in the selected variables. the following table presents to disclose the communality of each variable, eigen value, percentage of variances and cumulative percentages of each factor. table 2 communalities of variables and eigen values, prcentage of variances, cumulative percentages of each factor it could be seen from the table that factor 1 has the maximum eigen value of 2.17190. all the factors are arranged in order of importance, cumulative percentages of 6 factor model explains that there are only 44 percent of variance in the selected variables. although the factor matrix obtained in the extraction phase indicates the relationship between the factors and the individual variables, to enhance the interpretability of the factors' rotation is done. the most common method of varimax rotation is used and the rotated factor matrix values are given in table no.3. table 3 rotated factor matrix for six factors sl. no & variables factor 1 factor 2 factor 3 factor 4 factor 5 factor 6 1 x1 .61684 .05210 -.16855 -.13668 -.23376 -.07847 2 x9 .59204 -.19106 .19594 .15146 .01214 .25458 3 x7 -.55008 .20685 .46800 -.13161 .05645 .25478 4 x10 .49869 -.13028 -.17268 .38800 .18123 .36542 5 x2 .49655 .06302 -.30625 -.25531 .29335 .02546 6 x8 -.38379 .21892 -.08252 .34063 .09356 -.25464 7 x17 .13272 .70915 .04370 -.08244 .07242 -.25478 8 x15 .29138 .55696 -.4282 .05877 .22215 .23458 9 x18 -.05645 .42508 .23836 -.17441 -.19687 .05648 10 x16 .03879 .33658 -.24846 .33544 .11564 .03256 11 x12 .02210 .22421 -.7382 .11955 -.05462 .32145 12 x5 .32843 -.01380 0.6114 .17255 -.15465 .02546 13 x4 .14852 .07005 .60783 .42889 -.25465 -.10335 14 x6 .24357 .09235 .46555 -.31982 .14758 .09545 15 x11 -.15298 .04520 -.30643 .40065 .06541 -.02145 16 x20 .18470 -.13934 .33069 -.20041 .64507 .02458 17 x21 .15559 -.11207 -.00474 -.36312 .14447 .02548 18 x19 -.01324 -.06458 -.06161 .37746 .23548 .25489 19 x13 .11777 .35504 -.05316 .10821 .12548 .50622 20 x14 .29664 .32640 -.20153 .04565 .15487 .25648 21 x3 .21296 .17021 .025481 .025451 .05878 .12421 variable communality factor eigen value percentage of variance cumulative percentage x1 x2 x8 x9 x14 x15 x16 x17 x3 x7 x10 x18 x19 x4 x5 x6 x20 x21 x11 x12 x13 .49116 .52238 .36721 .51280 .43982 .43774 .31408 .54521 .19075 .38007 .48545 .30192 .44599 .60456 .60380 .38075 .63435 .62562 .32627 .08262 .56333 1 2 3 4 5 6 2.17190 1.62159 1.51260 1.36664 1.36518 1.22216 10.3 7.7 7.2 6.5 6.5 5.8 10.3 18.1 25.3 31.8 38.3 44.1 variable factor 1 factor 2 factor 3 factor 4 factor 5 factor 6 x2 x1 x9 x8 x17 x15 x14 x16 .68873 .60454 .52173 .50906 .00121 .07354 .06928 .08794 .12159 .20091 .09066 .13179 .72176 .59215 .51481 .40784 .03360 .22888 .38395 .04377 .13716 .05148 .38392 .06535 .11854 .12451 .23564 .21456 .24574 .02145 .00548 .04578 .11545 .10655 .25461 .24579 .32456 .01245 .02457 .12699 .01245 .12345 .14547 .36564 .12455 .26452 .10676 .12456 38 x gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 although the factor matrix obtained in the extraction phase indicates the relationship between the factors and the individual variables, it is usually difficult to identify meaningful factors based on the matrix. often variables and factors do not appear correlated in any interpretable pattern. most factors are correlated with many variables. thus to summarise the sets of closely related variables, the rotation is done. from the above table, it could be seen that each factors identi�es itself with a few sets of variables closely connected to it. in each factor, most preferred variables are placed �rst and the remaining in the order of ranks secured by them. from the analysis, it is inferred that the investors give more importance to the factor one which implies a positive and stubborn attitude towards savings. factor two stands to disclose the importance of investment practices and returns. factor three is to reveal the attitude of the investors towards the present investment climate. factor four stresses the importance saving. role of government in regulating the investment climate in the country is disclosed the factor �ve. factor six contains statements of overall concern of investors. recommendations and conclusion many private sector �nance companies failed to meet their repayment schedule and hence dispute arose between the investors and institutions. government’s belated intervention in the past resulted in the loss of crores of rupees of investors. they also expect that the government must misery will �nd a solution. the long pending court proceedings ultimately increase their burden. almost all the investors feel that the rate of interest on government securities is very less when compared to the return available outside. for such higher return, investors are tempted to invest with private parties. investors expect the government to enhance the rate of interest slightly higher than the present. this will ensure satis�ed return to them and safety of capital. some investors reported that they had subscribed retirement bene�t plans and private sector mutual fund organisation. they expect some additional tax concession from the government. since, these schemes are mostly subscribed by private sector employees, the tax concession will be a boost for their saving habit. the central and state government should spread saving and investment habit by making foolproof safety mechanism. only with prevalence of a healthy atmosphere, individual investors will be inclined to deploy their funds on a continuous basis in various types of on a continuous basis in various types of �nancial instruments of government. investor education is the need of the hour. though number of institutions part with investor education, they are not sufficient. a mass and continuous awareness programme shall be conducted. before investing, one has to equip himself with relevant information, which will have a long run impact on his investment practices. but in practice, investors with little time to discuss investment matters are not serious in the matter. owing to the availability of little relevant information, general talks and rumors induce the investors to choose the investment instrument though it does not suit his interest. hence, a systematic and long run investors’ awareness programme would be a boon to the investing community. references 1. shamira malekar , brahmabhatta and p.s.raghu kumari, “a study of investor behavior on investment avenues in mumbai fenil” trans asian journal of marketing and management research, vol.1 issue 1, september 2018,pp. 49 – 66. 2. agrawal, g. d., “mutual funds and investors’ interest” the journal for corporate professionals, vol. 22 (1), 1992, pp. 23-24. 3. sanjay kanti das, “middle class household’s investment behaviour: an empirical analysis”, a journal of radix international educational and research consortium, september 2018 , volume 1, issue 9, issn: 2277100x. 4. krishna chitanay, vadlamannati and lokanandha reddy, “investors perception and domestic private investments in india role of direct foreign investments and economic reforms”, indian journal of economics and business, vol.8, no.1, 2014, pp.145-159. 5. jayabal g., and kasilingam r., “determinants of expected return of salaried class investors in tamil nadu”, the journal of indian management and strategy, vol.14, july-sep 2015, pp.14-25. 6. sanjay sehgal, g.s. sood and namitha rajput, “investor sentiment in india – a survey”, vision –the journal of businessperspective, vol.13,no.2, apriljune 2015, pp.13-20. 7. hamid bahmanpour, “national savings and investment behaviour in iranian economy”, prajnan, 31(4) 2002, pp. 313-314. 8. statman, “a century of investors”, santa clara university, department of finance, working paper no.02-07, 2002. 9. rajarajan,v, “investors demographics and risk bearing capacity”, finance india, 17(2) june 2003, pp.565-576. 10. ramakrishna reddy and ch. krishnudu “investment behavior of rural investors”, finance india, vol. 23, no.4, 2009, pp.12-17 11. shinde c.m., and priyanka zanvar, “an empirical study on factors in�uencing in investment decision making in pune”, international research journal of management and commerce”, vol. 1, issue. 6, 2014, pp. 10-23. x10 x7 x19 x18 x3 x4 x5 x6 x21 x20 x13 x11 x12 .17858 .32333 .36457 .02888 .06486 .11345 .12337 .25754 .05071 .05104 .05456 .18597 .02893 .03522 .02253 .15058 .33057 .00548 .02569 .02107 .11962 .01766 .02856 .20759 .10555 .15919 .65456 .43546 .42564 .36545 .25645 .00877 .22457 .29878 .32564 .21456 .02626 .00545 .45251 .00830 .07955 .88440 .05454 .25461 .01475 .02454 .25478 .32458 .78787 .78451 .02154 .02457 .22454 .01245 .32451 .04545 .05454 .03214 .24545 .14725 .02457 .02654 .45781 .12456 .12422 .12451 .23121 .31462 .04141 .32154 .01458 .01245 .32145 .15457 .23155 .23121 .14514 .01299 x 39gjra global journal for research analysis volume-7, issue-12, december-2018 • print issn no 2277 8160 introduction the major depressive disorder, or simply termed as depression is the most prevalent mental disorder, and it is thought to be the most common cause of human disability. depression is one the top ten causes of daly lost currently and according the estimations made by who it is set to become one of top three causes of daly lost by the year 2030 [1]. according to who statistics, a total number of 322 million were found to be living with depression which makes the prevalance of depression in the world to be about 4.4%. depressive disorders caused about 50 million years lived with disability (yld) in 2015 [2]. there is a scarcity in literature for sociodemographic studies in context of basal thyroid functions occurring in patients of major depressive disorder. our study focuses on various sociodemographic and clinical parameters of the patients suffering from depression. however, gender differences, age, education, marital status, socio-economic status, locality, culture are few factors which are implicated to have an impact on onset and progression of depressive disorders. hence present comparative study was undertaken to study various clinical and socio-demographic variables in patients of depression and healthy controls. methodologythe present study is cross sectional in design where we included 100 (52 females,48 males) drug naïve rst episode of depression patients in the age range of 18 to 65 years as cases and 100 healthy controls. the study was conducted in department of psychiatry, m.g.m. medical college, indore between january 2018 to december 2018. the study was approved by institutional scientic and ethics committee. inclusion criteriapatients meeting diagnosis of depression (f32 depressive disorder, rst episode) according to international classication of diseases diagnostic criteria for reasearch (icd-10 dcr)[3]. patients aged between 18-65 years, either sex. patients giving written, informed consent. patients cooperative for interview. exclusion criteriaincluded any co-morbid psychiatric illness, any substance dependence except nicotine , patients with history neoplasm of endocrine gland, radiation exposure, any medical comorbidity, hypertension, any endocrinological disorder ,pregnancy and lactation, current use of anti-hypertensive drugs, steroid hormones, retinoids, antipsychotics, mood stabilizer (lithium), amiodarone, immune-suppressants and immunomodulatory agents, antithyroid drugs, hypothyro idism drugs. toolsthe hamilton depression rating scale (ham-d 17)[4], general health questionnaire(ghq-12)[5], icd-10 dcr were used for assessment of the subjects. procedure after complete description of the study to the subjects, written informed consent was obtained from all participants. the diagnosis of major depression was made using structured clinical interview based on icd 10(dcr) criteria. sociodemographic data was collected using a semi-structured proforma. after that clinical assessment of patient group was done using ham-d to ascertain severity. statistical analysis was performed using the statistical package for social sciences (spss for windows, version 23, spss inc.). results table 1 table 1 shows the comparison of socio-demographic variables between the depressive and the control groups. the a comparative study of sociodemographic and clinical profile of patients having first episode of depression and healthy controls original research paper chauhan beema resident doctor, department of psychiatry, m.g.m. medical college, indore psychiatry background : gender differences, age, education, marital status, socio-economic status, locality, culture are few factors which are implicated to have an impact on onset and progression of depressive disorders. there is a scarcity in literature for sociodemographic studies in context of basal thyroid functions occurring in patients of major depressive disorder. our study focuses on various sociodemographic and clinical parameters of the patients suffering from depression. methodology: the diagnosis of rst episode of major depression was made using structured clinical interview based on icd 10 (dcr) criteria. the patients were classied into mild, moderate, severe, very severe category on the basis of ham-d scale. results: the mean age of case group was 34.9 ± 10.6 years while that of control group was 35.5 ± 10 years. the case group had more married, rural background, other religion based, illiterate, low socioeconomic status, nuclear family subjects. mean duration of illness of 4.24 ± 2.45 months or almost 21-22 weeks. the mean age of onset was 32.6 ± 11.90 years, ham-d scores were 20.36 ± 7.04, 63% of severe to very severe depression, 36% moderate depression and 1% mild depression patients. females had majority of severe depression cases (52%). married cases had most patients in the moderate to severe depression category (84.7%) while unmarried cases also had most samples in the severe depression category (39.3%). conclusion: knowing the clinical and socio-demographic variables helps in better understanding of depression and its management. abstract keywords : rst episode depression, sociodemographic variables volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra rastogi pali* associate professor, department of psychiatry, m.g.m. medical college, indore *corresponding author pal v. s professor, department of psychiatry, m.g.m. medical college indore lohokare rajeev associate professor, department of biochemistry, m.g.m. medical college, indore 12 x gjra global journal for research analysis mean age of case group was 34.9 ± 10.6 years while that of control group was 35.5 ± 10 years. the gender was evenly distributed in the case and control group alike due to matching of cases with control group as per inclusion criteria. female gender had a slight preponderance in both groups. the case group had more married, rural background, other religion based, illiterate, low socioeconomic status, nuclear family subjects in comparison to control group. table 2 table 2 shows the depression patients had precipitating factors in 35% sample, while family history was positive in 22% samples of cases and only 7% of controls. table 3 table 3 showing the depression patients had a mean duration of illness of 4.24 ± 2.45 months or almost 21-22 weeks. the mean age of onset was 32.6 ± 11.90 years, while mean ham-d scores were 20.36 ± 7.04. table 4 : severity of depression in various groups as per ham-d 17. table 4 : depression's severity in rst episode of major depression as per ham-d scores showing that in our sample rst episode had 63% of severe to very severe depression, 36% moderate depression and 1% mild depression patients. table -5: table 5 shows distribution of depression's severity in context of gender in depression patients. females had majority of severe depression cases (52%), as compared to males. males had more moderate and very depression cases. discussion the mean age of case group was 34.9 ± 10.6 years while that of control group was 35.5 ± 10 years (table 1) similar mean age were found by chopra et al,2001[6], islam et al.[7] dar et al.[8]. the gender distribution in the case and control group was alike due to matching of cases with control group as per inclusion criteria . however, female gender had a slight preponderance in both groups which is agreement with chopra et al.,2001[6] , kassaee et al.,2016[9]. most of the participants in both the case (72%) and control (67%) groups were married. data obtained by chopra et al, okeafor et al.[10] and milanović et al.[11] corroborate our ndings. the better part of participants in both case (75%) and control (88%) groups were hindu by religion, while rest subjects belonged to other religions. in our study we have found hindu people were in excess in both study and control group similar to agarwal et al.[12] and this nding is in concordance of the usual ethnic distribution as per geographical distribution. case group had 20% illiterate and 80% literate samples while the control group had 18% illiterate and 82% literate samples but there was no signicant differences found between two groups with respect to education status. resembling ndings were obtained by chopra et al[6]., kassaee et al[9]. however, from our ndings it was not evident that educational status have a signicant effect on depression. low socio-economic income groups were found to be the majority in both case (61%) and control groups (58%), followed by middle income and lastly high income. in terms of socioeconomic variables studies have shown that depression is more common in poor economic background individuals, this nding is consistent with poongothai s et al., 2009;[13], bagadia vn et al., 1973[14], coentre et al.[15]. the distribution of case (85%) and control (88%) sample were urban in majority, while 15% cases and 12% controls groups belonged to rural background . islam et al[7] found similar results with their sample population having 64% urban residents which is in concordance with srivastava et al.[16]. the urban majority can be explained by the fact that our study centre is a tertiary healthcare institute which is based in an urban setting and most patients who visited the hospital were urban dwellers. the makeup of family type displayed case group had greater distribution of nuclear family at 61% while joint family being at 39% of samples. the control group had nuclear (57%) family preponderance than joint family sample. hence, from the above ndings it can be summarized that nuclear family suffered depression more than joint family samples. our ndings are similar to the ndings of chopra et al.,[6] kamble et al. [17]. this nding is consistent with the fact that joint family have a rm and consistent family support which might be a factor preventing depressive disorder. we would like to emphasize that the higher prevalence of depression in nuclear family, hindu religion, married subtype volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra variable variable controls (n=100) (n=100) age 34.9 ± 10.6 35.5 ± 10 sex male 48 48 female 52 52 others 0 0 marital status married 72 67 unmarried 28 33 domicile rural 15 12 urban 85 88 religion hindu 75 88 non-hindu 25 12 education illiterate 20 18 till class 5 32 30 6th to 12 44 44 graduation 6 8 socio economic status low 61 58 middle 34 38 high 5 4 family type nuclear 61 57 joint 39 43 variables depression patients (n=100) healthy controls precipitating factor yes 35 (35%) no 65 (65%) family history negative 78 (78%) 93 (93%) positive 22 (22%) 7 (7%) variables depression patients (mean ± sd) age of onset of illness ( years) duration of illness (months) ham-d score 32.6 ± 11.90 4.24 2.45 20.36 ± 7.04 severity of depression frequency percent mild 1 1.0 moderate 36 36.0 severe 46 46.0 very severe 17 17.0 total 100 100 sex female male total mild 0(0%) 1(2.1%) 1 moderate 18(34.6%) 18(37.5%) 36 severe 27(51.9%) 19(39.6%) 46 very severe 7(13.5%) 10(20.8%) 17 total 52 48 100 x 13gjra global journal for research analysis can be attributed to the abundance of such samples in our study which is a bias secondary to the purposive sampling technique and hence these ndings shouldn't be generalized to all settings. both case (78%) and control (93%) groups (table 2) had negative family history in abundance with only 22% of cases and 7% of control samples having positive family history which was also evidenced by srivastava et al.[16]. this nding is indicative of depression having a stronger genetic predisposition and risk of transmission in pedigree. the depression patients had a mean duration of illness of 4.24 ± 2.45 months or almost 21-22 weeks (table 3) . this is keeping with the mean duration of depression which was replicated by solomon et al.1997 [18].on assessment of continuous variables (table 3) age of onset, duration of illness and ham-d scores in depression patients we found the mean age of onset was 32.6 ± 11.90 years, mean duration of illness in depression patients was 4.24 ± 2.45 months while mean ham-d scores were 20.36 ± 7.04 park et al.[19], yang et al.[20], srivastava et al.[16] also found similar results in their studies. the depression patients had presence of precipitating factor in 35% of samples while family history was positive in 22% cases. this is a result which is indicative of the fact that although depression is associated with precipitating factors in about one fourth samples and general population who have experienced a signicant stressor should be closely monitored, but even in the absence of any such factors depressive disorder may develop which is inconspicuous in origin. depression's severity in rst episode of major depression (table 4) as per ham-d scores demonstrated that in our sample rst episode had 17% very severe, 46% severe depression, 36% moderate depression and 1% mild depression patients . talukdar et al.,2018 [21] also displayed similar ndings in their work. both genders had majority of severe depression cases (52%), while mild depression was least of all in both case and control groups (table 5). married cases had most patients in the severe depression category (48.6%) while unmarried cases also had most samples in the severe depression category (39.3%), chopra and ram, das, kamble found resembling results in their studies. mild depression were the least prominent samples in married and unmarried groups of depression patients. as we have limited our study to rst episode of depression, future studies should widen the horizon including depression with psychotic symptoms, recurrent depression and bipolar depression for a more comprehensive result. conclusion the mean age of depression was 34.9 years. most of the participants were married, hindu by religion,. maximum subjects were literate. in terms of socioeconomic variables, nuclear, urban and low socio-economic income groups were found to be the majority . nuclear family suffered depression more than joint family samples. the depression patients had presence of precipitating factor in 35% of samples while family history was positive in about a quarter of cases. general population who have experienced a signicant stressor should be closely monitored, but even in the absence of any such factors depressive disorder may develop. depression patients had a mean duration of illness of 4.24 ± 2.45 months or almost 21-22 weeks. the mean age of onset was 32.6 ± 11.90 years, while mean ham-d scores were 20.36 ± 7.04. depression's severity in rst episode of major depression demonstrated 63% of severe to very severe depression cases. both genders had majority of severe depression cases, married cases had most patients in the severe depression category while unmarried cases also had most samples in the severe depression category. hence, we conclude that knowing the clinical and socio-demographic variables helps in better understanding of depression and its management. references 1. wo r l d h e a l t h o r g a n i s a t i o n r e p o r t o n d e p r e s s i o n 2 0 1 9 http://www.emro.who.int/health-topics/depression/index.html 2. üstün tn, ayuso-mateos jl, chatterji s, mathers c, murray cjl. global burden of depressivedisorders in the year 2000. british journal of psychiatry, 200; 184: 386-392. 3. world health organization. the icd-10 classication of mental and behavioural disorders: diagnostic criteria for research. geneva: world health organization;1993.p.89-103 4. hamilton m. a rating scale for depression. j neurol neurosurg psychiatry 1960;23:56-62. 5. goldberg,d.,& williams,p.(1988).a user’s guide to the general health questionnaire. windsor, uk:nfer-nelson. 6. chopra vk, ram d. basal thyroid functions in rst episode depressive illness : a controlled study. indian j psychiatry. 2001;43(1):61–66. 7. islam, md.r. and adnan, r. (2017) socio-demographic factors and their correlation with the severity of major depressive disorder: a population b a s e d s t u d y. wo r l d j o u r n a l o f n e u r o s c i e n c e , 7 , 1 9 3 2 0 2 . https://doi.org/10.4236/wjns.2017.72014 8. maqbool dar, mohammad &tarfarosh, shah faisal ahmad & manzoor kullah, shahid & mushtaq, raheel& manzoor, mushbiq& maqbool, sumaira. (2016). socio-demographic and clinical prole of patients suffering from severe depressive disorders in kashmir valley. international journal of contemporary medical research. 3. 3389-3392. 9. kassaee, seyed mehrdad & ahmadi, rahim &seif, asghar &molaei, sedigheh. (2016). assessment of serum tri-iodothyronine (t3), thyroxin (t4) and thyroid-stimulating hormone (tsh) levels among patients with major depressive disorder (mdd) in hamedan, northwestern iran. jentashapir journal of health research. in press. 10.17795/jjhr-23066. 10. okeafor cu, chukwujekwu cd, olose eo (2017) socio demographic correlates of depressed patients attending a tertiary hospital in nigeria. j addict res ther 8:313. doi:10.4172/2155-6105.1000313 11. . sanja musić milanović, katja erjavec, tamara poljičanin, božena vrabec & petrana brečić: prevalence of depression symptoms and associated sociodemographic factors in primary health care patients psychiatriadanubina, 2015; vol. 27, no. 1, pp 31–37 12. agarwal a, agarwal m, garg k, dalal pk, trivedi jk, srivastava js. metabolic syndrome and central obesity in depression: a cross-sectional study. indian j psychiatry 2016;58:281-6. 13. poongothai s, pradeepa r, ganesan a, mohan v (2009) prevalence of depression in a large urban south indian population — the chennai urban rural epidemiology study (cures–70).plosone4(9): e 7185 . https :// doi.org/10.1371/zjournal.pone.0007185 14. bagadia vn, shah lp, pradhan pv, gada mt. a double blind controlled study of amoxapine and imipramine in cases of depression. currther res. 1979;26:417–29. 15. coentre r, faravelli c, figueira ml. assessment of depression and suicidal behaviour among medical students in portugal. int j med educ. 2016;7:354–363. published 2016 oct 29. doi:10.5116/ijme.57f8.c468 16. srivastava a s, kumar r. suicidal ideation and attempts in patients with major depression: sociodemographic and clinical variables. indian j psychiatry 2005;47:225-8 17. kamble mt, nandedkar pd, dharme pv, l ls, bhosale pg. thyroid function and mental disorders: an insight into the complex interaction. j clin diagn res. 2013;7(1):11–14. doi :10.7860/jcdr /2012/4861.2656 18. solomon da, keller mb, leon ac, mueller ti, shea mt, warshaw m, maser jd, coryell w, endicott j arch gen psychiatry. 1997 nov; 54(11):1001-6 19. park sc, hahn sw, hwang ty, et al. does age at onset of rst major depressive episode indicate the subtype of major depressive disorder?: the cl inical research center for depression study. yonsei med j . 2014;55(6):1712–1720. doi:10.3349/ymj.2014.55.6.1712 20. yang f, li y, xie d, shao c, ren j, wu w, et al. age at onset of major depressive disorder in han chinese women: relationship. 21. goswami h., talukdar b thyroid prole in drug naive cases of depression. journal of depression and anxiety. 07. 10.4172/2167-1044.1000300. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 14 x gjra global journal for research analysis introductionaccording to modern science mukhpak is nothing but stomatitis i.e inammation of the mouth . it affects the mucous membrane,which are the thin skin covering on the inside surface of mouth. stomatitis can be caused by variety of different factors like injury, infection, allergy or skin disease. 21st century is the century of science and innovations; life is become faster in this time. civilizations have changed human life considerably; with not only good benets of it, but some bad effects on human health. as the life style is changed individuals are consuming excessive quantity of apthyakar ahar i.e. mixed type of food, acidic foods, spicy foods, chat foods, instant foods, chinese, cold drinks etc. also addiction like chewing tobacco, supari-(betel nut), gutka, tobacco with lime, smoking, drinking alcohol etc. which in turn disturb in the normal physiology of the body. these dietary irregulations, dietary allergen, habits and addictions perform long bad effects on human body which reduces the immunity and make them prone to many diseases; one of them is mukhapak i.e. stomatitis. many treatment modalities like antibiotics, antiinammatory, anesthetics drugs, supplements like vitamins etc. are tried in modern science, which are either limited or unsatisfactory. hence medical science is in the search of a safe, easily available cost effective, therapy for this disease. in mukhapak mainly pitta dosha and raktavaha and mamsa are the dushyas. to break this samprapt i , p i t ta doshahar, rakta prasadak, vranashodhak, vranropak, shothahar chikitsa is essential. review of ayurvedic text was done and according to various acharyas, prescribed treatment for mukhapak is in the form of kawalgraha, gandush, pratisaran, raktmokshan etc. particularly in case of mukhapak panchpallav kwathalong with madhu gandush is adviced. both are having properties like-anti-inammatory, vedanasthapan, vranashodhan, vrana ropan and rakta pittahar, kaphashamak, ulcer healing properties. aim : a study on the efcacy of panchpallav kwath with madhu in management of mukhapka. objectives to study mukhapaka vyadhi according to ayurveda. to study stomatitis according to modern medical science. to study the role of gandush chikitsa & efcacy of panchpallav kwath in mukhapaka . to study the panchpallav kwath according to ayurveda. review of ayurvedic literature mukharoga nidana – hetu – in general aayoge, atiyoga and mithya yoga of kala, buddhi and indriyarth. are the causative factors for any disease. in other words, the causes of the diseases relating to both mind and body are threefold wrong utilization, non-utilization and excessive utilization of time, mental facilities and objects of sense organs in ayurvedic literature, special nidan has been mentioned for mukharoga. the causative factors in general are mentioned for all types of mukharoga. samanya samprapti of mukharoga due to specied etiological factors, tridosha get vitiated and among which kapha is aggravated more producing mukharoga. mukha is sthan of the bodhak kapha.c so the etidogical factors, of the mukhroga do the vikruti of the bodhak kapha. madhur and amla rasas are the main etiological factors for the vikruiti of the bodhak kapha. due to the above factors mainly kapha pradhan prakopit dosha causes the mukharog. mukharoga samanya chikista sutra – in mukharoga mainly kapha and rakta dusti is there so rakta mokshana is main chikitksa, kosteshudhi by virechana, kawalagraha, gandusha, nasya, shirovirechana, pratisarana, dhooma, agnikarma, ksharakarma are also helpful in mukhrogas. charak has told pradhamana nasya, virechana, vaman, lekhana and vat, pitta, kapha, shamak ahar and dravyas. mukhroga samanya pathya – generally in all mukhroga-old rice, joa, muga, kulalthya, karella, paravala, komal, muli, hot water tikta and kandu rasa are all pathayakar. specially kapha and rakta shodhak ahar is useful in mukh a study on the efficacy of panchpallav kwathwith madhu in management of mukhapaka. original research paper dr.sunil. s. walvekar. associate professor, dept.of shalakyatantra loknete rajaram bapu patil ayurvedic medical college & hospital, islampur,tal-walwa,dis-sangli,pin415409. x 15gjra global journal for research analysis ayurveda according to modern science mukhpak is nothing but stomatitis i.e inammation of the mouth . it affects the mucous membrane,which are the thin skin covering on the inside surface of mouth. stomatitis can be caused by variety of different factors like injury, infection, allergy or skin disease. mukhapaka is a common problem seen in day to day practices. in todays era we can see many patients suffering from mukhpak, hence choosen disease for clinical study is mukhpaktreated withpanchpallav kwath with madhu. study was conducted on 60 patients, 30 patients were allocated in trial group and 30 patient in control group by random selection method. the patients in control group were treated with kamdudha churn with madhu pratisaran,while in trial group patient were treated with panchpallav kwathwith madhu for 30days . no internal medicine given to both group during cilnical trail.it is seen that there is highly signicant reduction in vedana , daha, mukhadurgandhi and number of sites of ulcers and size of ulcer in trial group.signicant reduction in aarochaka was observed. panchpallav kwthhas vranaropaka,vranashodhana,sandhankaraka,shothahara properties.by all these properties,by this study it is proved that aspanchpallav kwathis better option in the treatment of mukhapaka. abstract keywords : panchpallav kwath, madhu, mukhroga, mukhapaka. dr.ashwini bharat kamble* assiatant professor shalakya tantra department loknete rajaram bapu patil ayurvedic medical college & hospital, islampur,tal-walwa,dissangli,pin-415409. *corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 16 x gjra global journal for research analysis roga. green vegetables, fruit, dry fruits, butter, carrot, tomato, orange, limes, santra, palaka, awala, hari-dhaniya are useful in mukhroga which contains vit. a, b, c. etc . apathyas – generally – in all mukhroga – amala padartha, cured milk,, sweet padartha, vidahi, rukshanna, kathina bhari and abhishyandi ahar are apathyakar, cold water, brushing, eating of hard padartha, sh, anupadesh, goat animals mamsa, sleeping at day time are ahitkar. adhomukha shayana is also ahitkar . disease review acharya sushruta had described mukhroga in nidansthan. there are 65 mukhroga which occur at seven locations such as lips, teeth tongue, palate, throat and oral cavity. out of them 8 occur in lips, 15 in gums, 8 in teeth, 3 in tongue, 9 in palate, 17 in throat and 3 in entire mouth. mukhapaka the disease, which affects the whole oral cavity, i.e. buccal mucosa is called as mukhapaka. as the disease spreads very quickly in the oral cavity it is called as mukhapaka. acharya sushruta had told types of mukhapaka as vataj, pittaj, kaphaj, and raktaj. pittaj mukhapaka – 1. burning type of red and yellow coloured crackling thing blisters / boils or ulcers in the mouth 2. burning and combusting type of pain with feeling of bitterness in the mouth 3. ulcers in the mouth are formed like that of the ulcers formed by alkalies. samanya chikitsa of the mukhapaka – 1. sheera vedha 2. sheero virechana 3. kaya virechana 4. kawalgrah (gargels) – with mutra, oil, ghee, madhu, milk. gandush – kawalgraha & gandusha are the procedures of gargling with the medicinal liquids either kwatha, taila etc. kept in mouth for a period of a dharana kala which is 5-10 min. basic difference in kawala and gandusha is kawala is that of quantity of drug which can be easily moved in mouth and if it is taken full of mouth is called as gandusha. vishesha chikitsa pittaja mukhapaka – in case of pittaja mukhapaka pittahar chikitsa of all types with the help of madhu and sheetal medicinal dravyas are advised. pitta and rakta shaman chikitsa should be done in pittaja mukhpaka. drug review – materials and methods materials for examination of patient 1. bulls lamp 2. head mirror 3. torch 4. tongue depressor 5. autoclaved hand gloves 6. autoclaved cotton. materials for administration of medicament ÿ chair to sit the patient ÿ madhu – in a sterile bottle ÿ sterile gloves ÿ panch-pallav kwath ÿ head mirror, napkin etc. ÿ sterile glass for lling kwath study design: the whole study was divided in 2 group / types. 1) conceptual study. 2) clinical study. 1) conceptual study – detailed review of ayurvedic and modern literature was carried out to know about disease – pittaj mukhapakaentity and treatment and drugs used to treat i.e panch-pallav . 2) clinical study – total 60. patients of pittaj mukhapaka was selected and randomly divided into two groups viz. clinical trial group & control group patients were reviewed at 3rd, 5th, 7th day and 15th, 30th day. 1) experimental group – the study group i.e. trial group was treated with panch-pallav kwath with madhu twice a day. therapy will be given upto 7 days and follow up will be taken on every 3rd, 5th, 7th, day & necessary advice was given to the patient time to time. 2) control group control group was treated with kamdudha churn with madhu pratisarana 2 times in a day for 7 days. follow up was taken as per study group. sampling techniques – a random sampling technique was adopted. inclusion criteria – : patient of age group 21 to 50 yr. of both sex. : that the patient should give history of burning sensation in oral cavity. : patient with intolerance to eat spicy foods. : change in colour of oral mucosa. : ulcers in oral cavity. : above complains with recurrent episodes of pittaj mukhapaka. exclusive criteria – : patients having gingivitis, pyrorrhoea, etc. : tubercular ulcers / syphilitic ulcers / diabetic ulcer. : candidial ulcer, oral thrush . : ulcers due to herpes zoster. : traumatic ulcers . : immuno-suppressive disorders. : oro-dental stula. : known oral, throat, tongue malignancies etc. : severe anaemia. : osmf(oral submucosal brosis). volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra drug name botanical name part kapitha feronia limoni 1 part bijpurak citrus medica 1 part bilwa aegle marmelose 1 part amra mangifera indica 1 part jambu syzygium cumini 1 part drug name ras virya vipak gun kapitha madhur, amla, kashay shit madhur laghu bijpurak madhur, amla ushna amla laghu, snigdha bilwa katu, tikta, kashay ushna katu laghu, snigdha amra madhur shit madhur guru, snigdha jambu kashay, madhur, amla shit katu guru, snigdha madhu madhur, kashay shit madhur laghu, ruksha discussion – mukhapaka is a disease of oral cavity; it is the paka of oral mucosa and produces ulcers in oral cavity. various treatment modalities from different medical faculties are in this disease like – local application, local antiinammatory, agents like kenalog, orabase. the paste application locally upto heal the ulcer. tetracyelline mouthelline mouthwash, then application of thick layer of triamcinolone acetoride is recommended. oral or systemic antibiotic are administered if necessary. supplementation of vitamins and iron is also recommended. these treatment have very limited or unsatisfactory results.during this study result of panchpallav kwath is assessed on th basis of shool, mukhdah, shoth, lalima, ulceration. in mukhapaka pitta dosh prokopa and rakta, mamsa dhatu dushti is there, localizing in oral cavity. hence the line of treatment should be pittashamaka, shothahara, vedanasthapana, vranashodhana, vranaropana, rakta prasadaka, mamsa dhatu pushtikara. i have selected panchpallav kwathwith madhu , proved to be very effective in this disease.panchpallav kwathis madhur rastkmak,having shit virya wich act as pittashamak. laghu,snigdh gunas which is vaedanasthapak and shothahar. madhu having property of vrana shodhan, vrana ropak gun which helps in healing of ulcers.. madhu when applied locally to mucous membrane, it causes stimulation of mucous membrane. madhu removes vitiated doshas, improve wound healing. patients of study group trated with panchpallav kwathwith madhu and that of control group with kamdudha churna with madhu, for same period and same pattern, follow up of each nding was recorded symptom wise in qualitative form and difference noted before and after treatment. after study we came across the effect of panchpallav kwathwith madhu is better in all respect than that of control group. conclusionpanchpallav kwathwith madhu acts better result on mukhapaka. it gives best relief from symptoms like shool, sparshasahatva, mukhdah, shoth,lailma, ulceration. refferences: 1. vangasen samhita,pandit.hariprasad tripathi,chaukhambha sanskrit series,rst edition,shishurogadhikar,chapter 19,shlok no 109,pg no 235. 2. bharat bhaishajya ratnakar,shree.vd.gopinath bhishagratnen krutya,publisher b.jain, reprint augst 1999,2005,parishishta a,akardi kashaya prakaranam,athakaradilep prakaranam,shlok no 8898 ashwathadilep[1],pg no 585. 3. charaka samhita[purvardha]by dr.brahmanand tripathi,publisher chaukhambha surbharati prakashan,varanasi. 4. sushruta samhita[english translation]by priyavart sharma,publisher chaukhambha vishvabharti,varanasi,first edition 1999. 5. dravya guna vigyan.[vol-2]by vd.priyavart sharma. modern literature: 1. clinical medicine [4th edition]editor-parveen kumar and michael clark. 2. diseases of ent-p l dhingra [4th edition]-2007. 3. www.google.com 4. text book of ent diseases-s.k.bhargav,t.m.shaha-usha publication, mumbai. x 17gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: megaloblastic anemia is a panmyelosis. the morphologic hallmark is nuclear-cytoplasmic dissociation, which is the best appreciated in precursor cells in the bone marrow aspirate. megaloblastic nuclei are larger than normoblastic nuclei, and their chromatin appears abnormally dispersed due to its retarded condensation (figure 2]). giant band forms and metamyelocytes are usually seen. there are various causes for the deciency of both vitamin b 12 and folate that include parasitic infections like diphyllo bothrium latum, alcoholism, vegetarianism, gastrectomy, pernicious anemia, drugs like oral contraceptives and anticonvulsants. with achlorhydria and loss of pepsin secretion, vitamin b is not readily released from proteins in 12 food. with gastrectomy and pernicious anemia, intrinsic factor is not available for transport to the ileum. the only dietary sources of vitamin b are foods of animal protein 12 origin such as kidney, liver, heart, muscle meats, sh, eggs, cheese and milk. in contrast to folate, vegetables contain practically no vitamin b . cooking has little effect on its 12 activity. the humans are entirely dependent upon dietary sources. vegetarians are more prone for megaloblastic anemia as compared to that of nonvegetarians. the term macrocytosis refers to a blood condition in which red blood cells (rbc) are larger than normal. macrocytosis is reported in terms of mean corpuscular volume (mcv). normal mcv values range from 80 to 100 femtoliters () and vary by age and reference laboratory (1).mcv is calculated according to the following formula: macrocytosis can be identied by reviewing peripheral blood smears and/or by automated rbc indices. the peripheral blood smear is more sensitive than rbc indices for identifying early macrocytic changes because the mcv represents the mean of the distribution curve and is insensitive to the presence of small numbers of macrocytes(2).however, compared to the peripheral blood smear, mcv may underestimate macrocytosis in over 30% of cases (3) rarely hyperglycemia, marked leukocytosis and cold agglutinins may result in false elevations of the mcv (4, 6). moreover, partial occlusion of the instrument aperture and/or leaving the blood sample at room temperature for several hours may also result in false elevations of the mcv value. macrocytosis, dened as a mean corpuscular volume greater than 100 fl, occurs in approximately 3 percent of the general population (1). this article describes a strategy for the evaluation of patients with macrocytosis, as well as a brief discussion on treatment of vitamin b and folate deciencies. 12 the hypersegmented neutrophils and macroovalocytes are present in megaloblastic macrocytic anemia (figure 1). nonmegaloblastic anemia has round macrocytes or macroreticulocytes when peripheral smear b level, and , 12. reticulocyte count have not lead to an obvious diagnosis, consider a comprehensive metabolic panel to look for liver and kidney disease, thyroid-stimulating hormone for thyroid disorders, and methylmalonic acid and homocysteine levels to assess for vitamin b deciency, despite a normal vitamin 12 b level. bone marrow aspiration and biopsy are very helpful 12 in conrming diagnosis of megaloblastic anemia in difcult cases. 35 percent of patients with alcoholism and macrocytic anemia are folate decient, which can be caused by poor nutrition, malabsorption, hepatobiliary dysfunction, and possibly increased folate catabolism (7, 8).some medications that are used to treat seizure disorders, cancer, and autoimmune diseases can lead to folate deciency. for example, methotrexate directly inhibits dihydrofolate reductase, which leads to a functional folate deciency. serum folate levels are not much useful because they uctuate rapidly with diet (9, 11). rbc folate levels more accurately correlate with folate stores and should be performed if folate deciency is suspected. in differentiating the cause of megaloblastic anemia, a methylmalonic acid level that is within normal range also points toward a diagnosis of folate deciency. because of the limitations of measuring serum folate, rbc folate levels have been advocated as a more reliable source of measuring tissue stores of folate. rbc folate levels remain constant throughout the lifespan of the cell and are not hematological changes in megaloblastic anemia: a study of 25 cases original research paper vijay kumar sinha assistant professor, department of pathology, anugrah narain magadh medical college, gaya, bihar. x 43gjra global journal for research analysis pathology materials and methods: a teaching hospital-based retrospective study was done for a period of 1 year. 25 cases of megaloblastic anemia were analyzed and we correlated signs, symptoms, and hematological investigations. results: totally, 25 patients with megaloblastic anemia in the above said period were studied. the patient's age group was ranged from 12 years to 87 years .male female ratio was 4:1. megaloblastic anemia was observed in all the cases. pancytopenia was seen in all cases. 25 patients had isolated vitamin b12 deciency. 3 patients had both folic acid and vitamin b12 deciency. one had only isolated folic acid deciency. conclusion: megaloblastic anemia is one of the common causes of undiagnosed anemia, and the treatment is simple and easily affordable. if left untreated, it can lead to morbidity both because of anemia and attendant neurological involvement. abstract keywords : megaloblastic anemia, vitamin b12, folic acid, pancytopenia volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra subhash chandra jha assistant professor, department of pathology, government medical college, bettiah, west champaran, bihar parshuram prasad* assistant professor, department of pathology, anugrah narain magadh medical college, gaya, bihar. *corresponding author dilip kumar pandey assistant professor, department of pathology, anugrah narain magadh medical college, gaya, bihar. 44 x gjra global journal for research analysis affected by short-term dietary changes that can alter serum levels. however, assays for measuring rbc folate levels have also been fraught with unreliability (10, 11). it should be noted that low rbc folate levels have been reported with alcohol use, pregnancy and anticonvulsant medications. another important cause of low rbc folate levels is vitamin b12 deciency(12,13).it is estimated that approximately 60% of patients with pernicious anemia have low rbc folate levels, presumably because vitamin b12 is necessary for normal transfer of methyltetrahydrofolate from plasma to rbc. vitamin b12 levels may be reported as normal or elevated in myeloproliferative disorders, liver disease, congenital transcobalamin ii deciency, intestinal bacterial overgrowth and antecedent administration of vitamin b12(14).moreover, there are reports of falsely low vitamin b12 levels with folate deciency, pregnancy, use of oral contraceptives, congenital deciency of serum haptocorrins and multiple myeloma. the prevalence of vitamin b12 deciency among the elderly 25ranges from 1.5% to 4.6% and was reported to be as high as 15% in the population over the age of 60 years. the deciency in many cases is associated with gastric achlorhydria, resulting in decreased synthesis and availability of intrinsic factor, a necessary binding protein that facilitates vitamin b12 absorption in the ileum. vitamin b is absorbed by the ileum when bound by intrinsic 12 factor, which is produced by the parietal cells of the gastric mucosa. nutritional deciency is most common cause of vitamin b12 in vegetarians and vegans in india , especially in hindu community. in pernicious anemia, the loss of parietal cells leads to insufcient absorption of vitamin b , which then 12 leads to vitamin b deciency over time. it is common cause in 12 western world.pernicious anemia is most commonly caused by auto-immune atrophic gastritis, in which autoantibodies are directed against parietal cells and intrinsic factor. the diagnosis of pernicious anemia can be conrmed by identifying and measuring intrinsic antibody levels in the serum. parietal cell antibodies, although not specic, are also commonly present less commonly, pernicious anemia can be caused by nonautoimmune gastritis secondary to h. pylori infections and zollinger-ellison syndrome. the spectrum of etiologies associated with macrocytic anemia includes nutritional deciencies (e.g., vitamin b12 and folate), drugs , primary bone marrow disorders (e.g., myelodysplasia and leukemia) and other chronic illnesses. macrocytosis due to vitamin b12 or folate deciency is a direct result of ineffective or dysplastic erythropoiesis. these important vitamins and cofactors are required for normal maturation of all cells. when either of these two factors is decient, rbc proliferation and maturation result in large erythroblasts with nuclear/cytoplasmic asynchrony. these abnormalities are caused by a defect in dna synthesis that interferes with cellular proliferation and maturation. rna synthesis and cytoplasmic components remain relatively unaffected. the marrow is hypercellular with all forms of the myeloid cell line being increased and erythroid elements being dominant on the marrow aspirate smear preparations. the erythroblasts become large, oval shaped and contain a characteristic immature, lacy nucleus. these bone marrow features are called “megaloblastic” and are highly suspicious of a vitamin b12 or folate deciency. megaloblastoid (megaloblastic-like) abnormalities of the marrow are frequently seen in other hematologic disorders not associated with vitamin b12 or folate deciency, (e.g., myelodysplasia and leukemia) and a careful examination of the bone marrow is necessary to make this distinction. determining the underlying cause of the macrocytosis can be particularly challenging when thalassemia trait or iron deciency or other nutritional deciencies coexist with a vitamin b12 or folate deciency. in these instances the peripheral blood smear may show a mixed population of microcytic and macrocytic rbcs with an elevated distribution width. in cases of macrocytosis related to alcoholism the elevated mcv may be due to the direct effect of the alcohol, liver disease and/or folate decient.a review of the peripheral smear is imperative in determining the etiology of macrocytosis. the presence of macro-ovalocytes having an m c v > 1 1 5  , a n i s o c y t o s i s , p o i k i l o c y t o s i s a n d hypersegmented neutrophils suggests a megaloblastic disorder associated with a nutritional deciency, i.e., vitamin b12 or folate deciency. round macrocytes are commonly seen in a variety of chronic illnesses, and round targetappearing macrocytes are characteristic of liver disease such as hepatitis, obstructive jaundice, and acute and chronic alcoholism with liver disease . for patients who present with disordered immaturity, hypogranulated or hyposegmented neutrophils, and cytopenias, a bone marrow examination is necessary to rule out or conrm a primary bone marrow disorder such as a myelodysplastic syndrome or leukemi a reticulocyte count should be obtained if there is evidence of hemolysis on the peripheral smear, i.e., increased polychromasia , nuc leated rbcs, spherocytes or 18schistocytes. the presence of increased polychromasia of the macrocytes on the peripheral smear and a reticulocyte count of >10% should raise suspicion of hemolysis or an acute bleed. these large polychromatophilic erythrocytes noted on the peripheral smear represent reticulocytes, immature rbcs that are larger than mature rbcs, and are indicative of increased erythropoiesis or rbc production and, if present in increased number, can raise the mcv. additionally, the reticulocyte maturation parameters performed on the peripheral blood may also be helpful to differentiate megaloblastic from nonmegaloblastic causes of the 19macrocytosis. an elevated reticulocyte maturation value is more suggestive of a megaloblastic rather than a nonmegaloblastic anemia macrocytosis associated with a megaloblastic marrow is usually accompanied by anemia due to ineffective erythropoiesis. the bone marrow is hypercellular, showing evidence of abnormal proliferation and maturation of multiple myeloid cell lines. these abnormalities are most evident in the erythroid precursors with large megaloblastic erythroblasts present in increased numbers throughout the marrow. similar morphologic abnormalities can be seen in the other myeloid elements, e.g., large or giant metamyelocytes and other granulocytic precursors. this ineffective erythropoiesis is accompanied by intramedullary hemolysis causing an elevated lactate dehydrogenase and indirect bilirubin in the serum(14,15).however, the reticulocyte count is low due to the abnormal maturation process. more severe degrees of abnormal proliferation and maturation are seen with myelodysplasia and myeloid leukemias. it is imperative that a hematologist or hematopathologist examine the marrow in order to appreciate these important, subtle, hematopoietic abnormalities. patients with macrocytosis who are not anemic and have no other abnormalities noted on the peripheral blood smear do not usually need a bone marrow examination.macrocytosis is the earliest abnormality seen in complete blood counts of patients with folate or vitamin b12 deciency. in patients with elevated mcv values, laboratory tests for vitamin b12 and folate deciencies are routinely ordered by physicians, although these tests are limited by their low sensitivity and specicit.cobalamin and folate are cofactors in several important metabolic pathways in the cell. the hydroxylated form of cobalamin plays an important role in the metabolism of homocysteine and mma. the conversion of homocysteine to methionine requires both vitamin b12 and folate as cofactors. however, the metabolism of lmethylmalonyl coa to succinyl coa, an enzymatic pathway involved in oxidative phosphorylation reactions within the cell, only requires vitamin b12. these metabolites provide volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra early information regarding the cellular state of vitamin b12 and folate and can be used to distinguish folate from vitamin b12 deciency, since most patients with folate deciency have normal mma or mildly elevated levels. it should be kept in mind that nearly 50% of those with elevation of these metabolites will have normal serum vitamin b12 levels. holotc ii is an emerging marker that may be useful in establishing a diagnosis of early vitamin b12 deciency in cases where there is discordance between vitamin b12 levels and its metabolites, or in lieu of measuring vitamin b12, mma 41and/or homocysteine concentrations. holotc ii can also be used in cases of renal failure or myeloproliferative diseases in which vitamin b12 concentrations may be falsely elevated (30,31).holotc ii is a metabolically active protein that transports cobalamin to cell membrane receptors. its serum concentration can be used to measure the amount of vitamin b12 attached to the binding protein transcobalamin ii. compared to measurements of serum vitamin b12, holotc ii seems to have greater sensitivity and specicity. however, routine ordering of this test as part of the work-up to establish the diagnosis of vitamin b12 deciency is not currently recommended(16,17) patients with vitamin b12 deciency from any cause have received cyanocobalamin intramuscularly/ intravenous 1000 to 1500 μg/ alternate day for one week, , twice weekly 2 weeks and weekly for 1 month and monthly, thereafter. this timehonored method remains an acceptable form of treatment for all causes of vitamin b12 deciency, particularly when cognitive impairment or neurologic disease is present. alternatively, hydroxocobalamin given in the same dose every 1–3 months intramuscularly is also effective therapy. this form of cobalamin remains in the tissues longer than the cyanocobalamin forms and can, therefore, be given less 46frequently. in cases of deciency due to inadequate intake, food-cobalamin malabsorption and pernicious anemia, oral cyanocobalamin administered at 1000–2000 μg/day for 1 month, followed by 125–500 μg/day is recommended and 47considered a safe and effective method of treatment. other oral administration regimens have demonstrated efcacy and have proven to be equally as effective as intramuscular 48,49administration. because of the inherent unreliability of measuring either serum or rbc folate, it is recommended that patients receiving treatment for vitamin b12 deciency receive 27,45,51empiric folate supplementation of 400 �g/day to 1 mg/day. maintenance therapy should continue until the underlying cause of the deciency is corrected.in folate deciency, responds well to short-term treatment with oral 5mg twice daily or intravenous 50 mg twice daily in acute and severe deciency , especially in methotrexate toxicity. . long-term treatment is not warranted except with chronic conditions such as malnutrition, exfoliative dermatitis or hemolysis .a complete blood cell count 10–14 days after starting the treatment for vitamin b12 or folate deciency should reveal a rise in hemoglobin and a decrease in mcv. a full hematologic response should occur within 8 weeks. during treatment, further monitoring of the complete blood cell count or measuring vitamin b12 and folate levels or their metabolites is 52not necessary. in patients taking long-term treatment for vitamin b12 deciency, an annual complete blood cell count may be a reasonable consideration to monitor therapy. materials and methods: retrospective analysis of case records of all patients admitted and diagnosed as megaloblastic anemia was done. those with a diagnosis of aplastic anemia and myelodysplastic syndromes were excluded from the study. the data were collected, and multivariate analysis was done to determine the correlation between symptoms, signs, and hematological investigations. retrospective study of hematological, biochemical and bone marrow data of 25 patients of megaloblastic anemia were done in teaching medical colleges of bihar. salient clinical features were noted. relevant photomicrographs were taken of pbs and bone marrow slides of classical cases of megaloblastic. especial emphasis was given on cbc ndings and relevant cbc parameters were notated and tabulated. result: total 25 megaloblastic anemia cases were included in this retrospective study. male female ratio was 4:1 and age ranged from 12 years to 87 years . pancytopenia was seen in all cases. 21 patients had isolated vitamin b12 deciency. 3 patients had both folic acid and vitamin b12 deciency (table 1) .one had only isolated folic acid deciency. all patients had mcv 100 or more than 100 fl (table 1). majority showed hypersegmented neutrophils on pbs (figure 1). classical sieve like nuclei and giant metamyelomyelocytes are found in most (figure 2). bone marrow revealed cellular bone marrow with megaloblastic change in erythroid, granulocytic and megakaryocytic series in majority. however few revealed depressed megakaryopoiesis. patients who had severe anemia (hemoglobin <7 g %) was 22 (88%).all patients except one had moderate to severe thrombocytopenia (platelet count<1, 00,000/ µl.) figure: 1 figure: 2 figure: 3 x 45gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 1.cbc parameters in megaloblastic anemia case no. rbc hb mcv mch wbc plt b12 folic acid age/gender 1 2.5 5.9 110 40.2 3.4 50 112 12y/m 2 2.2 4.8 115 40.5 2.5 40 135 30y/m 3 3.0 5.0 108 39.5 2.0 35 120 23y/f normal range: b12: 211-911 pg/ml, folic acid :3.7-9.2mg/dl mcv: 833100fl ,mch: 27 -33%, platelets: 150-450x10 /µ l ,hemoglobin: (m) 12-15gm/dl, (f) 12-14gm/dl discussion: the adult age distribution and male predominance were expected given the demographics of vitamin b deciency in 12 hindu population of india. nutritional deciency of vitamin b12 is more common .drug induced folate deciency is more common .nutritional deciency of folic acid more commonly occur with vitamin b12 deciency, especially in alcoholic (19). low b levels are more common in vegans and alcoholic. 12 other causes of macrocytosis with or without anemia are hemolysis with reticulocytosis, drug-related macrocytosis, mds, or other neoplasm. myelodysplastic syndromes often present with pancytopenia, particularly 5q syndrome, present with a macrocytic anemia with normal platelet count or thrombocytosis. the dramatic treatment response of patients with full-blown vitamin b deciency occurs in 3 to 5 days.the 12 hypersegmented neutrophils were of no help in diagnosing vitamin b deciency. although most reports in the literature 12 stating that the presence of hypersegmented neutrophils on the peripheral blood smear is neither sensitive nor specic for this purpose(20,21). approximately 75% of serum b is bound 12 9to haptocorrin (transcobalamin i) whose function is unknown. therefore, total serum b levels largely reect b that is not 12 12 bio-available. total transcobalamin, consisting of holotc and apo-transcobalamin, is the major carrier protein in the plasma/serum that delivers b to the tissues.holotc should 12 more accurately reect intracellular b levels. if the vitamin b 12 12 level s borderline low, methylmalonic acid and homocysteine levels should be ordered and, if elevated, may provide evidence of b deciency.12 patients with vitamin b deciency may describe paresthesias 12 related to peripheral neuropathy. neurologic signs such as ataxia, decreased proprioception, and vibratory sensation are more common. patients may also have poor dentition or nonspecic oral stomatitis or glossitis. macrocytic anemia due to folic acid deciency is more common in drug induced bone marrow depression and in alcoholic .much less common is during pregnancy(23).other uncommon causes include diphyllobothrium latum (i.e., sh tapeworm) infection. only 10 percent of persons with vitamin b deciency are actually anemic (26.27).oral therapy 12 appears to be as effective as intramuscular therapy for the treatment of vitamin b deciency, nutritional type. however 12 intramuscular/intravenous b12 is more effective in pernicious anemia .relapse of pernicious anemia occurs at a mean interval of 65 months after cessation of treatment. it is important for patients to adhere to long-term therapy because the deciency will recur if treatment is stopped, unless a reversible cause is identied. conclusion: megaloblastic anemia is common cause of anemia amongst vegans and vegetarians .it is also common in alcoholic.serum b12 testing without a clear clinical indication should be avoided; ie, macrocytosis (usually with anemia) or (less commonly) neurologic signs or symptoms potentially referable to vitamin b deciency. we should obtain a vitamin 12 b level for every patient with an elevated mcv.we should 12 evaluate peripheral smear for megaloblastosis and perform a reticulocyte count in patients with suspected macrocytosis. order methylmalonic acid and homocysteine levels if vitamin b level is borderline low (i.e., 100 to 400 pg/ml. oral vitamin 12 b may be as effective as intramuscular therapy for vitamin b 12 12 deciency. obtain red blood cell folate level if other etiologies are not found, serum folate levels may be misleading. references: 1. chanarin i, metz j. diagnosis of 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[pmc free article] [pubmed] [google scholar] volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 47gjra global journal for research analysis introduction most drug companies appear to be employing marketing strategies that leave them open to various risks, including failing to clearly understand the target market, and wasting valuable time and resources (harris, 2001). the elevated costs for marketing are ascribed to the fact that most companies are not quite sure of the marketing technique that works best for them, therefore employing several methods, some of which are ineffective though costly. the improvement of pharmaceutical marketing strategies, policies, and regulations minimize healthcare cost on patients (chimonas, brennan & rothman, 2007). description ethical questions are always being asked. is it ethically permissible to provide free medicines to physicians (noordin, 2012)? it is substantial to mention that gifts whether cheap or expensive cost the pharmaceutical company money that will be added to the cost of medication (chimonas, brennan & rothman, 2007) that in return will have negative economic consequences on the patients. public policymakers should take prescription behavior more seriously by conducting prescription behavior studies at regular intervals, to specically understand the impact of tangible rewards on physicians' prescribing patterns and control unethical practices by both pharmaceutical companies and physicians. for example, studies can be conducted by the ministry of public health in collaboration with who. it is also recommended to fulll the need for establishing more detailed laws to regulate interactions between physicians and each one of the pharmaceutical marketing strategies used by drug companies. there should be rules and regulations where promotional materials offered to doctors are only limited to scientic materials. from another hand, the illusion that industry is a generous, avuncular partner to physicians is the cornerstone of a sophisticated, multifaceted process of pharmaceutical and medical device promotion. subconscious biases render physicians unable to assess the effects of conicts of interest. academic medical institutions need to counteract the medical profession's improper dependencies on the industry. herein, there is a need to enact strong policies and regulations to educate medical students at faculties about the social psychology underlying such manipulative marketing techniques and how to resist them (sah, moore & maccoun, 2013). a culture where the acceptance of gifts creates shame in physicians will make the practice of accepting gifts less common and mitigate the social norm of reciprocation. if a critical mass of respected physicians avoids being placed in positions of indebtedness to industry and if greater academic prestige accrues to an arms-length rather than to a close relationship with industry, in this case, a new social norm may emerge that rejects transactions if-aught with conicts of interest (goyal & pareek, 2013). that norm would promote rather than undermine patient care and scientic integrity. generally, physicians should take care to seriously consider the consequences of their cooperation with any drug company; overestimate rather than underestimate the effect that subtle social inuences may have on their clinical judgments, and make efforts to obtain information regarding drugs from independent and varied sources (lefer, 1981). physicians must resist industry inuence (sah & maccoun, 2013). the rst step toward increasing physicians' resistance to industry inuence is for them to understand and accept that they are individually vulnerable to subconscious bias. indeed, seminars increase physicians' and medical students' awareness of their susceptibility to industry marketing. the ministry of public health should continuously develop the ethical code based on the newly developed laws to control pharmaceutical promotional activities of professionals, and it has to put in place processes for implementation. local companies need to adopt policies similar to those of big international pharmaceutical companies which have two ethical centers, a medical department that imposes selection criteria for congresses and an audit ofce that checks and audits all expenses and activities. national companies are invited to self-impose their internal ethical codes which are beyond the lebanese law requirements, and they are invited to become members of the international federation of pharmaceutical manufacturers and associations (ifpma). also, because people do not attempt to avoid risks to which they do not consider themselves susceptible (brett, burr & moloo, 2003), it is highly recommended to be sure that all physicians are aware of the laws and the regulations when legislated. physicians should stay updated regarding any new laws, regulations, and guidelines. reminders to companies and physicians and pharmacies regarding this issue should be sent regularly. finally, pol icymakers have to control guidelines ' implementation to limit unethical promotion practices and unethical prescription patterns. we suggest implementing a reporting system that keeps track of physicians' prescription patterns, and their interactions with pharmaceutical companies. conclusion several variables must be taken into account while regulating the interaction between physicians and pharmaceutical companies in order to best serve the patients. it is highly recommended to not only set internal guidelines and regulations inside the drug companies as well as national and improvements of the relationship between physicians and drug companies original research paper dr. micheline khazzaka independent researcher medical science there is always a high need for more strengthening the ethical norms regulating the interaction between physicians and pharmaceutical industries. the improvement of policies and regulations minimize healthcare cost on patients. for this purpose, this paper proposes several guidelines. abstract keywords : cost, patients, pharmaceutical companies, physicians, regulations. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 70 x gjra global journal for research analysis international guidelines, but also to strictly implement them. references 1. brett, a. s., burr, w., & moloo, j. (2003). are gifts from pharmaceutical companies ethically problematic?: a survey of physicians. archives of internal medicine, 163(18), 2213-2218. 2. chimonas, s., brennan, t.a., & rothman, d.j. (2007). physicians and drug representatives: exploring the dynamics of the relationship. society of general internal medicine, 22(2), 184-190. 3. goyal, r., & pareek, p. (2013). a review article on prescription behavior of doctors, inuenced by the medical representative in rajasthan, india. iosr journal of business and management, 8(1), 56-60. 4. harris, i. (2001). closing the door on sample closets. minn med, 84(1), 17-20. 5. lefer, k. b. (1981). persuasion or information? the economics of prescription drug advertising. the journal of law and economics, 24(1), 45-74. 6. noordin, m.i. (2012). ethics in pharmaceutical issues, contemporary issues in bioethics. 7. sah, s., moore, d. a., & maccoun, r. (2013). cheap talk and credibility: the consequences of condence and accuracy on advisor credibility and persuasiveness, organizational behavior and human decision processes, 121( 2), 246-255 volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 71gjra global journal for research analysis surgical technique o shaped circular incisions were taken on both scrotal halves.subcutaneous dissection was performed on both sides till adequate mobilization of both scrotal aps.t shaped incision was taken at intervening skin just proximal to hypospadiac urethral meatus and subcutaneous tissue dissection done till adequate margins raised.then both the scrotal aps were brought posterior to penis and more caudal [figure 1, 2,3] all incisions were closed primarily with good tissue approximation [figure 4].urinary diversion and pressure dressing were given for 5 days. hypospadias repair was done after 6 months. no patient had any complications like penile lymphoedema,ap necrosis or infection. satisfactory anatomical, cosmetic and functional results were obtained in most of the patients. the follow up period ranged from 6 to 18 months. complications include only urethral stulas in 2 patients (9%) that was successfully treated with repeated dilatations and no patient required redo surgery. in this technique, no circumferential incision of the skin around the penile base was taken. in fact, whole penile skin left attached to skin of mons pubis. there was almost nil post operative edema and rapid wound healing. figures figure 1 figure 2 penoscrotal transposition with hypospadias: hambarde`s technique of o-t-o plasty original research paper dr. sandeep r. hambarde* paediatric surgeon, ramkrishna hospital, n 5, cidco,aurangabad, india *corresponding author x 123gjra global journal for research analysis surgery background/ purpose: penoscrotal transposition , partial or complete is result of positional exchanges between the penis and the scrotum. earlier correction of penoscrotal transposition was done transposing the penis to a neo hole created in the skin of mons pubis or creating scrotal rotational aps and bringing them caudal to penis. modied glenn anderson's method is commonly used. this method is known to cause major penile lymphoedema following surgery due to circular incision around the root of the penis that delay correction of the frequently associated hypospadias and increase the incidence of complications. we used novel method to correct 22 cases of penoscrotal transposition i.e.hambarde`s technique of o-t-o plasty. this method has given excellent cosmetic and functional outcome,allowed early surgical correction of hypospadias after 6 months with almost nil complications. material and methods we retrospectively reviewed 22 patients ,age ranging from 2 to 23 years that underwent two-stage repair for penoscrotal transposition with hypospadias. the operative principle was based on achieving a normal anatomical position of the penis and scrotum using a novel method i.e. hambarde`s technique of o-t-o plasty. all cases were associated with midpenile or penoscrotal hypospadias. hypospadias correction was performed after a period of 6 months with onlay tube urethroplasty. 7 patients were having unilateral undescended testis and 1 patient was having unilateral inguinal hernia. results cosmetic and functional results of hambarde`s technique of o-t-o plasty were excellent. no major complications were observed. of 22 patients, only 2[9%] had stula after hypospadias repair. conclusion hambarde`s technique of o-t-o plasty for reconstruction of penoscrotal transposition is a simple technique, free of major complications. the purpose of this innovative method is to improve functional outcome and cosmetic appearance of the penis. a minimum period of 6 months between consecutive urethroplasties is important. preserving the prepuce and making its use for subsequent urethroplasty after 6 months gives excellent short term and long term outcome. abstract keywords : penoscrotal transposition,hypospadias,hambarde`s technique , o-t-o plasty dr. ashwini s. hambarde gynaecologist, ramkrishna hospital,n 5,cidco,aurangabad, india dr. thavendra dihare paediatric surgeon,wardha sawangi, india volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 124 x gjra global journal for research analysis figure 3 figure 4 discussion penoscrotal transposition results from abnormal genital tubercle development with delay in the midline fusion of the urethral folds. 90% patients had associated anomalies like hypospadias, chordee,undescended testis and renal agenesis . imperforate anus may present in some cases.1,2,3 differential diagnosis must include pseudohermaphroditism, penoscrotal hypospadias, micropenis, intrauterine penile amputation and penile agenesis with a midline skin tag anterior to the anus. surgery of more complex cases of penoscrotal transposition is technically challenging.4,5,6,7,8 various surgeries have been advocated by many surgeons. mcllvoy and harris rst performed surgery to move the penis into a more cranial position through a subcutaneous tunnel beneath the prepenile scrotum. forshall and rickham used a 9 different technique in two patients in whom the cranially located scrotal aps were elevated, rotated medially and caudally and sutured beneath the penis. this method was 10 also used by glenn and anderson. the technique was later 11 modied by dresner in 1982. mark and his colleagues in 12 2000 presented a radically divergent view of penoscrotal 13 transposition stating that the penis and not the scrotum was malpositioned. they transferred the penis after straightening into a button hole designed in the skin of the mons-pubis. complications of penoscrotal transposition include urethral and testicular injury, urinary stula, ap necrosis and penile edema. circular incision at the root of the penis partially compromises lymphatic drainage, which may interfere with healing of the neourethra. majority of the studies showed 14 signicant number of complications like arena . study in et al 2005 showed 38% complications in their work, glassberg 15 et 16al et al. in 1998 reported 50% complications and koyanagi . in 1994 found 48% complications in their work. all of them used 17 same technique with hypospadias correction in the same stage. hence, to reduce the complications, we planned hypospadias correction at later date. glenn-anderson technique left gross penile edema with dark pigmentation later on. saleh et al. demonstrated a 10% 18 complication rate by just preserving the dorsal strip of penile skin. we have modied it with o shaped circular incisions on 18 both scrotal halves and t shaped incision at intervening skin just proximal to hypospadiac urethral meatus. penile base was left intact.hence completely avoided complications like penile lymphoedema,ap necrosis or infection none of our patients had signicant edema and all were discharged on 7th post-op day. penoscrotal transposition is a rare congenital anomaly often with severe hypospadias and other genital anomalies. surgical correction of these anomalies is technically demanding and should be done in stages. with our experience of 22 cases of penoscrotal transposition by o-t-o plasty,this method is completely free of complications like penile edema,ap necrosis and infection.this supple and untouched prepuce can be more useful in future chordee correction and onlay tube repair.we can authenticate that this is the best repair technique cosmetically and functionally. references 1. pinke la, rathbun sr, husmann da, kramer sa. penoscrotal transposition: review of 53 patients. j urol . 2001;166:1865–8 2. glenn j, anderson e. surgical correction of incomplete penoscrotal transposition. j urol. 1973;110:603–5 3. ehrlich r, scardino p. surgical correction of scrotal transposition and perineal hypospadias. j pediatr surg. 1982;17:175–7 4. glassberg k, hansbrough f, horowitz m. the koyangi-nonomura1-stage bucket repair of severe hypospadias with and without penoscrotal transposition. jurol. 1998;60:1104–7 5. mori y, ikoma f. surgical correction of incomplete penoscrotal transposition associated with hypospadias. j pediatr surg. 1986;21:46–8 6. levy j, darson m, bite u, kramer sa. modied pudendal-thigh ap for penoscrotal transposition. urology. 1997;50:597–600. 7. kolligian me, franco i, reda ef. correction of penoscrotal transposition: a novel approach. j urol. 2000;164:994–7. 8. méndez-gallart r, tellado mg, somoza i. extreme penoscrotal transposition. world j pediatr. 2010;6:89. 9. mcllvoy db, harris hs. transposition of the penis and scrotum: case report. j urol. 1955;73:540–3. 10. forshall i, rickham pp. transposition of the penis and scrotum. br j urol. 1956;38:250–213. 11. glenn jf, anderson ee. surgical correction of incomplete penoscrotal transposition.j urol. 1973;110:603–5. 12. dresener ml. surgical revision of scrotal engulfment. urol clin north am. 1982;9:305–10 13. kolligian me, franco i, reda ef. correction of penoscrotal transposition: a novel approach. j urol. 2000;164:994–7 14 . germiyanoglu c, ozkardes h, altug u et al.reconstruction of penoscrotal transposition. br j url.73:202-3,1994. 15. arena f, romeo c, manganaro a, arena s, zuccarello b, romeo g. surgical correction of penoscrotal transposition associated with hypospadias and bid scrotum: our experience of two-stage repair. j pediatr urol. 2005;1:289–4. 16. glassberg ki, hansbrough f, horowitz m. the koyanagi-nonomura 1-stage bucket repair of severe hypospadias with and without penoscrotal transposition. j urol. 1998;160:114–7. 17. koyanagi t, nonomura k, yamashita t, kanagawa k, kakizaki h. one-stage repair of hypospadias: is there no simple method universally applicable to all types of hypospadias? j urol. 1994;152:1232–7. 18. saleh a. correction of incomplete penoscrotal transposition by a modied glenn-anderson technique. afr j paediatr surg . 2010;7:181–4. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction clinical pathways, common in many health care organizations throughout the world, are best described as planned and systematic detailing of the usual patterns of care for a patient with a specic disease or diagnosis. clinical pathways are paths that health professionals can follow that should enable them to provide the best possible outcome for patient, the health care team, and health care organization. need of the study harry et al suggested that the ideal clinical pathway should includes medical notes with care plan for nursing staff and allied health professionals for reducing redundant information and improves the understanding of the roles of other disciplines. (harry et al, 1998) nurse's have a key role in all aspects of clinical pathway use. nurse's participation is essential for successful impleme ntation of clinical pathways, and ultimately, the opportunity to improve patient care. (brunner, 2004) asthma affects an estimated 25,000,000 indians every year and this number is likely to increase by 50% by the year 2016. copds and asthma account for nearly 1.5 % of total disease burden in the country. among adults, women have a 30 % greater prevalence of asthma than man. yet there are over 4000 deaths per year from asthma. (lewis, 2011) hence it would be benecial if a study is conducted among the staff nurses, to assess effect of teaching on clinical pathway of respiratory diseases like asthma, chronic obstructive pulmonary disease (copd), and pneumonia. this would help in bringing the need for clinical pathway awareness among nurses on the need & importance. statement of the problem “a study to assess the effect of teaching on knowledge regarding the clinical pathway of selected respiratory diseases among staff nurses working in selected hospitals of pcmc, pune.” objectives of study 1) to assess the level of knowledge of staff nurses regarding clinical pathway of selected respiratory diseases. 2) to assess the effect of teaching regarding knowledge of clinical pathway of selected respiratory diseases among staff nurses. 3) to correlate the knowledge score regarding clinical pathway with selected demographic variable of staff nurses. hypothesis h : there will be no signicant difference between the pre & 0 post test knowledge score on clinical pathway among staff nurses. research methodology research design a preexperimental pre and post test study design used for the present study. sample, sample size and sampling technique the 60 sample were selected for the present study by using non probability convenience sampling technique. development & description of the tool after an extensive review of literature and discussion with experts the tool was developed. the tool was divided into two parts section 1: consist of ve items for obtaining the base line information of the staff nurses regarding age, gender, educational qualication, years of experience, area of experience and sources of knowledge on clinical pathway of selected respiratory diseases. section 2: consist of 20 items of structured knowledge questionnaire, which covers the following categories, clinical pathway, clinical pathway of asthma, chronic obstructive pulmonary disease (copd) pneumonia. and role of nurse in clinical pathway based care. the areas covered in teaching were: clinical pathways of asthma, copd, pneumonia and role of nurse in clinical pathway based care scoring procedure: each correct answer carried one score and the total score of the structured knowledge questionnaire was 20. validity and reliability to ensure the content validity of the tool, the structured knowledge questionnaire and lesson plan was submitted to 18 experts. the opinion and suggestions were considered and tool was prepared. to check the reliability of the tool, it was clinical pathway of selected respiratory diseases among staff nurses working in hospitals of pcmc, pune original research paper mrs. banashankari p hiremath m.sc nursing assistant professor, dr. hedgewar college of nursing aurangabad. maharashtra, india. nursing clinical pathways are care plans developed collaboratively by physicians, nurses, physical therapists, technicians, pharmacists, speech therapists, case managers, and other staff members involved in patient care. nurses are instrumental in ensuring the successful use of clinical pathways and can best contribute by gaining a thorough understanding of why and how pathways are used. hence, a study was conducted to assess the effect of teaching on knowledge regarding the clinical pathway of selected respiratory diseases among staff nurses working in selected hospitals of pcmc, pune. a pre experimental one group pre test-post test was adopted for the study. a non probability convenient sampling technique was used to draw 60 samples. the data was collected by using structured knowledge questionnaire with 20 items. major findings of the study depict that mean difference between the post-test (18.2) & pre-test (9) was signicant (t(59)=44.2;p<0.05). the study concluded that teaching was effective in increasing the knowledge of staff nurses on clinical pathway of selected respiratory diseases. abstract keywords : clinical pathway, teaching, respiratory diseases, staff nurses. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 28 x gjra global journal for research analysis administered to 10 samples as per the criteria. reliability was assessed using test-retest method. pearson's correlation coefcient was found to be 0.99. data collection formal written permission was obtained from the medical superintendent selected hospitals of pcmc area pune. a pretest was conducted by using structured knowledge questionnaire; on same day teaching was administered to the thsubjects. post-test was conducted on 7 day. data analysis and interpretation the study reveals that, most of the nurses 71.7% were from the age group 21-30 years and 16.7 % were from 41-50 years. majority 75% were female and 25% were male. 61.7% were from medicine ward and 28.3% were from icu. table no 1 distribution of knowledge score among staff nurses table 1shaows paired t test value to compare difference between average scoring of before and after teaching. since p value is less than 0.05 (p value = 0.000) difference in average scores is statistically signicant. there is 5% level of signicance and 59 degrees of freedom that the above data gives sufcient evidence that staff nurses after receiving teaching regarding clinical pathway of selected respiratory diseases had higher mean knowledge scores in post-test than in pre-test. hence the null hypothesis is rejected and research hypothesis is accepted. it can be concluded that, the teaching on clinical pathway of selected respiratory diseases among staff nurses was effective. bar diagram showing area-wise mean pretest and posttest knowledge score on clinical pathway none of the demographic variable was found to have signicant association with pretest knowledge score. recommendations: based on the ndings of the present study the following recommendation is made: 1. similar study can be conducted to assess the practice of staff nurses on clinical pathway. 2. a similar study may be conducted to teach clinical pathway other respiratory diseases. 3. similar study can be conducted to assess the practice of staff nurses on clinical pathway. references 1. brunner and suddarth (2004), text book of medical surgical nursing, lippincott williams and wilkins publication, 10th edition, pp 492-595. 2. gail p.poirrier & melinda g.oberleitner, 1999‘clinical pathway in nursing’ springhouse publication, st,edition,pp:1-5. 3. harry et al (1998), “integrated care pathways” british medical journal, vol, 316, d.o.p,10 jan,1998.pp:133-137. 4. lewis’s (2011) ‘medical-surgical nursing’ elsevier publication, 7th edition, pp608-632. 5. nicasio am,2010 et al (2010), ‘pharmacodynamic-based clinical pathway for empiric antibiotic choice in patients with ventilator-associated pneumonia’, journal 2010 mar;25(1):69-77. epub 2009 may 7. 6. nishimura et al, (2011), ‘a prospective study clinical pathway for acute exacerbations of chronic obstructive pulmonary disease: method development and ve years of experience’, international journal of copd, 2011; 6: 365–372, published online 2011 june 29. doi:10.2147/copd.s20423 7. sciartelli c (1995), ‘a study using a clinical pathway approach to document patient teaching for breast cancer surgical procedures’, oncology nursing forum, 1995 jan-feb;22(1):131-7. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra test mean sd t df p-value pretest 9.0 2.3 44.2 59 0.000 posttest 18.2 1.0 x 29gjra global journal for research analysis introduction: obesity is a condition in which excess body fat has accumulated to such an extent that health may be negatively affected. it is commonly dened as a body mass index (bmi = 2weight divided by height squared) of 30 kg/m or higher. circulating plasma crp levels are elevated in obese subjects. the reference range of crp is 0-10mg/l. for most clinical purposes, crp value less than 0.1 or 0.2 mg/dl can be regarded as normal value, over 1.0 as indicating clinically signicant inammation, value between 0.2 and 1.0 mg/dl may reect minor degree of inammation but may also reect obesity, cigarette smoking, and diabetes mellitus. 3 months walking exercise was associated with low crp levels independent of body fat in the healthy subjects. this study was conceptualized to get an idea regarding the effect of exercise on crp level in indian patients with obesity. review of literature obesity is a condition where excess body fat accumulates in the body in such a way that health may be affected negatively. it is commonly dened as a body mass index (bmi = weight 2divided by height squared) of 30 kg/m or higher. obesity is also dened as purely statistical grounds as a weight that is 20% or more above the average weight per height.the absolute waist circumference (>102 cm in men and >88 cm in women) or waist–hip ratio (>0.9 for men and >0.85 for women) are both used as measures of central obesity. body fat percentage is total body fat expressed as a percentage of total body weight. body fat % = 1.2 ×bmi + 0.23 × age − 5.4 − 10.8 × gender, where gender is 0 if female and 1 if male, ). obesity on average reduces life expectancy by 6–7 years. severe obesity (bmis >40) reduces life expectancy by 20 years for men and 5 years for women , excess weight is responsible for 64% of cases of diabetes in men and 77% in women. circulating plasma crp levels are elevated in obese subjects. c-reactive protein--named for its capacity to precipitate the somatic c-polysaccharide of streptococcus pneumoniae was the rst acute-phase protein to be described and is an exquisitely sensitive systemic marker of inammation and tissue damage. the close correlation between the degree of obesity and crp levels in cross-sectional and prospective epidemiological studies has led us to hypothesize that adipose tissue is a potential source of crp. aims and objective: to study the effect of aerobic exercise on the c reactive protein level in obese patients. materials and methods type of study: prospective follow-up study study population: consecutive obese patients (bmi >30) of either sex, aged between 18 years to 50 years. selection of cases: it was decided to include a minimum of 30 obese consecutive patients (bmi>30) that was considered to be a feasible minimum sample size required for such a study. place of study: pmr department, pmch patna period of study: november 2018 to october 2019. inclusion criteria: 1. obese patients of both sexes. 2. age group of 18 50 years. 3. patients who understand and agree to follow the exercise program. exclusion criteria: 1. patients suffering from inammatory conditions or diseases which may change the serum crp level like vasculitis and inammatory arthritis, infection and cancer etc. 2. patients who are on medical therapy for obesity. 3. patients in whom exercises are contra-indicated. 4. patients who smoke & consume alcohol. methodology: the patients' demographic prole like age, sex, education, occupation and type of treatment was recorded. then proper history and examination was performed and patients with illness and associated diseases which might affect the crp level were excluded and assessed baseline investigations like height, weight, bmi, fat mass, fat %, fat free mass and bmr by body composition analyzer and serum crp was measured, following blood examinations were done hb, effect of exercise on the creactive protein level in obese indian patients original research paper dr sumant kumar singh asst. professor, dept. of physical medicine and rehabilitation, patna medical college & hospital, patna general medicine obesity has been recognized as an epidemic worldwide due to changes in lifestyle, unhealthy food-habit and lack of health knowledge among the population and linked to a large number of diseases. for 2 2.asians, overweight is a bmi between 23 and 29.9 kg/m and obesity a bmi >30 kg/m obesity is a state of excess adipose tissue mass. adipose tissue is an active endocrine and paracrine organ that releases a large number of cytokines and bioactive mediators, eg tnf-�, il-6, crp etc. the study of 3 months walking-exercise interventions on 33 obese patients showed that 65% reduction of crp were due to changes in fat mass and fat free mass. these are the most important candidate factor for reduction of crp after 3 month of intervention. there were some other factors responsible for reduction in crp, which might be weight and bmi and independent of other base line investigations. in addition, more studies are needed to assess the effects of different modes and intensities of exercise oncrp. abstract keywords : obesity, bmi (body mass index), crp (c-reactive protein), exercise. dr. poonam singh* junior resident, dept. of forensic medicine, patna medical college & hospital, patna *corresponding author dr arun kumar associate professor & hod , dept. of physical medicine and rehabilitation, patna medical college & hospital, patna volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 12 x gjra global journal for research analysis it was noticed that, there was 26.2% signicant reduction in creactive protein value, 2.55% reduction in weight, 2.72% reduction in bmi, 4.83% reduction in fat mass and 3.92% reduction in fat free mass after 3 month of intervention, but there was no signicant changes seen in other parameters like fat percentage, bmr, hb, tlc, dlc, esr, sgot, sgpt, serum urea, serum creatinine. change of crp with different variables: there was no signicant change (p-value=0.31) in crp among the male and female, different occupation (pvalue=0.55) and among the medical ailments (p-value 0.265). we found that the changes of crp value correlated positively with changes of weight (d crp=0.368), fat mass (d crp=0.528), fat free mass (d crp=0.323). these data indicate that signicant reduction in crp values were mainly associated with reduction in weight (p-value=0.035), fat mass (p-value=0.002) and fat free mass (p-value=0.047). but there was no correlation of changes in crp values with changes of others variables. as per the who classication of obesity according to the body mass index (bmi), the majority of patients belonged to class 1 obesity (bmi=30-34.9) that is 23 patients (69.7%), 10 patients (30.3%) in class 2 obesity (bmi=35-39.9) and there was no patient in class 3 obesity (bmi>40) in our study as depicted in table 2 so the reduction of crp values were not signicantly associated with change of bmi (p-value=0.073), fat % (pvalue=0.125), bmr (p-value=0.154), hb (p-value=0.07), tlc (p-value=0.613), neutrophil (p-value=0.499), lymphocyte (pvalue=0.839), eosinophil (p-value=0.256), esr (pvalue=0.90), sgot (p-value=0.878), sgpt (p-value=0.812), serum urea (p-value=0.708), serum creatinine ( pvalue=0.176) discussion: this prospective follow-up study was designed to assess the changes in crp levels after 3 months of walking, aerobic exercise regimen in obese patients of different age, sex, occupation and associated physical ailments. there were no signicant difference in the change of crp volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra item time of assessment 0 month 3 month p value mean difference±sd percentage change mean±sd mean±sd crp 10.15±15 7.49±3.12 <0.001 2.66±2.14 26.20 weight 80.67±9.4 78.60±9.86 <0.001 2.06±1.60 2.55 bmi 33.73±3.34 32.8±3.43 <0.001 0.92±0.71 2.72 fat mass 32.48±5.91 30.90±6.61 <0.001 1.57±1.93 4.83 ffm 46.37±8.33 46.55±7.74 <0.001 1.82±2.14 3.92 bmr 1665.1±774.2 1657.2±777.9 0.141 7.84±29.83 0.47 hb 12.37±1.12 12.47±1.12 0.432 0.103±0.74 0.83 tlc 7660.6±1852 7722±2037.7 0.793 62.36±1352.7 0.81 nuetrophil 67.42±7.47 68±7.17 0.499 0.66±5.59 0.97 lymphocyte 31.36±5.86 31.18±4.41 0.839 0.182±5.10 0.58 eosinophil 2.26±0.81 2.45±0.90 0.256 0.218±1.05 9.2 esr 23.97±12.3 22.52±10.84 0.138 1.45±5.48 6.04 sgot 31.30±12.30 32±12.03 0.674 0.69±9.44 2.20 sgpt 34.42±16.22 31.94±12.52 0.188 2.48±10.61 7.20 s.urea 24.55±7.54 25.34±6.85 0.472 0.78±6.18 3.17 s.creatinine 0.73±0.16 0.70±0.14 0.171 0.03±0.15 4.10 table1: distribution of continuous variables (paired t-test): total / differential blood count, esr, sgpt, sgot, serum urea and creatinine and c reactive protein. interventions: the patients were asked to follow an aerobic walking programme in addition to the normal activity. the total time of walking suggested was 25 minutes every day, at least 5 days a week for the rst month, 30 minutes each day in the second month and to 35 minutes in the third month. the patient's aerobic walking program consisted of, warm up period walking slowly for 5 minutes, target zonewalking briskly for st nd rd15, 20 and 25 minutes in 1 , 2 and 3 month respectively and cool down periodwalking slowly for 5 minutes. statistical analysis: this was a prospective follow up study with one follow up after baseline values. paired t-test was used to see the signicant change in baseline at the end of 3 month follow-up after intervention and to test the mean difference changes between 3 month from baseline (0 month) by using spss15 software and level of signicance was xed at p value of <0.05%. observation and results: all the 33 obese patients who had completed the study were advised for some baseline investigations like wt., bmi, fat mass, fat free mass, fat percentage, bmr, hb, tlc, dlc, esr, sgot, sgpt, serum urea, serum creatinine along with crp, at zero month (time of rst visit). after 3 month of intervention, above investigations were done again, the results obtained were depicted in table 1. it was found that, there was signicant change seen in the following parameters: crp (p-value<0.001), weight (p-value<0.001), bmi (p-value<0.001), fat mass (p-value<0.001), fat free mass (p-value<0.001) but no signicant changes were seen in others parameters like bmr (p-value=0.141), hb (pvalue=0.432), tlc (p-value=0.793), neutrophil (pvalue=0.499), lymphocyte (p-value=0.839), eosinophil (pvalue=0.256), esr (p-value=0.138), sgpt (p-value=0.674), sgot (p-value=0.188), serum urea (p-value=0.472), serum creatinine (p-value=0.171) after 3 month of walking aerobic exercise regimen. 30-34.9 class 1 23 69.7 35-39.9 class 2 10 30.3 >40 class 3 0 0 total 33 100 bmi classication of obesity no. of patients (n) percentage table 2: the distribution of no. of patients according to bmi x 13gjra global journal for research analysis values in male and female, different ages of patients, different occupation, change of physical ailments, different grade of obesity in our study. change of crp with other variables: all the 33 obese patients undertake baseline investigations like wt., bmi, fat mass, fat free mass, fat percentage, bmr, hb, tlc, dlc, esr, sgot, sgpt, serum urea, serum creatinine along with crp, at 0 month and after 3 month of intervention, there were signicant changes in the following parameters likecrp (p-value<0.001), weight (p-value<0.001), bmi (pvalue<0.001), fat mass (p-value<0.001), fat free mass (pvalue<0.001) but no signicant change seen in others parameters like bmr, hb, tlc, neutrophil, lymphocyte, eosinophil, esr, sgpt, sgot, serum urea, serum creatinine after 3 month of walking aerobic exercise regimen. in our study, the average decrease in crp, the best overall marker of underlying chronic inammation was (2.66mg/dl). the mean weight loss because of the exercise intervention was 2.06 kg. it was noticed that, there were 26.2% reduction in c-reactive protein value, 2.55% reduction in weight, 2.72% reduction in bmi, 4.83% reduction in fat mass and 3.92% reduction in fat free mass after 3 month of intervention, but there were no signicant changes seen in other parameters. in a study by laurie barclay et al, in those patients who received exercise intervention, the overall weight loss was minimal (~1.8 kg). there were linear trends between crp levels and 12-month changes in aerobic tness (p = .006), trend exercise adherence (p = .004), percentage body fat (p = trend trend .002), body weight (p = .002), wc (p = .02), and intra-trend trend abdominal fat (p = .03). unfortunately, no data are trend availableregarding the clinical manifestations of this decline in crp, although 15% reduction in crp after 1 year of statin use is associated with a lowered risk of coronary events. although our ndings indicate that exercise induced weight loss can be advocated as an effective therapy for reducing chronic inammation, our study did not test whether this reduction is associatedwith an improvement in risk factors for diseases associatedwith inammation. in consistentwith our ndings, the results of previous study, 12 wk of aerobic exercise in patients with stable congestive heart failure reduced tnf & crp concentrations, and improvements in physical performance (6-minute walk) correlated with the reductions in tnf . the data from our study indicate that signicant reduction in crp values were mainly associated with reduction in weight (p=0.035), fat mass (p=0.002) and fat free mass (p=0.047). but there was no correlation of change in crp value with changes of others variables. so the reduction of crp values were not signicantly associated with change of bmi, fat %, bmr, hb, tlc, dlc, esr, sgot, sgpt, serum urea and serum creatinine. the data, calculated by stepwise multiple regression technique shown that 65% reduction of crp were due to changes in fat mass and fat free mass. conclusions the results of 3 months aerobic-exercise interventions on 33 obese patients showed weight-loss, decrease in fat mass, and reduction in the circulating concentrations of crp. the change in crp levels were strongly correlated with the changes in fat mass and fat free mass and partially dependent of the changes in body weight and bmi, and independent of other base line investigations. limitation of study: the study, being conducted over a period of 3 months only may show the short term benecial effects of aerobic exercise and lifestyle changes on the body composition and the risk factors for various life-style related diseases. moreover the number of patients enrolled in the study was small to predict a very signicant or powerful inference. in our study, there were no control group for comparing the results with the study group. so, the extent of benets due to the exercise and lifestyle interventions cannot be quantied. and we could not verify whether the compliance of the patients as they reported matched with that of what they really followed. references 1. laurie barclay. one-year exercise program may reduce crp in obese postmenopausal women, medicine & science in sports & exercise july 2009; 24:120-125. 2. moldoveanu ai, shephard rj, shek pn. the cytokine response to physical activity and training. sports med 2001; 31:115–44. 3. ford, es. does exercise reduce inammation, physical activity and c-reactive protein among u.s. adults, epidemiology 2002; 13:561-568. 4. world health organization, technical report series 894: obesity, preventing and managing the global epidemic, geneva: world health organization 2000; 92-4-120894-5. 5. hill jo, melanson el. overview of the determinants of overweight and obesity: current evidence and research issues. med sci sports exerc 1999; 31:515-21. 6. mohamed ali v, pinkney jh and coppack sw. adipose tissue as an endocrine and paracrine organ. int j obes relat metab discord 1998; 22:1145-1158. 7. ferroni p, basili s falco a and davi g. inamation, insulin resistance and obesity. curr atheroscler rep 2004; 6:424-431. 8. ridker pm, buring je, cook nr and rifai n, c reactive protein, the metabolic syndrome and risk of incident cardiovascular events, circulation 2003; 107:391-397. 9. pradhan ad,manson je, rafai n, buring je and ridker pm. c-reactive protein and il6 and risk of developing type 2 dm. jama 2001; 286:327-334. 10. ridker pm.clinical application of c-reactive protein for cardiovascular disease and prevention. circulation 2003; 107:363-369. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 14 x gjra global journal for research analysis introduction cholestasis is dened as defect in bile secretary mechanism leading to accumulation of substances in blood, which are (1)normally excreted in bile. histologically, cholestasis is presence of visible bile in tissue sections. normally liver biopsy does not show presence of bile, if present it is always pathological. cholestasis can be either intrahepatic or extrahepatic. extrahepatic causes are mostly diagnosed with radiological (1)investigations like usg, ct and mri. (2)liver biopsy is indicated in intrahepatic cholestasis. the systemic approach to reach the diagnosis in a patient with suspected cholestasis should be in the following manner: 1. firstly, thorough history followed by physical examination 2. laboratory investigations 3. abdominal imaging – usg, ct, mri 4. serology studies and 5. lastly, liver biopsy aims and objectives a. to evaluate patterns of intra-hepatic cholestasis on liver biopsy in adults. b. to study probable etiology of intrahepatic cholestasis. c. to determine the association between patterns of intrahepatic cholestasis and etiology. materials and methods retrospective observational study over a period of 5 years january 2011 to december 2015. institutional ethics committee clearance was obtained. sample size – 70 inclusion criteria: ÿ all adult liver biopsies showing intrahepatic cholestasis in which complete clinical information was available. exclusion criteria ÿ extra hepatic cholestasis ÿ all patients with malignancy showing cholestasis ÿ patient with inadequate biopsy specimen ÿ paediatric biopsy specimens ÿ biopsy with cholestasis but without any clinical information already processed & stained slides of liver biopsy referred to principal investigator showing intrahepatic cholestasis were reviewed. review was done by the principal investigator in blinded fashion (without knowing the clinical ndings, laboratory and radiological investigations) and thereafter viewed by coinvestigator. liver biopsy in case of cholestatic disease shows many changes in the portal tract as well as in the liver parenchyma. changes in the portal tracts like portal tract oedema, duct loss, ductopenia, portal tract proliferation, neutrophils around proliferating ducts, ductular epithelial changes and periductal brosis were noted. changes in the parenchyma namely feathery degeneration, ballooning degeneration, ground glass hepatocytes, mallory bodies, steatosis, brosis and cirrhosis were looked for. site of cholestasis that is whether it is at the level of hepatocytes (gure1), bile canaliculi (gure2) and/or bile (2)ductules (gure 3) was mentioned. figure 1:hepatocytes showing intracytoplasmic choles tasis (h&e 400x) figure 2: canalicular cholestasis (h&e 400x) patterns of intrahepatic cholestatsis on liver biopsy original research paper dr reema rana x 47gjra global journal for research analysis pathology histologically, cholestasis is presence of visible bile in tissue sections. normally liver biopsy does not show presence of bile, if present it is always pathological. cholestasis can be either intrahepatic or extrahepatic. extrahepatic causes are mostly diagnosed with radiological investigations like usg, ct and mri. liver biopsy is indicated in intrahepatic causes of cholestasis. intrahepatic cholestasis on liver biopsy shows four patterns namely acute cholestasis with large duct obstruction, bland cholestasis, intrahepatic bile duct loss or ductopenia and cholestasis associated with hepatitis. these four patterns are derived based on the histological changes seen in liver parenchyma and portal tract. summary: we have studied different patterns of intrahepatic cholestasis and shortlisted a number of probable etiologies. in addition to the patterns of intrahepatic cholestasis, we also studied other histologic features seen in the liver parenchyma and portal tract and correlated our ndings with clinical history, laboratory investigations and radiological investigations to reach a nal diagnosis. abstract keywords : cholestasis, intrahepatic, patterns dr rakesh shedge* *corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 48 x gjra global journal for research analysis figure 3: cholestasis in bile ductules (h&e 400x) above ndings were formulated as present or absent and based on the ndings, liver biopsies were divided into four (3)patterns 1. acute cholestasis in large duct obstruction 2. bland cholestasis 3. intrahepatic bile duct loss/ductopenia 4. cholestasis associated with hepatitis (viral hepatitis, autoimmune hepatitis, drugs) results and discussion acute cholestasis with large duct obstruction included 2 cases of psc (primary sclerosing cholangitis) and sepsis each. these 2 cases of psc showed prominent ductular reaction, moderate to severe degree of intracytoplasmic and canalicular cholestasis, with one case showing periductal brosis and other case showing ductular epithelial changes, probable diagnosis based on these ndings were pbc (primary biliary cirrhosis), psc and sepsis. on unveiling of clinical examination, laboratory investigations and radiological ndings these cases revealed raised serum alp (alkaline phosphatase) and ggt (gamma glutamyltr ansferase) levels with p-anca positive in both case, no ihbrd (intrahepatic biliary radicle dilatation) was seen in both the cases so nal diagnosis given was psc. the other two cases also showed ductular reaction with signicant neutrophilic inammatory inltrate in portal tracts forming abscess in portal tracts with severe degree of bile ductular cholestasis. the probable diagnosis given on histological examination were pbc, psc, sepsis and overlap syndrome but clinical and radiological correlation revealed a raised ast/alt, ggt, alp, bilirubin with hepatolithiasis which led us to the nal diagnosis of sepsis with features of large (5)duct obstruction. bland cholestasis pattern showed normal portal tracts with mild to moderate inammation, few parenchymal changes like steatosis, copper deposition and moderate to severe (6)degree of canalicular and cytoplasmic cholestasis. the differential diagnosis given based on histologic picture were bric (benign recurrent intrahepatic cholestasis), dili (drug induced liver injury), sepsis and wilson's disease. the nal diagnosis of bric was given in patients who had recurrent episodes of jaundice, complain of severe pruritus, positive history of similar complains in family members, raised alp but normal ggt levels with no history of intake of drugs or pregnancy. diagnosis of dili under bland cholestasis was given in cases which had above mentioned histologic features with positive history of intake of anabolic steroids and oc pills (drugs showing bland cholestasis). diagnosis of wilsons disease under above mentioned category was given in patients which in addition to above ndings showed variable degree of cirrhosis, piecemeal and (8)panlobular necrosis with positive stains for copper (orcein). pattern showing duct damage and duct loss included 8 cases of pbc, 6 cases of psc, 2 cases of dili, 4 cases of overlap syndrome and 1 granulomatous hepatitis. cases of pbc showed ductopenia, duct damage with few showing prominent ductular reaction, signicant lymphoid cell inltrate in portal tract, granulomas in portal tracts and parenchyma showing bridging necrosis, brosis to cirrhosis, feathery degeneration of hepatocytes (gure 4), moderate to (9)severe intracytoplasmic to canalicular cholestasis. the probable diagnosis given based on these histologic features were chronic hepatitis c, aih (autoimmune hepatitis), pbc, psc and granulomatous hepatitis. on unveiling of other investigations, all these cases had complains of jaundice, pruritus, raised alp, ggt, serum bilirubin levels, mild to moderate rise in sgot/sgpt levels, positive ama titres , radiology showed cirrhosis and altered liver parenchyma, clinical impression was variable ranging from acute on chronic liver failure, aih, chronic liver disease to pbc. based on correlation of histology, clinical ndings and investigations these cases were concluded as pbc. figure 4: feathery degeneration, hepatocytes with rareed and reticular cytoplasm (h&e 400x) figure 5: biliary cirrhosis, jigsaw pattern (h&e 100x) of the total 8 cases of psc, 6 cases showed this pattern of cholestasis. these cases showed variable presence of ductopenia, classic “onion skin brosis”, biliary pattern of cirrhosis (gure 5), feathery degeneration of hepatocytes and moderate to severe degree of intracytoplasmic and canalicular cholestasis. on viewing the detailed work up of the patient, one case was a known case of psc, 2 cases had history of inammatory bowel disease, complains of jaundice, pruritus with increase in sgot/sgpt levels, raised alp, ggt, serum bilirubin and positive titres for p-anca, ama, asma , on cholangiography all cases had ihbrd, and clinical impression was psc in 5 of the cases. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra the 2 cases of dili included under this pattern showed ductopenia, ductular epithelial changes, 1 case showed signicant (+++) eosinophilic inammatory inltrate in portal tract, with parenchyma showing bridging necrosis, moderate to severe intracytoplasmic and canalicular cholestasis. the probable diagnosis based on the above ndings were dili and pbc. on exposure to detailed history and investigations, both these cases had history of long term use of hepatotoxic medication, one case had history of series of dental extraction and on going amoxicillin-clavulanic acid treatment course for the same while the other case had history of carbamazepine intake for psychosis. laboratory investigations showed deranged sgot/sgpt, raised alp, ggt, serum bilirubin with ultrasonography of abdomen showing no signicant abnormality in one case and altered liver parenchyma in other case. our nal diagnosis based on correlating the histology ndings with history, clinical presentation, laboratory investigations, radiological investigations and clinical impresssion were dili induced ductopenia. one case of granulomatous hepatitis showed portal tracts lled with epithelioid cell granulomas, langhan's giant cells in portal tract and parenchyma with marked ductular damage and mild canalicular cholestasis ,probable diagnosis given was granulomatous hepatitis and pbc, on further evaluation this case was a diagnosed case of tuberculosis, had near normal sgot/sgpt levels, raised alp, ggt, serum bilirubin levels, radiology was suggestive of inlrative disease of liver, clinical impression was granulomatous hepatitis. finally, considering all ndings this case was put under granulomatous hepatitis with pattern of cholestasis showing duct damage and loss. 4 cases of overlap syndrome showed presence of ductular reaction, ductular epithelial changes, signicant lymphoplasmacytic inammatory inltrate in portal tracts, periductal brosis, duct loss, granulomas in portal tract, piecemeal necrosis, bridging necrosis, cirrhosis, brosis, feathery degeneration of hepatocytes, moderate to severe degree of intra-cytoplasmic and canalicular cholestasis. based on the histologic ndings probable diagnosis given were chronic hepatitis b, pbc, psc, overlap syndrome.on unveiling of entire work up of these cases it revealed that 2 cases having positive titres of ana, p-anca, asma with ihbrd on cholangiography in addition to raised alp, ggt and serum bilirubin levels and history of uc these were labelled as aih + psc. rest of the 2 cases were labelled as aih+pbc had ama, ana titres with raised igg levels and picture of cirrhotic liver on radiology. pattern of cholestasis associated with hepatitis majority of cases were grouped under this pattern of cholestasis. it included cases of chronic hepatitis b, chronic hepatitis c, acute hepatitis, aih, dili, overlap syndrome. 6 cases of chronic hepatitis c on histology showed lymphoid aggregates in the portal tracts few showing germinal centre, hepatitis rosettes, periportal steatosis, portal to portal bridging necrosis, piecemeal necrosis, brosis and cirrhosis, one case showed giant cell transformation, moderate to (10)severe cytoplasm and canalicular cholestasis. probable diagnosis based of these histologic ndings were chronic hepatitis c, chronic hepatitis b, aih and pbc. on viewing the entire work up, these cases had hcv rna positive, one was a known case of hepatitis c, there was positive history of blood transfusion in past in 2 cases, one case was retrovirus positive, laboratory investigations of these patients revealed normal to deranged sgot/sgpt levels, normal to slightly raised alp and ggt levels, raised serum bilirubin levels.on radiology, impression was cirrhosis and liver parenchymal disease. chronic hepatitis b was the nal diagnosis in 10 cases, histology of these cases revealed ballooning degeneration of hepatocytes, ground glass hepatocytes, central vein to portal tract bridging necrosis, glycogenated nuclei of hepatocytes, moderate to severe degree of intracytoplasmic and canalicular cholestasis. probable diagnosis given based on the afore mentioned ndings were aih, chronic hepatitis c and chronic hepatitis b. on unveiling of complete details, all cases presented with jaundice and variably present other symptoms like abdominal pain, abdominal distension, pruritus, deranged sgot/sgpt levels, normal to slightly raised alp, ggt and elevated serum bilirubin levels. all patients were positive for hepatitis b surface antigen. cirrhosis was evident on radiology. clinical impression received in all cases of hepatitis b were chronic liver disease under evaluation. 2 cases of overlap syndrome were cases which had features of both aih and pbc, but features of aih more predominant than features of pbc, on histology. they showed presence of ductular reaction, duct epithelial changes, signicant lymphoplasmacytic inltrate in portal tracts, hepatic pseudo rosettes (gure 6), piecemeal necrosis, bridging necrosis, cirrhosis and moderate degree of intracytoplasmic and canalicular cholestasis. probable etiology given by us included overlap syndrome, aih and chronic hepatitis b. investigations of these patients revealed elevated ana titres, raised igg levels, raised sgot/sgpt, elevated alp, ggt and serum bilirubin levels, jaundice, abdominal pain and distension as presenting complaints. cirrhosis was found on radiology and clinical impression was of aih. 5 cases of acute hepatitis showed extensive lobular inammation, neocholangioles, conuent necrosis, feathery degenera t ion o f hepatocy tes , severe degree o f intracytoplasmic and intracanalicular cholestasis. probable diagnosis which were thought of were acute hepatitis and dili. investigations revealed elevated levels ( >1000 iu/l) sgot/sgpt, serum bilirubin and mild to moderate increase in alp and ggt levels. 4 cases were positive for hav with one case showing hev positivity, clinical impression was intrahepatic cholestatic jaundice with radiology showing no signicant abnormality. cases of aih showed signicant lymphoplasmacytic inammatory inltrate in portal tracts, piecemeal necrosis, pseudo rosettes, cirrhosis, giant cell transformation of hepatocytes (gure 7) and moderate intracytoplasmic and canalicular cholestasis. probable diagnosis were autoimmune hepatitis and dili. on investigations all cases showed strongly positive ana titres with one case showing antilkm antibody positivity and elevated igg titres, sgot/sgpt , serum bilirubin, alp/ggt showed raised levels. clinical impression in all three cases were aih whereas radiology showed no signicant ndings. figure 6: hepatic pseudo-rosettes (h&e 400x) table 1 : showing statistical signicance between a group of diagnosis and the pattern they repeatedly showed on liver biopsy. figure 7: post infantile giant cell transformation of hepatocytes (h&e 400x) x 49gjra global journal for research analysis volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra statistically signicant association was noted between bric and the pattern of bland cholestasis ( p value = 0.0004) (table 1). in this pattern there was intrahepatocytic and canalicular cholestasis without signicant portal tract pathology. (2) statistically signicant association was noted between pbc ( p value = 0.0001) (table 1) and psc ( p value = 0.007) with the pat tern of cholestasis associated wi th bi le duct loss/ductopenia. in this pattern there was bile duct epithelial damage or duct loss. however statistically signicant relation could not be established between various etiologies like dili, aih, sepsis, overlap syndrome and granulomatous hepatitis with different patterns of cholestasis considered in our study. this was due to either the small sample size or a single etiology presenting with different patterns of cholestasis (for example, cases of dili). the pattern of cholestasis associated with hepatitis was found to be statistically signicant (ss) in all 5 cases of acute hepatitis and all cases of chronic hepatitis b and c as all of them showed lobular disarray, ballooning and apoptosis of hepatocytes with portal tract inammation which is a feature of this pattern. the pattern of bland cholestasis was found to be statistically signicant in all 6 cases of bric as all of them showed centrilobular cholestasis within hepatocytes and/or bile canaliculi without signicant portal tract pathology. the pattern of cholestasis associated with intrahepatic bile duct disease (duct damage/duct loss/ductopenia) showed ss in all cases of pbc and majority cases of psc where both inammatory and brosing type of duct damage was seen in respective etiologies. conclusion our study aimed at analyzing patterns of intra-hepatic cholestasis on liver biopsy to help us narrow down the list of probable etiologies and to reach a nal diagnosis after complete knowledge of clinical history, laboratory investigations and radiological imaging. so we concluded from our study that analysis of different patterns of cholestasis helps us to short list the probable etiology/diagnosis however complete correlation with clinical, radiological and laboratory investigations is needed to reach the nal diagnosis. references 1. panqueva r. approaches to pathological diagnosis of cholestatic diseases2014. 187-99 p. 2. lefkowitch jh. cholestasis in hepatobiliary diseases: a practical guide to diagnosis--including the easily (and not so easily) missed diagnoses. 3. lefkowitch jh. histological assessment of cholestasis. clin liver dis. 2004;8(1):27-40, v. 4. ramachandran r, kakar s. histological patterns in drug-induced liver disease. j clin pathol. 2009;62(6):481-92. 5. lefkowitch jh. bile ductular cholestasis: an ominous histopathologic sign related to sepsis and "cholangitis lenta". hum pathol. 1982;13(1):19-24. 6. chhetri d, gupta r, duseja a, dhiman rk, chawla y, das a. benign recurrent intrahepatic cholestasis (bric) in an adult. trop gastroenterol. 2007;28(4):186-7. 7. harrison rf, hubscher sg. the spectrum of bile duct lesions in end-stage primary sclerosing cholangitis. histopathology. 1991;19(4):321-7. 8. stromeyer fw, ishak kg. histology of the liver in wilson's disease: a study of 34 cases. am j clin pathol. 1980;73(1):12-24. 9. mayo mj. cholestatic liver disease overlap syndromes. clin liver dis. 2013;17(2):243-53. 10. lefkowitch jh, scheuer pj. scheuer's liver biopsy interpretation. edinburg elsevier; 2016. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 50 x gjra global journal for research analysis introduction: illness of the body will affect the mind and vice versa. a good cardiac health is vital for the human existence and any discrepancy in cardiac health will ruin both social and personal life. cardiovascular disease (cvd) is the major health risk for millions of people all over the world. cardiovascular disease accounts for approximately 30% of the deaths worldwide. the global rise in cvd is due to industrialization, urbanization and associated life style changes taking place all over the world. among the cardiovascular diseases, ischemic cardiac diseases is responsible for one third of all deaths from the age of 45 to 64 years.a study done by m.moosavi, m.eslami ,o. sheikh baglooon found that the subjects with more stressful life events, and greater mental strain smoked more cigars which caused life threatening events such as atherosclerosis/ myocardial ischemia(1). z.n.hatmi et al conducted a study of stressful life events with myocardial infarction and association with psychiatric symptoms. his study revealed that depressive features, anxiety symptoms, phobia, obsessions and psychosis were more in myocardial infarction patients(2). roseman and friedman in 1960 gave a study which clearly established that personality characteristics of individual and coping methodologies towards stress play a role in the individual's predisposition to coronary artery disease(3). type a behavior patterns in the middle class westerners were found to be more prone for acute coronary syndrome. among many other factors, personality and behavioural traits have been linked to acute coronary syndrome (acs) risk (rozanski, blumenthal, & kaplan, 1999)(4). anger and hostility have been foremost among the personality and behavioural traits that have been linked to acs. aims and objectives: this study was undertaken to know the prevalence of anxiety and depression in patients affected with acute coronary syndrome and to study the burden of stressful life events, hostility and personality over anxiety and depression in these patients and eventually in course and outcome of acs. materials and methods: those diagnosed with acute coronary artery syndrome and age 18 and above were included and those with co-morbid physical illness, previous history of psychiatric illness and non-consenting patient were excluded. after obtaining approval from the institutional ethical committee this study was conducted on acute coronary artery syndrome patients admitted in cardiology ward at govt. rajaji hospital, th thmadurai. the tests were administered between the 5 to 14 day of admission. consecutive patients fullling inclusion and exclusion criteria were included in the study till the attainment of sample size of 60 and the following scales were administered to them. 1. hospital anxiety and depression scale(hads) 2. eysenck personality inventory(epi) 3. presumptive stressful life events scale(psles) 4. hostility and direction of hostility(hdh) statistical design: statistical design was formulated using the data collected as above. chi-square test, karl pearson's correlation coefcient and student t test for were used. the data was analyzed by means of the statistical package for social sciences (spss) version 17.0 for windows. “p” value of < 0.05 was considered signicant. results: table 1: epi neuroticism vs depression and anxiety a cross sectional study of anxiety and depression with personality, hostility and stressful life events in patients admitted with acute coronary syndrome original research paper dr. b. kannan assistant professor, department of psychiatry, govt. medical college and esi hospital, coimbatore dt-641015 x 35gjra global journal for research analysis psychiatry background: illness of the body will affect the mind and vice versa. emotional stress and physical illness has a causal relationship. the epidemic of coronary heart disease started in india in the past two decades. this study was undertaken to study anxiety and depression with personality, hostility and stressful life events in patients admitted with acute coronary syndrome (acs). methods: 60 patients diagnosed with acute coronary artery syndrome were selected. tools like hospital anxiety and depression scale (hads), eysenck personality inventory (epi), presumptive stressful life events scale (psles), hostility and direction of hostility (hdh) were applied and and student t test were chi-square test, karl pearson's correlation coefcient applied to the data. the results obtained were studied. results: among the 60 patients with acute coronary syndrome, 46.7% (n=28) had depressive symptoms, 45% (n=27) had anxiety symptoms. acute coronary syndrome patients with depressive features had increase in neuroticism scores as well as increased frequency of stressful life events and a direct positive correlation was observed between psles score and life events with hads anxiety scores. conclusion: study of psychiatric morbidities in particular anxiety and depression in patients with acute coronary syndrome revealed signicant association with depression, anxiety, neuroticism, hostility and life events. the present study and those numerous other studies that have parallel results found in the literature, underlines the need to screen for anxiety and depressive symptoms in patients with acs, so that appropriate intervention can be incorporated in the management plan. abstract keywords : acute coronary syndrome, depression and anxiety, neuroticism, stressful life events. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. v. p. navaneethan* assistant professor, department of psychiatry, govt. irt perundurai medical college & hospital, erode dt-638053 *corresponding author epineuroticism depression(n=28) anxiety(n=27) n chi df p value n chi df p value 1.tendency to be neurotic 9 2x =2.6 2 p> 0.05 10 2x =0 .794 2 p> 0.05 2.neurotic 19 17 total 28 27 36 x gjra global journal for research analysis table1: shows that a major part of the patients were found to be neurotic in the group of patients who had depressive symptoms and also in the group of anxiety patients. table 2: hdh vs depression and anxiety table 2: shows that a major portion of both the depression (p<0.05 signicant) and anxiety group of patients were intropunitive. table 3: psles vs depression and anxiety table 3: shows that 13 out of 28 depression patients (p<0.05 signicant) and 10 out of 27 anxiety patients came under severe stress category. table 4: life events vsdepression and anxiety table4: shows that 15/28 depressive patients (p<0.05 signicant) and 13/27 anxiety patients were found to have more than 2 stressful events in the psles scale. table 5: correlations matrix for the variables under study * correlation is signicant at the 0.05 level (2-tailed). ** correlation is signicant at the 0.01 level (2-tailed). discussion: among the 60 patients, patients 46.7% (n=28) had depressive symptoms, 45% (n=27) had anxiety symptoms. we divided patients into groups such as depressive group & anxiety group for various analyses. the group was made through hads score of 8-10 as borderline and more than 11 as clinically signicant depression for depressive group, hadsscore anxiety of 8-10 as borderline and more than 11 as clinically signicant anxiety as anxiety group. in india, the depression prevalence is reported to be about 25% to 34% among post-mi subjects (5). depression and anxiety were found to be highly correlated with each other. this could be due to two factors – primarily the acs sufferers experience a state of general distress rather than from a possible spectrum of specic psychopathologies. secondarily, the state may be a possible combination of the acs plus co-morbidity, co-existing illness besides other constitutional and environmental factors that contribute to the levels of overall psychopathology (6). in addition, hads has multiple overlap in the symptom domain contributing the over diagnosis of the condition, thereby causing higher coexistence of these two conditions. according to menon et al., the neuroticism score, in their study emerged as an independent predictor of scores on the hads and is best described as dimension of a personality that is associated with a tendency to experience negative affect(7). this relationship has been identied in the present study also. thus, the association of the negative feelings such as anxiety and depression has a high possibility (7,8). a study from netherlands by van jaarseld and his colleagues has conrmed that neuroticism is a predictor of hads anxiety and depressive symptoms(9). the present results are in concurrence with the their study. as the exact mechanism of this phenomenon is un-deciphered, further studies are necessary to explore and explain the link between the triad of anxiety, depression and neuroticism in acs and post myocardial infarction survivors. frasure-smith has earlier shown that depression following a myocardial infarction will cause a raise the likelihood of the risk of subsequent mortality(10). the 2008 american heart association science advisory concluded that depression is commonly present inpatients with coronary heart disease and is independently associated with increased cardiovascular morbidity and mortality. therefore, screening tests for depressive symptoms should be applied to identify patients who may require further assessment and treatment. in view of adverse outcome of depression associated with coronary heart disease and the availability of easy-to-administer and reasonably accurate screening tools, it is reasonable to screen for depression to improve outcomes. in this study hdh has a statistically signicant association with depression. as there are not enough studies to support this nding, it is needed to check for such an association in future similar studies. in a study by haldar a et al., it was observed in the control group individuals most often to have experienced an average of two (2.24) stressful life events during the past one-year without suffering from any adverse physical or psychological disturbance. on the contrary, among patients with acute myocardial infarction, the mean number of stressful life events was 4.16 in the past one year(11). previously, geyer and others have compared data of three life event studies among depressives, mi patients, and industrial workers. after indepth of analysis of their data, they related that the number of life events and the depression severity ratings were positively correlated with good statistical signicance (12). earlier studies that correlated cardiovascular diseases with psychological diseases have concluded that work-related life events, particularly those with any work load, were signicantly associated with the risk of myocardial infarction (13). hatmi et al., found that change in nancial state, departure of spouse/son/daughter leaving home and detention/arrest in the past 6 months, and retirement, emigration in the 6 months before were related to increased susceptibility to myocardial infarction(2). similarly, in the present study, several life stressor events were identied. the difference in the life related stressor events would be attributed to difference in the socio-cultural-economic demographical factors. limitations: it is a time bound cross-sectional study, so follow up of cases after onetime assessment was not done. the number of cases included is less, so results cannot be generalized. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra hdh depression(n=28) anxiety(n=27) n chi df p value n chi df p value 1.extra punitive 6 2x =8.9 2 p< 0.05 (sig) 11 2x =0.41 2 p> 0.05 2.intro punitive 22 16 total 28 27 psles depression(n=28) anxiety(n=27) n chi df p value n chi df p value 1.moderate stress 15 2x = 11.3 2 p< 0.05 (sig) 17 2x =4. 4 2 p> 0.05 2.severe stress 13 10 total 28 27 life events depression(n=28) anxiety(n=27) n chi df p value n chi df p value 1.normal 13 2x =7.6 2 p< 0.05 (sig) 14 2x =3.8 2 p> 0.052.abnormal 15 13 total 28 27 sno variables hads depres sion hads anxiety epi neuro psles life events 1 hads depression 1 2 hads anxiety 0.239 1 3 epi neuro 0.288(*) 0.208 1 4 psles 0.389(**) 0.310(*) 0.339(*) 1 5 life events 0.421(**) 0.3016(*) 0.388(*) .877(**) 1 conclusion: with chance of increase of depressive states, as reected by hads depressive score, there was increased frequency of neuroticism as well as increased frequency of stressful life events and such scores. based on the hads anxiety score, a directly positive correlation was observed with psles score and life events. in patients who had higher degrees of neuroticism, had higher scores of psles as well as increased stressful life events. the present study and those numerous other studies that have parallel results found in the literature, underlines the need to screen for anxiety and depressive symptoms in patients with acs so that appropriate intervention can be incorporated in the management plan. life stressor events are major risk factors of acs and psychiatric intervention is needed to be planned for those at risk to prevent future acs. references 1. mental strain, more important than stressful life events in myocardial infarction -m. moosavi1, m. eslami , o. sheikh bagloo and b. birashk .acta medica iranica,42(2): 125-130; 2004 2. hatmi zn, nasiri lf, sadegianmehr z, mirkia s, darbooy s. association ofmyocardial infarction with stressful life events and psychiatric symptoms: a population-based survey. eastern mediterranean health journal 2011;17:398-403. 3. friedman, m., byers, s. o., rosenman, r. h., & henman, r. (1960). 'coronary prone individuals (type a) behavioural pattern growth hormone responses'—jama 217: 929. 4. alan rozanski, james a. blumenthal, jay kaplan. impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. circulation 1999; 99: 2192-2217. 5. sarkar s, chadda rk, kumar n, narang r. anxiety and depression in patients with myocardial infarction: ndings from a centre in india. gen hosp psychiatry 2012;34: 160-66. 6. lane d, carroll d, ring c, beevers dg, lip gy. the prevalence and persistence of depression and anxiety following myocardial infarction. br j health psychol 2002; 7:11-21 7. menon v, chandrasekaran r. depressive and anxiety symptoms after myocardial infarction:a follow up study from south india. mjp 8. costa pt & mccrae rr. revised neo personality inventory (neopir) and neo ve-factor inventory (neo-ffi) professional manual. odessa, fl: psychological assessment resources, 1992 9. van jaarsveld ch, ranchor av, sanderman r, ormel j and kempen gi. the role of premorbid psychological attributes in shortand longterm adjustment after cardiac disease. a prospective study in the elderly in the netherlands. soc sci med 2005; 60(5): 1035 45. 10. frasure-smith n, lesperance f, talajic m. depression and 18-month prognosis after myocardial infarction. circulation 1995;91:999-1005 11. haldar a, saha s, mandal s, haldar s, mundle m, mitra sp. life events as risk factors for myocardial infarction: a pilot case-control study in kolkata, india. j health ppulnutr2005;23:131-36. 12. geyer s, broer m, haltenhof h, buhler ke, merschbacher u. the evaluation of life event data. j psychosom res 1994;38:823-35 13. theorell t, floderus-myrhed b. ‘workload’ and risk of myocardial infarction–a prospective psychosocial analysis. international journal of epidemiology, 1977, 6:17–21. x 37gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction tuberculosis (tb) is a disease of great antiquity. worldwide, tb is one of the top 10 causes of death and the leading cause from a single infectious agent (above hiv/aids). globally, the best estimate is that 10 million people developed tb disease in 12017. there were a total of 16 lakhs tb related deaths. the estimated incidence of tb in india was approximately 28,00,000 accounting for about a quarter of the world's tb 2cases and mortality due to tb (exclude hiv) was 4,23,000. to curb the menace of tb and to reduce the tb load, national tuberculosis control programme (ntcp) was launched throughout the country in 1962. goi with sida reviewed the ntcp and launches its revised strategy, i.e. revised national tuberculosis control programme (rntcp) with the objectives of achieving at least 85% cure rate through dots (directly observed treatment, short course) and case nding 70% of 3the estimated cases. this revised programme was introduced in india as a pilot project since 1993 in a phased manner and proposed to be expanded throughout the country by the year 42005. during 2006-2011, in its second phase rntcp improved the quality and reach of service and work to reach global case detection and cure targets. signicant interventions and initiatives were taken during national strategic plan (nsp) 2012-2017 in terms of mandatory notication of all tb cases, integration of the programme with the general health services (national health mission), expansion of diagnostics services, programmatic management of drug resistant tb (pmdt) service expansion, single window service for tb-hiv cases, national drug resistance surveillance and revision of partnership guidelines. rntcp has released a 'national strategic plan for tb 2017-2025 for control and elimination of tb in india by 2025. according to nsp, tb elimination have been integrated into 5four strategic pillars of “detect-treat-prevent-build” (dtpb). the essential principles of dots were rst demonstrated in india. the key to the success of the dots strategy is that it places the responsibility for curing tb patients on the health 12workers-not the patients. the one important component of the dots strategy is systemic monitoring and accountability. that means a systemic recording, reporting and evaluating the treatment outcome of every patient treated at different 6levels of the health systems. objective to evaluate the effectiveness of dots regimen in term of cure rate, failure rate, defaulter rate and relapse rate in different categories of tb under rntcp programme. methodology the study was a retrospective type, carried out at 3 tuberculosis units of jodhpur city (kn chest hospital, satellite hospital paota and dtc jalori gate) under department of community medicine, sn medical college, jodhpur, rajasthan from july 2010 to september 2010. patients registered under rntcp in all 3 tuberculosis units during study period were study population. information about the name, age, sex, socio-demographic prole, initial sputum smear result, during and at the end of their treatment, treatment category, date of start of treatment and outcome were collected from tuberculosis register maintained at a study of effectiveness on dots on tuberculosis patients treated under rntcp original research paper chandan mal fatehpuria* assistanr professor, department of community medicine, rnt medical college, udaipur, rajasthan, india *corresponding author community medicine background: tuberculosis is one of the top 10 causes of death and the leading cause from a single infectious agent. india accounts for one fourth of the global tb burden. ntp was introduced for tb control and this ntp was become rntcp after review and performance of ntp with adaptation of dots strategy. the key to the success of the dots strategy is that it places the responsibility for curing tb patients on the health workers methods: those patients of tuberculosis, who were registered from july 2010 to september 2010 at tuberculosis units of jodhpur city. all informations were collected from tuberculosis register and by interview. these patients were followed up for sputum examination during three visits. the data collected was grouped into cured and non-cured group. the cured group includes cured and completed the treatment. the non-cured group includes treatment failures, defaulters, died and transferred out cases. results: total 363 patients were registered with m/f ratio 1.47:1. 264, 81 and 36 patients registered in category i, ii and iii respectively. mostly patients (66.94%) were in 15-45 years age group among these, 72.18% (262) had pulmonary tuberculosis; of these 167 were new smear positive cases and remaining were retreatment cases. treatment success (cured/treatment completed) among category-i was 221/246 (89.84%), among category-ii was 56/81 (69.13%) and among category-iii was 31/36 (86.11%). 30 patients were defaulter, 15 were died, 6 were transferred out and 4 were failed treatment. conclusion: higher cure and sputum conversion rates due to strict supervision and monitoring along with motivation of cases by health and non-health personnel. experiences from the past also emphasized the importance of these factors. abstract keywords : tb, rntcp, dots, nsp mahesh chand bairwa senior resident, department of respiratory medicine, rnt medical college, udaipur, rajasthan, india rita meena senior professor, department of community medicine, sn medical college, jodhpur, rajasthan, india volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra pratap bhan kaushik statstician, department of community medicine, rnt medical college, udaipur, rajasthan, india 84 x gjra global journal for research analysis tuberculosis units. all the patients were interviewed, door to door, at their homes with the help of health visitor. these patients were followed up for sputum examination by smear microscopy during 3 visits carried out namely at the end of intensive period, mid-way of continuation phase and at the completion of treatment regimen. the nal outcome was conrmed with the help of tb register. the data collected was grouped into cured and non-cured group and expressed in percentage. the cured group includes all those who were declared cured and completed the treatment. the non-cured group includes treatment failures, defaulters, died and transferred out cases. all collected data were transferred in a computer. chi-square test was applied as a test of signicance using spss 21. tuberculosis patients were not on dots regime and not gave consent, excluded for the study. p value < 0.05 was considered as signicant. result during study period, a total of 363 patients were registered for treatment in all categories (cat i: 264, cat ii: 81, cat iii: 36). of these, 216 (59.51%) were males and 147 (40.49%) were females, mostly patients 243 (66.94%) were in 15-45 years age group. (table 1) 262 (72.18%) patients had pulmonary tuberculosis and 101 (27.82%) had extra-pulmonary tuberculosis. among 262 pulmonary tuberculosis patients, new smear positive (nsp) patients were 167 (63.74%) and 95 (36.26%) were retreatment cases. (table 3) table1: distribution of patients according to age and sex volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra age in years males females total 0 – 15 07 (30.43%) 16 (69.57%) 23 (06.34) 16 – 25 37 (49.33%) 38 (50.67%) 75 (20.66) 26 – 35 44 (48.89%) 46 (51.11%) 90 (24.79) 36 – 45 58 (74.36%) 20 (25.64%) 78 (21.49) 46 – 55 39 (81.25%) 09 (18.75%) 48 (13.22) 56 – 65 12 (54.54%) 10 (45.46%) 22 (06.06) >65 19 (70.37%) 08 (29.63%) 27 (07.44) total 216 (59.51%) 147 (40.49%) 363 (100) category patient registered cured treatment completed defaulter failure died transferred out i 246 (67.77%) 91 (36.99%) 130 (52.84%) 14 (5.69%) 1 (0.41%) 7 (2.84%) 3 (1.22%) ii 81 (22.31%) 35 (43.21%) 21 (25.92%) 11 (13.58%) 3 (3.7%) 8 (9.88%) 3 (3.7%) iii 36 (9.92%) 0 (0%) 31 (86.11%) 5 (13.89%) 0 (0%) 0 (0%) 0 (0%) total 363 (100%) 126 (34.71%) 182 (50.14%) 30 (8.26%) 4 (1.1%) 15 (4.13%) 6 (1.65%) table 2: outcome of patients after completion of dots overall treatment success (cured/treatment completed) in study group were 308/363 (84.84%). treatment success among category-i was 221/246 (89.84%), among category-ii was 56/81 (69.13%) and among category-iii was 31/36 (86.11%). it is observed that in category-i patients, 91 (36.99%) cured, treatment complete 130 (52.84%), 14 (5.69%) defaulted, 1 (0.41%) failed treatment, 7 (2.84%) died, and 3 (1.22%) were transferred out. it is observed that in category-ii patient, 35 (43.21%) cured, treatment complete 21 (25.92%), 11 (13.58%) defaulted, 3 (3.7%) failed treatment, 8 (9.88%) died, and 3 (3.7%) were transferred out. it is observed that in category-iii patients, treatment completed 31 (86.11%) and 5 (13.87%) defaulted. table 3: distribution of patients according to category and sputum status majority of patients 262 (72.18%) had pulmonary tuberculosis whereas 101 (27.82%) had extra pulmonary tuberculosis. among category i (246), 107 (43.49%) were sputum positive cases, 72 (29.27%) were sputum negative pulmonary tb (serious ill extension pulmonary involvement) and 67 (27.23%) were extra pulmonary seriously ill. in category ii (81) cases, 60 (74.07%) were sputum positive cases, 14 (17.28%) were sputum negative pulmonary tb and 7 (8.64%) were extra pulmonary seriously ill. in category iii (36) patients, 9 (25%) were sputum negative and 27 (75%) had eptb which was not seriously ill. discussion tb mostly affects the lungs but it may affect other organs of the body. our study had found that most common organ affected by tuberculosis is lung (72.18%), while extra-pulmonary tb accounted for about 27.82% of the disease. k.jagarajamma et al (2007) also found that mostly patients 92.22% were having pulmonary manifestation of tb, while only 7.78% patients had 7extra pulmonary tb disease. the study had also found out that tb was more common in males (59.5%) compared to female (40.5%). dipesh v. parmar et al (2009) in rajkot, gujarat found that 68.08% were males 8and 31.92% were females. it is observed that maximum number patients 90 (24.79%) were in 25-34 years age group followed by 78 (21.49%) in 35-44 years age group and 75 (20.66%) in 15-24 year age group. the mean age of male patients being 36.7 years, while that of female patients is 30.5 years. thejeshwari h.l. et al (2008) found that mean age of males was 40.36±14.34 years and 928.97±13.33 years in females. rahul saini et al (2004) found that 50.23% patients were in 1630 years followed by 35.21% patients were 31-50 years and 11.97% patients were > 50 years. only 2.58% patients were < 1015 years. it is observed that majority of patients were in category-i; 246 (67.77%). about 81 (22.7%) had past history of tb and treated for the same, so they were classied as category-ii. only 36 (9.92%) patients were being treated as category-iii. a. mishra et al (2007) found that there were 46.47%, 27.88% and 32.05% 11belonged to category-i, ii and iii respectively. it is observed that in category-i mostly patients were sputum positive 43.49% (107), whereas in category-ii sputum positive were 74.07% (60) and in category-iii 75% (27) were extra pulmonary cases. mahadev b et al (2004) in bangalore observed similar result that mostly patients 156 (87.6%) were pulmonary and 22(12.4%) extra pulmonary cases. out of 69 smear positive, 50 (72.46%) were new sputum smear positive 12and 19 (27.54%) were re-treatment cases. it is observed that in category-i 36.99% (91) cured, treatment category pulmonary tuberculosis (n=262) extra pulmonary tuberculosis (n=101) total sputum positive sputum negative seriously ill not seriously ill i 107 (43.49%) 72 (29.27%) 67 (27.23%) 0 (0%) 246 (67.77%) ii 60 (74.07%) 14 (17.28%) 7 (8.64%) 0 (0%) 81 (22.31%) iii 0 (0%) 9 (25%) 0 (0%) 27 (75%) 36 (9.92%) total 167 (46.01%) 95 (26.17%) 74 (20.38%) 27 (7.44%) 363 (100%) x 85gjra global journal for research analysis volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra complete 130 (52.84%), 5.69% (14) defaulted, 0.41% (1) failed treatment, 2.84% (7) died and 1.22% (3) were transferred out. singh a et al (2005) also found that the treatment outcome of 388 nsp cases was; treatment success 310(80%), death 10(3%), failure 18(5%), defaulted 45(12%), and transferred out 136(2%). among the 7 died, 1 (14.28%) are smear positive and 6 (85.71%) patients are smear negative in our study. the other known risk factor for mortality in tb are advanced age, low literacy, alcoholism, hiv infection and delayed careseeking. it is observed that out of 14 defaulters, 50% were smear positive, 50% smear negative. chadha et al (2000) also found that default rate was 8.5% and 14failure rate was 1.6%. one patient failed treatment, even though regular in treatment. the failure rate of 0.41% is either due to wrong categorization or due to drug resistance in our study. it is observed that overall cure rate is more among the ep seriously ill 100% (67) followed by smear positive 90.65% (97) and new smear negative 79.17% (57). it is observed that in category-ii, 50.62% (41) were relapsed, 6.17% (5) failure, 18.52% (15) treatment after default cases and 24.69% (20) others. it is observed that in category-ii patient, 35 (43.21%) cured, treatment complete 21 (25.92%), 11 (13.58%) defaulted, 3 (3.7%) failed treatment, 8 (9.88%) died, and 3 (3.7%) were transferred out. among 41 relapse cases, 25 (60.98%) achieved treatment success (23 cured+02 treatment completed), 5 (12.19%) died, 2 (4.88%) failed treatment 6 (14.63%) defaulted the regimen and 3 (7.32%) transferred out. out of the 5 failure cases (6.17%), 3 cured, 1 died and 1 defaulted. out of 15 tad patients, 9 (60%) cured, 4 (26.67%) defaulted and 2 (13.33%) died. out of 20 others patients, 19 (95%) completed treatment and 1 (5%) defaulted. quy h.t.w. et al (2003) in vietnam found that the cure rate among 464 relapse and 119 failure cases was 82.5% and 47% respectively. the overall failure rate was 39% among cat-ii patients. quy h.t.w. says emergence of combined primary isoniazid and streptomycin resistance was a strong risk factor 15for the failure of relapse cases. it is observed that 86.11% (31) completed their treatment, 13.87% (5) defaulted in category iii. of the 9 pulmonary smear negative patients; 6 completed treatment and 3 defaulted under category iii patients. out of 27 extra pulmonary patients, 92.59% (25) had completed treatment and 7.41% (2) were defaulted. akramal islam et al (2002) found that in which of the 16 patients; 10 (62.5%) treatment completed, 3 (18.7%) died and 163(18.7%) defaulted. cure rate in different categories (table-35) in our study overall cure rate for cat-i and cat-ii was only 36.99% and 43.21%. only 86.11% cases could be labeled as treatment completed for cat-iii it is observed that overall outcome for category-i, ii and iii were 87.2%, 59.77% and 83% respectively. the cure rate was higher than the rates reported by various investigators such as bhat s et al (68%) and pio et al (50%) in their respective 17,18studies. conclusion higher cure and sputum conversion rates due to concrete efforts in the form of strict supervision and monitoring along with motivation of cases by health and non-health personnel. experiences from the past also emphasized the importance of these factors. recommendations 1. to discover new drugs, regimens and vaccine so that the treatment of tb becomes more shorter duration to reduce relapse, failure and drug resistance. to achieve this research and funding have to be strengthen. 2. collaboration of government health services with other social welfare measures to improve the economic condition of patients. 3. vacant posts in the rntcp centers must be lled up with training of the health staffs of the public sector regarding rntcp have to be undertaken. references 1. global tuberculosis report 2018. available at https://www. who. int/tb/ publications/global_report/en/. 2. india tb report 2018; rntcp annual status report. available at https://tbcindia.gov.in/showle.php?lid=3314. 3. khatri gr. the revised national tuberculosis control programme: a status report on rst 1,00,000 patients. indian j tuberculosis 1999; 46:157-166. 4. editorial indian j tuberculosis 1996; 43:3. 5. national health portal. available at https://www.nhp.gov.in/revised-nationaltuberculosis-control-programme_pg. 6. managing the rntcp in your area training module (1-4), central tb division dghs mohfw, newdelhi, 2005 april; 4. 7. jagarajamma k, sudha g, nirupa c,narayanan pr, ind.j. tb, 2007; 54: 130135. 8. pithadia pr, lodhiya kk, parmar dv, yadav sb. evaluation of performance of dots services under rntcp in rajkot district of gujrat. national j of comm med 2012; 3(4): 612-616. 9. thejeshwari hl; treatment outcome among tb patients under rntcp – in phcs attached to vims bellary; a dissertation submitted to rajiv gandhi university of health sciences, banglore, karnataka. 2009; 43-46. 10. rahul saini: a retrospective study of outcome of dots under rntcp and default in urban population (jodhpur city) in year 2002. 11. mishra a et al (2007); a study of effectiveness of dots on tb patients treated under rntcp programme. nti bulletin 2007, 43/3&4, 47-50. 12. b mahadev, vh balasangameshwara, sg radha krishna and r jitendra. treatment and diagnosis practices under rntcp in bangalorea cohort study. nti bulletin 2004; 40 (1&2) ; 7-12.] 13. singh a et al., effectiveness of community based anganwadi workers in dot; in a rural area of haryana. indian j tuberc 2005; 52; 15-20. 14. s.l chadha and r.p bhagi. treatment outcome in tb patients placed under dots-a cohort study. indian j tuberc 2000; 47 : 155-158. 15. quy h.t.w, et al. drug resistance among failure and relapse cases of tuberculosis; is the standard re-treatment regimen adequate? int j. tuberc lung dis 2003; 7(7): 631-636. 16. akram islam, susumu wakai, nobukatsu ishikawa, a.m.r chowdhary and j patrick vaughan.cost-effectiveness of community health workers in tuberculosis control in bangladesh. bulletin of world health organisation 2002 ; 80 ; 445-450. 17. bhat s. mukharjee s: unsupervised intermittent short course chemotherapy with intensive health education, ind j tb 1998, 45, 145-207. 18. pio a, lueimo, kumaresan, spinaci: national tb programme review experience over the period 1990-95, bull who, 1997, 75(5), 481-565. 86 x gjra global journal for research analysis introduction glioblastoma multiforme is the most common and most malignant primary tumour of the brain and associated with one of the worst 5-year survival rates among all human cancers. despite multimodal aggressive treatment, comprising surgical resection, local radiotherapy and systemic chemotherapy, the median survival time after diagnosis is still in the range of just 12 months (smith and jenkins, 2000), with population-based studies indicating even shorter median survival (ohgaki et al., 2004). nevertheless, a small fraction of glioblastoma patients survive for more than 36 months. these patients are referred to as long-term survivors. in addition, younger age and a good karnofsky performance score (kps) at the time of diagnosis are established clinical parameters associated with longer survival (curran jr et al., 1993). the investigation of glioblastoma long-term survivors could help to identify yet unknown clinical, environmental and/or molecular factors that are associated with favourable prognosis. here, we report on a retrospective analysis of 77 glioblastoma patients including 3 pediatric patients recruited within our hospital. materials and methods we conducted a retrospective review of gbm patients seen in pgimer & dr. ram manohar lohia hospital, new delhi from august 2015 to september 2017. demographic data and clinicopathological data and treatment parameters were collected from the hospital medical records and correlated with patient survival. results data of 71 gbm patients including 3 pediatric patients was analysed. we observed an increase in incidence with increasing age with majority patients being in the age group of 50 – 60 years. majority of our patients (28.2%) had a preoperative karnofsky performance score (kps) of 80 and 19.7% patients had a kps of <50. all our patients were subjected to either near total or subtotal tumour resection depending on clinical features, radiological prole and intraoperative ndings. after discharge, the treatment was continued with radiotherapy and adjuvant concurrent chemotherapy in all patients. the patient survival after discharge from hospital ranged from 2 months to 13 months with a median survival time of 6 months. 11 patients expired during their stay in the icu. using the spearman's rho test signicant correlation between poor preoperative karnofsky performance score (kps) and poor survival was seen (correlation coefcient = 0.435, p= 0.01). treatment with near total tumour resection, radiotherapy and adjuvant concurrent chemotherapy correlated with improved survival (p= 0.043) in comparison to patients subjected to subtotal tumour resection and chemoradiotherapy. the correlation between patient glioblastoma multiforme – outcomes and experriences at a tertiary care hospital original research paper dr. puneet kant associate consultant, department of neurosurgery, fortis memorial research institute, gurugram, haryana neurosurgery background glioblastoma multiforme (gbm) is the most common primary brain tumour in adults. although the survival rate for gbm has improved with recent advancements in treatment, the prognosis remains generally poor. method we conducted a retrospective review of gbm patients seen in pgimer & dr. ram manohar lohia hospital, new delhi from august 2015 to september 2017. demographic data and clinicopathological data and treatment parameters were collected from the hospital medical records and correlated with patient survival. results – data of 71 gbm patients including 3 pediatric patients was analysed. we observed an increase in incidence with increasing age with majority patients being in the age group of 50 – 60 years. majority of our patients (28.2%) had a preoperative karnofsky performance score (kps) of 80 and 19.7% patients had a kps of <50. all our patients were subjected to either near total or subtotal tumour resection depending on clinical features, radiological prole and intraoperative ndings. after discharge, the treatment was continued with radiotherapy and adjuvant concurrent chemotherapy in all patients. the patient survival after discharge from hospital ranged from 2 months to 13 months with a median survival time of 6 months. 11 patients expired during their stay in the icu. using the spearman's rho test signicant correlation between poor preoperative karnofsky performance score (kps) and poor survival was seen (correlation coefcient = 0.435, p= 0.01). treatment with near total tumour resection, radiotherapy and adjuvant concurrent chemotherapy correlated with improved survival (p= 0.043) in comparison to patients subjected to subtotal tumour resection and chemoradiotherapy. the correlation between patient survival and patient age is very weak and insignicant (p = 0.12) in our patient group. the approximate total blood loss was tabulated and mean blood loss during surgery was found to be 1504.23 ml ± 554.059 ml. type of resection showed no correlation with duration (in days) of postoperative ventilation ( p = 0.284) and duration of icu stay (p = 0.358). conclusion gbm confers a poor prognosis especially at extremes of age. extent of surgical resection, preoperative kps show direct association with improved survival. abstract keywords : dr. mahima singh* senior resident, department of anaesthesiology, vardhman mahavir medical college and safdarjung hospital, new delhi *corresponding author dr. ajay choudhary professor, department of neurosurgery, pgimer & dr. rml hospital, new delhi volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. l n gupta professor, department of neurosurgery, pgimer & dr. rml hospital, new delhi 106 x gjra global journal for research analysis survival and patient age is very weak and insignicant (p = 0.12) in our patient group. the approximate total blood loss was tabulated and mean blood loss during surgery was found to be 1504.23 ml ± 554.059 ml. type of resection showed no correlation with duration (in days) of postoperative ventilation ( p = 0.284) and duration of icu stay (p = 0.358). discussion in general, glioblastomas are more frequent in males, with a male/female ratio between 1.3 and 1.45, corresponding to a proportion of female patients of 43 and 41%, respectively (barnholtz-sloan et al., 2003; ohgaki and kleihues 2005). in line with these data, the male to female ratio in our series of 71 unselected glioblastoma patients was 1.43. the long-term survivors showed a trend to a higher proportion (50%, 95% ci 38–62%) of female patients, although the proportion reported in the literature is still within the limits of the condence interval. nevertheless, it seems that glioblastoma long-term survival is favoured by the combination of two basic clinical parameters—young age and female gender. unfortunately, the median follow up time in the control group did not allow validation of these ndings. several environmental and socioeconomic risk factors have been associated with the development of malignant glial tumours (lee et al., 1997; inskip et al., 2001; huncharek et al., 2003; schlehofer et al., 2005). one might assume that the absence of such factors could be associated with a better prognosis in those tumours. however, in the present study we failed to identify any of those factors to be obviously underor overrepresented in long-term survivors. also such data are difcult to obtain in a retrospective setting. all patients of our series were initially treated by (gross total or near total) tumour resection. recent data have conrmed that the extent of resection is associated with improved progression-free survival (stummer et al., 2006). the fact that majority glioblastoma long-term survivors had undergone gross total resection as initial treatment conrms that tumour resection enhances the chances for a favourable outcome. all patients had adjuvant radiotherapy. standard treatment for glioblastoma includes postoperative radiotherapy; hence radiotherapy is unlikely to be a positive selection factor. chemotherapy for malignant gliomas has experienced a renaissance since the publication of the eortc 26981/22981ncic ce3 phase iii randomized trial, which demonstrated that concomitant and adjuvant temozolomide chemotherapy has a positive effect on survival of patients with glioblastoma (stupp et al., 2005). however, the study design does not allow to dene chemotherapy as a prognostic factor. here, the same limitations apply as for the number of surgical interventions. patients who have a less malignant course of disease also have more options to undergo multiple surgical and chemotherapeutic interventions. there are very few case series of glioblastoma long-term survivors reported to date. we provide a clinical characte rization of 71 primary glioblastoma patients. the median age of glioblastoma patients is >60 years according to population-based studies (www.cbtrus.org) (ohgaki and kleihues, 2005; chakrabarti et al., 2005). in contrast with these data, the median age of our glioblastoma patients was 48 years. the median age of the long-term survivors in our study was also considerably lower, i.e. 42 years (p < 0.001). this is in accordance with numerous clinical studies indicating that young age at the time of diagnosis is an important parameter associated with longer survival (burger and green 1987; curran jr et al., 1993; devaux et al., 1993; chang et al., 2005). taking data from all 281 published glioblastoma long-term survivors (table 4), their median age is 36.9 years, which supports that age is of predictive value in glioblastoma. on the other hand, four of our long term survivor patients were 65 years or older, indicating that older age does not exclude long-term survival of glioblastoma. interestingly, the median age in our study is much below that of all published cases. this might in part be explained by the fact that older studies are possibly contaminated with low-grade tumours in older adults that were mistaken for glioblastoma, in particular pleomorphic xanthoastrocytomas. a contam ination of glioblastoma patients' cohorts by high grade tumours of the oligodendroglial lineage may also occur. however, in our series, only two cases showed a minor oligodendroglial component in an otherwise typical glioblastoma. we assume that further molecular analyses employing largescale microarray-based genomic and expression proling approaches will identify molecular features that are specic to glioblastomas of long-term survivors. for this purpose, the german glioma network is prospectively collecting fresh tissue from all glioblastoma patients operated at its participating centres and shall thus be able to perform comparative proling experiments on a reasonable number of long-term survivors from this large population within the next few years. references 1. brown pd, ballman kv, rummans ta, maurer mj, sloan ja, boeve bf, gupta l, tang-wai df, arusell rm, clark mm, buckner jc. prospective study of quality of life in adults with newly diagnosed high-grade gliomas. j neurooncol. 2006;76:283–291. 2. chaichana kl, halthore an, parker sl, olivi a, weingart jd, brem h, quinones-hinojosa a. factors involved in maintaining prolonged functional independence following supratentorial glioblastoma resection. clinical article. j neurosurg. 2011;114:604–612. 3. ciric i, ammirati m, vick n, mikhael m. supratentorial gliomas: surgical considerations and immediate postoperative results. gross total resection versus partial resection. neurosurgery. 1987;21:21–26 4. fadul c, wood j, thaler h, galicich j, patterson rh, jr, posner jb. morbidity and mortality of craniotomy for excision of supratentorial gliomas. neurology. 1988;38:1374–1379. 5. lacroix m, abi-said d, fourney dr, gokaslan zl, shi w, demonte f, lang ff, mccutcheon ie, hassenbusch sj, holland e, hess k, michael c, miller d, sawaya r. a multivariate analysis of 416 patients with glioblastoma multiforme: prognosis, extent of resection, and survival. j neurosurg. 2001;95:190–198. 6. louis dn, cavenee wk, ohgaki h, wiestler od. who classication of tumours of the central nervous system. world health organization; 2007. 7. mcgirt mj, mukherjee d, chaichana kl, than kd, weingart jd, quinoneshinojosa a. association of surgically acquired motor and language decits on overall survival after resection of glioblastoma multiforme. neurosurgery. 2009;65:463–469. discussion 469-470. 8. sanai n, mirzadeh z, berger ms. functional outcome after language mapping for glioma resection. n engl j med. 2008;358:18–27. 9. sanai n, polley my, mcdermott mw, parsa at, berger ms. an extent of resection threshold for newly diagnosed glioblastomas. j neurosurg. 2011 10. sawaya r, hammoud m, schoppa d, hess kr, wu sz, shi wm, wildrick dm. neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. neurosurgery. 1998;42:1044–1055. discussion 10551046. 11. signorelli f, ruggeri f, iofrida g, isnard j, chirchiglia d, lavano a, volpentesta g, signorelli cd, guyotat j. indications and limits of intraoperative cortico-subcortical mapping in brain tumor surgery: an analysis of 101 consecutive cases. j neurosurg sci. 2007;51:113–127. 12. stupp r, mason wp, van den bent mj, weller m, fisher b, taphoorn mj, belanger k, brandes aa, marosi c, bogdahn u, curschmann j, janzer rc, ludwin sk, gorlia t, allgeier a, lacombe d, cairncross jg, eisenhauer e, mirimanoff ro. radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. n engl j med. 2005;352:987–996. 13. wu js, zhou lf, tang wj, mao y, hu j, song yy, hong xn, du gh. clinical evaluation and follow-up outcome of diffusion tensor imaging-based functional neuronavigation: a prospective, controlled study in patients with gliomas involving pyramidal tracts. neurosurgery. 2007;61:935–948. discussion 948-939. 14. yasargil mg, kadri pa, yasargil dc. microsurgery for malignant gliomas. j neurooncol. 2004;69:67–81. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 107gjra global journal for research analysis introduction: the pathognomonic presentation of glomus tumour is painful (1) (2) (1)tip , cold hypersensitivity and nail deformity . the main focus of treating these tumours must take into account the (3)chance of recurrence , and post excision nail deformity. it (4)constitutes about 1 – 5 % of all hand tumours and 50 % occurs (5)in the subungual site . in this study we shall review eight cases of glomus tumour most of which presented to us more than 3 years of duration with severe nail deformity and pain. all cases were subungual in position. methodology: a retrospective study of eight patients with subungual glomus tumour from the march 2015 to september 2018 were studied. 6 female patients and 2 male patients with mean age of 29 (18 to 43). common presentation was nail deformity with colour change through the nail and 3 patients had cold (2)hypersensitivity (hildreth's test positive) and all patients had pain. mean age of presentation to was 30 years. cases were followed up for 1 year with no case of recurrence. three of the cases had completely deformed nail(figure 1-3) and nailbed and required reconstruction with a reverse cross (7-nger ap and the remaining 5 cases transungual approach 9) was done with reconstruction of nail bed and splinting with (10)the same nail . specimen was sent for histopathologic conrmation, and all 8 cases turned out to glomus tumour. follow up was done every 3 months for upto 1 year, and 2 patients had recurrence of pain which resolved with medications and no cases of recurrence. case 1: 23 year female patient with symptoms of nail deformity , pain and cold hypersensitivity for past 3 years, with previous surgical excision 4 years back. managed with total excision of the nail bed and the nail, reconstruction was possible only with a reverse cross nger ap. (figure 1 – 6) figure 1-3 – subungual glomus tumour of left middle nger with nail deformity 1) dorsal view 2) radial lateral view 3) tip of the nger figure 46: steps of the reverse cross nger ap 4) elevating the dermal ap 5) the subdermal fascial ap 6) nal inset over the defect case 2: a 26 year old female with similar symptom triad for past 2 years without signicant nail deformity figure 7 transungual approach subungual glomus tumours of hand: an institutional study original research paper dr. sridharan murugesan m.ch associate professor,department of plastic ,reconstructive & faciomaxillary surgery,madras medical college,chennai-3. plastic surgery glomus tumours were rst described by hoyer in 1877 , while the rst complete clinical description was given by masson in 1924. a glomus tumour is a rare neoplasm arising from the glomus body and mainly found under the nail, on the ngertip or in the foot. the majority of glomus tumours are benign, but they can also show malignant features in less than 2% cases. our study includes 8 clinical cases of glomus tumours and our institutional experience in their management. abstract keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. sathya pakkiri postgraduate resident, department of plastic ,reconstructive & faciomaxillary surgery,madras medical college,chennai-3. dr. gnana sezhian manogaran* postgraduate resident,department of plastic ,reconstructive & faciomaxillary surgery, madras medical college,chennai-3. *corresponding author dr. jaganmohan janardhanam professor & h.o.d, department of plastic ,reconstructive & faciomaxillary surgery,madras medical college,chennai-3. 26 x gjra global journal for research analysis discussion: glomus tumour is a rare benign tumour arising from the neuromyoarterial component termed as glomus body of the nger , most commonly from the subungual site. there is a predilection for females. it was rst described by wood in 1812 (11). varying symptoms may be present and often times diagnosis is missed or ignored in the initially stages. patient presents with severe nger tip pain, which maybe localised (12)with a love's pin test , nail colour change ,which later progresses to nail deformity and rarely but denite diagnostic (2)symptom of cold hypersensitivity tested by hildreth's test . glomus tumours have been observed in extracutaneous locations not known to contain glomus cells presumably arising from perivascular smooth muscle cells that differentiate into glomoid cells. glomus tumors have been found in a vast array of different organs including the lungs, liver, stomach, colon, and kidneys. glomus tumors in these locations mostly are discovered incidentally or with vague symptoms, but have been found to contain nerve bundles that (13)correlate with presenting symptoms of pain. histopathologically they resemble glomus bodies have 3 components: glomus cells, smooth muscle cells and vasculature. angiocentric uniform sheets of cells with oval nuclei , forming a perivascular “collar” around vessels. three histological variants of glomus tumors are observed. common or solid form with scant smooth muscle and poor vasculature. glomangiomyomas with prominent vasculature and smooth muscle components. glomangiomas with (14)prominent vascular component. a rare variant is the (15)glomangiopericytoma which occurs in the sinonasal tract immunohistochemical and electron microscopic analysis suggest glomus cells have both a smooth cell and pericyte phenotype. briey, glomus tumors are characteristically and diffusely immunoreactive for α-smooth muscle actin (αsma), muscle specic actin (msa), and h-caldesmon. although nonspecic, vimentin and collagen type iv are also expressed. variable expression of cd34, and to a lesser extent (16,17)desmin, has also been reported. besides the clinical features, this tumour occurs commonly in middle aged women, and imaging studies like x ray and mri helps in delineating the extent of the tumour. despite the well-documented cases of glomus tumor, the exact etiopathogenesis and cellular origins of this tumor is poorly understood. several lines of evidence suggest a modied pericytic/modied smooth muscle phenotype for glomus tumor. first, the classic appearance of glomus tumor is that of small uniform glomus cells that are seen in a perivascular (18)arrangement. the main focus of treatment is surgical excision with the (11)capsule and prevention of nail deformity and recurrence. transungual approach has the disadvantage of damaging the nail bed but gives adequate exposure for excision. periungual approach gives poor exposure but doesn't breach the nailbed. conclusion: in our study of 8 patients with subungual glomus tumour, we have observed that there was a predilection of occurrence in females. most patients had presented to us with more than 3 years of symptoms and misdiagnosis during that time. hence atleast 3 cases had severe nail deformity warranting a nail removal for cosmetic and functional reasons. all specimens were sent for histopathology and came out as glomus tumour. follow up for atleast 6 months , 3 cases had nail deformity due to surgery and one case had post op nail deformity. pain was insignicant and managed with analgesics alone. references: 1) bhaskaranand k, navadgi bc. glomus tumour of the hand. journal of hand surgery. 2002 jun;27(3):229-31. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra figure 8 – nailbed repair and splinting with the nail figure 9: mri nger – subungual tumour (6) mri was taken for cases with nail deformity to rule out the extent and degree of invasion xray may show bony indentation or erosion in some case, but it may not be diagnostic. results: the specimen was sent for histopathologic studies. all 8 specimens came as glomus tumour. during the follow up of one year, none of the patients had recurrence, but two had symptoms of painful tip which was treated with short term anti-inammatory and analgesic drugs. nail was deformed in about 3 cases for which reverse cross nger ap had been done. table 1: s..no age sex duration of symptoms symptoms post -op complication recurrence during follow uppain nail deformity cold hypersensitivity 1. 18 f 3 years ✓ ✓ ✓ nail deformity none 2. 21 f 2 years ✓ ✓ pain 〃 3. 43 m 4 years ✓ ✓ nail deformity 〃 4. 28 f 4 years ✓ ✓ 〃 5. 30 f 1 years ✓ ✓ pain 〃 6. 26 f 5 years ✓ 〃 7. 32 m 5 years ✓ nail deformity 〃 8. 37 f 6 years ✓ nail deformity 〃 x 27gjra global journal for research analysis 2) giele h. hildreth's test is a reliable clinical sign for the diagnosis of glomus tumours. the journal of hand surgery: british & european volume. 2002 apr 1;27(2):157-8. 3) dailiana zh, drape jl, viet d. a glomus tumour with four recurrences. the journal of hand surgery: british & european volume. 1999 feb 1;24(1):131-2. 4) rohrich r, hochstein l, millwee r. subungueal glomus tumors: an algorithmic approach. ann plast surg. 1994; 33:300-4. 5) pater t, marks r. glomus tumor of the hallux: case presentation and review of the literature. foot ankle int. 2004;25:434-7. 6) al-qattan mm, al-namla a, al-thunayan a, al-subhi f, el-shayeb af. magnetic resonance imaging in the diagnosis of glomus tumours of the hand. journal of hand surgery. 2005 oct;30(5):535-40. 7) carrol re, berman at. glomus tumors of the hand: review of the literature and report on 28 cases. j bone joint surg 1972; 54a: 691–703. 8) geertruyden jv, lorea p, goldschmidt d et al. glomus tumours of the hand. a retrospective study of 51 cases. j hand surg 1996; 21b: 257–260. 9) newmeyer wl. treatment of glomus tumours. in: green d, ed. operative hand surgery. vol. 2. new york: churchill livingstone, 1993: 2287. 10) ekin a, özkan m, kabaklioglu t. subungual glomus tumours: a different approach to diagnosis and treatment. journal of hand surgery. 1997 apr;22(2):228-9. 11) drape jl, peretti ii, goettmann s et al. subungual glomus tumors: evaluation with mr imaging. radiology 1995; 195: 507–515. 12) mcdermott em, weiss ap. glomus tumors. the journal of hand surgery. 2006 oct 1;31(8):1397-400. 13) batra rb, mehta a, mohan pr, singh kj. glomus tumor of the stomach. indian journal of pathology and microbiology. 2009 jan 1;52(1):77. 14) gombos z, zhang pj. glomus tumor. archives of pathology & laboratory medicine. 2008 sep;132(9):1448-52. 15) thompson ld. sinonasal tract, glomangiopericytoma ear, nose and throat journal. 2004 dec 1;83(12):807-8. 16) fletcher cd, bridge ja, hogendoorn pc, mertens f. who classication of tumours of soft tissue and bone. 2013. lyon: iarc. 2003:305-10. 17) fletcher cd, bridge ja, hogendoorn pc, mertens f. who classication oftumours of soft tissue and bone. 2013. lyon: iarc. 2003:305-10. 18) weiss sw, goldblum jr, folpe al. enzinger and weiss's soft tissue tumors. elsevier health sciences; 2007 nov 29. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 28 x gjra global journal for research analysis introduction para-ovarian cysts are found in between ovary and broad ligament. they constitute about 5-20% of the adnexal mass. they are usually benign and asymptomatic. the incidence of malignancy in these cysts is 2-3%. histopathologically they a r e c l a s s i  e d i n t o t h r e e t y p e s , m e s o n e p h r i c , paramesonephric, or mesothelial. they are a homogenous group of cystic masses originating from the mesosalpinx and lying adjacent to the fallopian tube and ovary. the rate of torsion, malignant transformation is very low in this group. clinical presentation a twenty-four years old nulligravida with primary infertility came to sree balaji medical college and hospital (out-patient department) with complaints of blood-stained mucus discharge for the past 12 days and history of irregular cycles for the past two years. the patient had no other signicant history suggestive of endometrial tuberculosis. on examination, the general condition was stable. abdominal examination (per abdomen) showed a mobile mass of size 14 to 16 weeks, felt more on the right side of the abdomen with cystic in consistency. on per vaginal examination, the cervix was posterior, uterus retroverted, a mobile non-tender cystic mass was felt on the right fornix. abdominal ultrasound examination showed a right sided para-ovarian cyst (size: 13 by 11 cm) noted in the right adnexa. left adnexa is normal. the endometrium was thickened up to th12 mm on day 7 of the cycle. the mri pelvis revealed a large cyst (size: 16 by 13 by 7 cm) in the right adnexa without solid component, probably exophytic mass. routine blood investigations showed no abnormalities. her ca-125 is 205 (index). the endometrial evaluation was done and found to be secretory endometrium and endometrial tuberculosis was ruled out. the risk malignancy index score was calculated, and it was found to be zero. the patient underwent exploratory laparotomy under spinal anesthesia. intraoperative ndings revealed right-sided para ovarian cyst (size: 10 by 9 cm) and right fallopian tube was stretched over the cyst, b/l ovaries and tube were normal. no evidence of endometriosis or tuberculosis was found. the cyst was enucleated and sent for histopathology. chromotubation was done on both sides and a spill was present. postoperative period was uneventful. on histopathological examination, a benign serous cystadenoma was diagnosed. discussion para-ovarian cystadenomas are usually unilateral and rarely cause an internal hemorrhage, torsion or rupture. large cysts can sometimes produce pain. these lesions arise from embryonic remnants or from peritoneal inclusions that are usually benign. clinically para ovarian cyst cannot be distinguished from the ovarian cysts. para ovarian cysts can be seen in any age group; the most commonly encountered age group is the third and fourth decade of life(genadry, parmley, & woodruff, 1977). para-ovarian cysts are simple cysts. there are three histopathological types according to the cells lining the cyst wall. majority of them, approximately 68%, arise from the mesothelium covering the peritoneum composed of the attened epithelium. around 30% arise from the mullerian remnants (paramesonephric) and 2% from the wolfan remnants (mesonephric). the mullerian remnants are lined by secretory ciliated columnar or cuboidal epithelium. the wolfan remnants are lined by attened epithelium or cuboidal epithelium. various types of neoplasms can also be found in the para-ovarian cyst and are not always benign condition. these include serious cystadenoma, serous adenobroma, papil lary serous malignancy, and cystadenocarcinoma. in one case series study (pepe et al. (ref)) out of 59 cases of para ovarian cyst, only 1 case of serous cystadenoma (1.69%) was reported(pepe, panella, pepe, & panella, 1986). in another study out of 140 cases, eight cases were reported as neoplasm (four benign cystadenoma and remaining four cases as malignant cystadenocarcinoma)(genadry et al., 1977). stein et al.'''(stein, koonings, schlaerth, grimes, & dablaing, 1990) concluded the overall incidence of malignancy was 2% in these cysts. savelli et al. have reported a higher incidence of neoplastic paraovarian tumours, 15 out of 50 cases. it is challenging to differentiate between an ovarian and para ovarian cyst clinically. sonography of cystadenoma shows a cystic mass, usually containing few solid nodules and a few septations occasionally(korbin, brown, & welch, 1998). apart from this to diagnose these cysts using ultrasound is not f e a s i b l e a n d r e q u i r e s g r e a t a w a r e n e s s a n d accuracy(darwish, amin, & mohammad, n.d.). in our case the a case report on paraovarian benign serous cystadenoma original research paper dr. srinisha soundararajan junior resident, department of obstetrics and gyanecology, sree balaji medical college and hospital, chennai. x 119gjra global journal for research analysis gynaecology serous tumors usually occur on the ovarian surface and sometimes rarely occur as a primary peritoneal tumor. the origin of extra-ovarian serous tumors is still unclear. here we present a rare case of paraovarian benign serous cystadenoma. case report: a 24-year-old nulligravida with primary infertility came with chief complaints of blood-stained mucus discharge for 12 days and irregular cycles for the past two years. the radiological examination showed a huge cyst in the right adnexal region, for which she was operated and intraoperatively it was found to be a para-ovarian cyst, hence subsequently removed. the histopathological examination revealed benign serous cystadenoma. conclusion: in this case report, we present a rare case of para-ovarian benign serous cystadenoma diagnosed in women of reproductive age group with primary infertility. abstract keywords : volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. c. amirtha* junior resident, department of obstetrics and gyanecology, sree balaji medical college and hospital, chennai. * corresponding auhtor dr. k. saraswathi prof. head of the department, department of obstetrics and gyanecology, sree balaji medical college and hospital, chennai. 120 x gjra global journal for research analysis ultrasound of the whole abdomen, showed a right sided cyst (size: 13 by 11 cm) noted. on mri, a large abdominopelvic cyst (size: 16 by 13 by 9 cm) was seen in right adnexa, the right ovary was seen attached to the cyst. kishimoto et al. concluded that on mri examination, these cysts were homogenous in nature located near the ipsilateral round ligament and uterus. the most important feature is visualizing the ovary separately(kishimoto et al., n.d.), which, in our case, was seen attached to the cyst. hence patient was taken up for exploratory laparotomy, which conrmed the diagnosis of the right para ovarian cyst. conclusion: the probability of the incidence of the neoplastic tumors in the large para-ovarian cyst is substantially high. hence, caution must be exercised to diagnose clinically when detected, and it is often very challenging to differentiate benign versus malignant nature of the lesion. radiological techniques such as ultrasound and mri can aid the diagnosis non-invasively. however, laparoscopy or laparotomy should be a preferred procedure to surgically excise large para-ovarian masses and subsequently perform histopathological examination to rule out the malignancy. figure: intraop picture of right paraovarian cyst references: 1. darwish, a. m., amin, a. f., & mohammad, s. a. (n.d.). laparoscopic management of paratubal and paraovarian cysts. jsls� : journal of the society of laparoendoscopic surgeons, 7(2), 101–106. retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12856838 2. genadry, r., parmley, t., & woodruff, j. d. (1977). the origin and clinical behavior of the parovarian tumor. american journal of obstetrics and gynecology, 129(8), 873–880. https://doi.org/10.1016/0002-9378(77)90520-8 3. kishimoto, k., ito, k., awaya, h., matsunaga, n., outwater, e. k., & siegelman, e. s. (n.d.). paraovarian cyst: mr imaging features. abdominal imaging, 27(6), 685–689. https://doi.org/10.1007/s00261-002-0014-6 4. korbin, c. d., brown, d. l., & welch, w. r. (1998). paraovarian cystadenomas and cystadenobromas: sonographic characteristics in 14 cases. radiology, 208(2), 459–462. https://doi.org/10.1148/radiology.208.2.9680576 5. pepe, f., panella, m., pepe, g., & panella, p. (1986). paraovarian tumors. european journal of gynaecological oncology, 7(3), 159–161. retrieved from http://www.ncbi.nlm.nih.gov/pubmed/3780756 6. stein, a. l., koonings, p. p., schlaerth, j. b., grimes, d. a., & d'ablaing, g. (1990). relative frequency of malignant parovarian tumors: should parovarian tumors be aspirated? obstetrics and gynecology, 75(6), 1029–1031. retrieved from http://www.ncbi.nlm.nih.gov/pubmed/2140437 volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra background in satwant singh sawnhey v. d. ramarathnam, asst. passport ofcer, the supreme court has held that a right to travel is a fundamental right under article 21 of indian constitution and the government has no right to refuse a passport to a person who has applied for the same. it thus became necessary to regulate the issuance of passport and travel documents by law. prior to the act, the government had issued passports in exercise of its executive power on foreign relations. as, the parliament was not in session at that time, the president of india promulgated an ordinance namely "the indian passport ordinance, 1967 (4 of 1967)". the aforesaid act was passed to replace the ordinance. classes of passports and travel documents indian passport cover the following classes of passports are issued under this act 1. ordinary passport; 2. ofcial passport; 3. diplomatic passport. the following classes of travel documents may be issued under this act 1. emergency certicate authorising a person to enter india; 2. certicate of identity for the purpose of establishing the identity of person; 3. such other certicate or document as may be prescribed. impounding of passport the passport authority may impound or cause to be impounded or revoke a passport or travel document:- 1. if the passport authority is satised that the holder of the passport or travel document is in wrongful possession thereof; 2. if the passport or travel document was obtained by the suppression of material information or on the basis of wrong information provided by the holder of the passport or travel document or any other person on his behalf; 3. if the passport authority deems it necessary so to do in the interests of the sovereignty and integrity of india, the security of india, friendly relations of india with any foreign country, or in the interests of the general public; 4. if the holder of the passport or travel document has, at any time after the issue of the passport or travel document, been convicted by a court in india for any offence involving moral turpitude and sentenced in respect thereof to imprisonment for not less than two years; 5. if proceedings in respect of an offence alleged to have been committed by the holder of the passport or travel document are pending before a criminal court in india; 6. if any of the conditions of the passport or travel documents is contravened; 7. if it is brought to the notice of the passport authority that a warrant or summons for the appearance, or a warrant for the arrest, of the holder of the passport or travel document has been issued by a court under any law for the time being in force or if an order prohibiting the departure from india of the holder of the passport or other travel document has been made by any such court and the passport authority is satised that a warrant or summons has been so issued or an order has been so made; 8. a court convicting the holder of a passport or travel document of any offence under this act or the rules made thereunder may also revoke the passport or travel document. restriction on granting passport the passport authority or central shall refuse to issue passport on any one or more of the following grounds, and no other ground 1. that the applicant may, or is likely to, engage in such country in activities prejudicial to the sovereignty and integrity of india: 2. that the presence of the applicant in such country may, or is likely to, be detrimental to the security of india; 3. that the presence of the applicant in such country may, or is likely to, prejudice the friendly relations of india with that or any other country; 4. that in the opinion of the central government the presence of the applicant in such country is not in the public interest; 5. that the applicant is not a citizen of india; 6. that the applicant has, at any time during the period of ve law relating to pass port in india a critical study original research paper mr. p. ashok kumar m.a, llm, phd, research scholar, department of law sv university tirupati.517502 x 9gjra global journal for research analysis arts this paper is purpose of research work. the passports act is an act of the parliament of india "for the issue of passports and travel documents, to regulate the departure from india of citizens of india and for other persons and for matters incidental or ancillary thereto." the act applies to whole of india extending to citizens of india living outside the country. the act replaced the indian passport ordinance 1967 and was enacted by act 15 of 1967 with retrospective effect from 5 may 1967. the act describes the procedures in getting an indian passport, which replaced the british indian passport and the passport act of 1920. in conformity with article 9 of the indian constitution, the act does not allow dual citizenship. under section 12 of the act, a person must surrender his passport if he has acquired the citizenship of a foreign country. abstract keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. t. sitakumari* research supervisor, department of law sv university tirupati.517502 *corresponding author 10 x gjra global journal for research analysis years immediately preceding the date of his application, been convicted by a court in india for any offence involving moral turpitude and sentenced in respect thereof to imprisonment for not less than two years; 7. that proceedings in respect of an offence alleged to have been committed by the applicant are pending before a criminal court in india; 8. that a warrant or summons for the appearance, or a warrant for the arrest, of the applicant has been issued by a court under any law for the time being in force or that an order prohibiting the departure from india of the applicant has been made by any such court; 9. that the applicant has been repatriated and has not reimbursed the expenditure incurred in connection with such repatriation. indian passport an indian passport is issued by the indian ministry of external affairs to indian citizens for the purpose of international travel. it enables the bearer to travel internationally and serves as proof of indian citizenship as per the passports act (1967). the passport seva (passport service) unit of the consular, passport & visa (cpv) division of the ministry of external affairs functions as the central passport organization, and is responsible for issuing indian passports on demand to all eligible indian citizens. indian passports are issued at 93 passport ofces located across india and at 162 indian diplomatic missions abroad. in 2015, india issued about 12 million passports, a number exceeded only by china and the uni ted states. approximately 65 million indians held valid passports as of the end of 2015. history muhammad ali jinnah's passport issued by the british indian empire. british indian passport issued during the british raj british raj british indian passports were issued to british subjects of the british indian empire, as well as to british subjects from other parts of the british empire, and subjects of the british protected states in india (i.e. british protected persons of the 'princely states'). these passports were introduced in british india after the first world war. the indian passport act of 1920 required the use of passports, established controls on the foreign travel of indians, and foreigners travelling to and within india. the passport was based on the format agreed upon by the 1920 league of nations international conference on passports. however, the british indian passport had very limited usage, being valid for travel only within the british empire, italy, switzerland, austria, czechoslovakia, germany, france, spain, norway, sweden and holland. dominion of india the use of the passport was discontinued after the establishment of the dominions of india and pakistan in 1947, and its bearers were entitled to opt for indian, pakistani or british nationality. passport laws were made strict in both the countries in 1952. citizens of both india and pakistan did not need a visa or were issued one on arrival until the second kashmir war. before the war, citizens of both countries could freely travel to each other's countries, despite having gone to war in 1947 over kashmir. joint india-pakistan passport issued to migrants to enable them to visit family, friends and ancestral homes located on the other side of the rad cliffe line. types of passport 3 types of indian passport 1. ordinary passport (dark blue) is issued to ordinary citizens for ordinary travel, such as for vacation, study and business trips (36 or 60 pages). it is a "type p" passport, where p stands for personal. 2. ofcial passport (white cover) is issued to individuals representing the indian government on ofcial business. it is a "type s" passport, s stands for service. 3. diplomatic passport (maroon cover) is issued to indian diplomats, top ranking government ofcials and diplomatic couriers. it is a "type d" passport with d stands for diplomatic. in addition, selected passport ofces in india as well as overseas missions were authorised to issue regular indobangladesh passports and indo-sri lankan passports to volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra indian nationals resident in west bengal, the north-eastern states, tamil nadu and puducherry. these two passports respectively permitted travel to bangladesh and sri lanka only and were not valid for travel to other foreign countries. india stopped issuing the indo-bangladeshi passport in 2013. tatkaal and svp tatkaal passports (for urgent needs), and short validity passport (svp) are also available and these are generally considered ordinary passports once issued. physical appearance contemporary ordinary indian passports have a black or deep bluish-black cover with golden coloured printing.the standard passport contains 36 pages, but frequent travellers can opt for a passport containing 60 pages. some early passports were handwritten, including some issued between 1997 and 2000 with 20 year validity dates. these passports have been ruled invalid by the indian government and holders must replace them with machine-readable versions good for 10 years due to icao regulations. identity information page bio-data page of an indian passport issued since 2013 bio-data page of an indian passport issued prior to 2013 the bio data page contains the following information: 1. type: “p"stands for "personal", "d"stands for "diplomatic", "s"stands for "service" 2. country code: ind 3. passport number 4. surname 5. given name(s) 6. nationality: indian 7. sex 8. date of birth 9. place of birth 10. place of issue 11. date of issue 12. date of expiry 13. photo of passport holder 14. ghost picture of the passport holder (only passports issued since 2013) 15. signature of the passport holder 16. the information page ends with the machine readable passport zone (mrz). the demographics page at the end of the passport book contains the following information: 1. name of father or legal guardian 2. name of mother 3. name of spouse 4. address 5. old passport number 6. file number passport note all passports contain a note in hindi and english, nominally from the president of india, addressing the authorities of all countries and territories: these are to request and require in the name of the president of the republic of india all those whom it may concern to allow the bearer to pass freely without let or hindrance, and to afford him or her, every assistance and protection of which he or she may stand in need. by order of the president of the republic of india” the note bearing page is typically stamped and signed by the issuing authority in the name of the president of the republic of india. languages the text of indian passport is printed in both hindi and english, two ofcial languages of india. emigration check a page in the indian passport with emigration check note. holders of emigration check required (ecr) type passports need a clearance called an emigration check from the government of india's protector of emigrants when going to selected countries on a work visa. this is to prevent the exploitation of indian workers (especially the unskilled and less-educated) when going abroad, particularly to middle eastern countries. ecr type passport holders travelling on a tourist visa do not need a clearance; this is known as an emigration check suspension. emigration check not required (ecnr) status passports are granted to: 1. indian nationals born abroad; 2. indian nationals holding at least a matriculation certicate; 3. all holders of diplomatic or ofcial passports. x 11gjra global journal for research analysis volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 4. all gazetted government servants; 5. all income-tax payers (including agricultural income-tax payers) in their individual capacity; 6. all graduate and professional degree holders (such as doctors, engineers, chartered accountants, scientists, lawyers, etc.); 7. spouses and dependent children of category of certain holders of ecnr passports; 8. seamen in possession of a cdc; 9. sea cadets and deck cadets who have: 1. passed their nal examination on a three-year b.sc. nautical sciences course at t.s. chanakya, mumbai; and 2. undergone three months' pre-sea training at any of the government-approved training institutes such as t.s. chanakya, t.s. rehman, t.s. jawahar, mti (sci), or nipm, chennai, after production of identity cards issued by the shipping master at mumbai, kolkata, or chennai; 10. persons holding a permanent immigration visa, such as visas issued by the uk, usa, or australia; 11. persons possessing a two years' diploma from any institute recognized by the national council for vocational training (ncvt) or the state council of vocational training (scvt), or persons holding a three years' diploma or equivalent degree from an institution such as a polytechnic recognized by the central or a state government; 12. nurses possessing qualications recognised under the indian nursing council act, 1947; 13. all persons above the age of 50 years; 14. all persons who have been staying abroad for more than three years (whether in one continuous period or in aggregate), as well as their spouses; 15. all children up to the age of 18 years. in accordance with a ruling by the ministry of external affairs, passports issued from 2007 onwards do not have the ecnr stamp afxed; instead, a blank page 2 of the passport is deemed to have been ecnr endorsed. as a result, only ecr stamps are now afxed to indian passports. for passports issued before january 2007, no notation in the passport means ecr. for passports issued in or after january 2007, no notation in the passport means ecnr. if emigration check is required, there will be an endorsement in the passport regarding ecr. features since 25 november 2015, indian passports that are handwritten or with an original date of expiry extending to 20 years have not had been valid under icao travel regulations. with more recent indian passports the personal particulars of the passport holder, that were hitherto printed on the inner cover page, are printed on the second page of the document. another added security feature in the newer non-handwritten passports is a ghost picture of the holder found on the right side of the second page. apart from stymieing criminals from printing fake passports, recent changes also help prevent smudging of the document because of inkjet printers. fees the price of a standard passport in india: 1. ₹1500 – fresh issuance or reissue of passport (36 pages, standard size) with 10 year validity. 2. ₹2000 – fresh issuance or renewal of passport (60 pages, 'jumbo' size) with 10 year validity. 3. ₹3500 – first time applicant or renewal with expedited ('tatkaal') service (36 pages) with 10 year validity. 4. ₹4000 – first time applicant or renewal with expedited ('tatkaal') service (60 pages) with 10 year validity. 5. ₹1000 – fresh passport issuance for minors (below 18 years of age) with 5 year validity or till the minor attains the age of 18, whichever is earlier. 6. ₹3000 – duplicate passport (36 pages) in lieu of lost, damaged or stolen passport. 7. ₹3500 – duplicate passport (60 pages) in lieu of lost, damaged or stolen passport. indian passports can also be issued outside india, for which fees varies by country. issuance passport seva kendra in september 2007, the indian union cabinet approved a new passport issuance system under the passport seva project. as per the project, front-end activities of passport issuance, dispatch of passports, online linking with police, and central printing unit for centralised printing of passports will be put in place. the new system is trying to be 'timely, transparent, more accessible and reliable manner' for passport issuance. the applicant has to apply for fresh/reissue of passport through the passport seva system at one of the 77 passport ofces known as "passport seva kendra"s operating throughout the country. biometric passport india has recently initiated the rst phase of biometric epassport for diplomatic passport holders in india and abroad. the new passports have been designed locally by the central passport organisation, the india security press and iit kanpur. it contains a security chip with all personal data and digital images. in the rst phase new passports will have a 64kb chip carrying a photograph of the passport holder and in subsequent phases it will have a ngerprint. the new passport has already been tested with passport readers in the united states and has 4-second response time, while the us passport has 10-second response time. it need not be carried in a metal jacket for security reasons. it will rst need to be skimmed through a reader, after which it would generate an access code which then unlocks the chip for reader access. in india, the e-passport is under its rst phase of deployment and is restricted to diplomatic passport holders. on 25 june 2008 the indian passport authority issued the e-passport to the then president of india pratibha patil. as of 2016, the government has plans to issue e-passports to all of its citizens. also the government has authorized indian security press to oat a global three-stage tender for procurement of icaocompliant electronic contactless inlays along with its operating system, which is required for the manufacture of biometric passports. the necessary procurement have been initiated by india security press, nasik by calling for global tender for the supply of electronic contactless inlays. the actual transition to the new age passport is expected to commence on the successful completion of the tendering and procurement process. passport power and visa requirements visa requirements for indian citizens are administrative entry restrictions by the authorities of other states placed on citizens of india. passport power ranking and visa-free travel visa requirements for indian citizens 1. india 2. visa free 3. freedom of movement 4. visa issued upon arrival volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 12 x gjra global journal for research analysis 5. electronic/pre arrival authorisation or evisa 6. visa available both on arrival or online 7. visa required prior to arrival as of september 2019, henley passport index ranks indian passport at 79th place with visa-free or visa on arrival access to 61 nations and territories to indian citizens.as of september 2019, the passport index ranks indian passport 70th place on global ranking with 66 mobility ranking (based on visa-free or visa on arrival access to nations or territories) and 144th individual rank (based on un human development index). furthermore, indian citizens may live and work freely in nepal under the terms of the 1950 indo-nepal treaty of peace and friendship. references wikipedia journals 1. "fee structure : document advisor passport seva". passportindia.gov.in. retrieved 26 march 2018. 2. "mea cpv division". cpv. 3. "india ranks third in issuing passports times of india". times of india. 1 january 2016. archived from the original on 2 january 2016. retrieved 29 january 2016. 4. "dominions 1931-1947". historical atlas of the british empire. retrieved 16 december 2015. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 13gjra global journal for research analysis introduction pthirus pubis linnaeus, 1758 (anoplura: pthiridae), is a hematophagous and ectoparasite insect, known as a crabs or lobster crab. the insect does not transmit any infectious agent, prefers temperatures from 28 to 32 °c and cannot live outside the body for more than one day (alarcón, hinostroza & santamaría 2001). the typical infestation of pthirus pubis in the world is approximately 2% of the adult population. according to ibarra 1993, p. pubis has a cosmopolitan distribution. records are often related to clinical records of sexually transmitted diseases or travel data (díaz, 2006). pubic lice have been present in the human population for thousands of years, but they have never been of great importance as a serious plague (anderson & chaney, 2009). in south america in pre-columbian cultures and the chiribaya culture in southern peru, evidence of the presence of pubic lice in human remains is reported (rick et al., 2002). the infestation of these parasites is attributed to the lack of hygiene and promiscuity, it is a parasite that is transmitted sexually, but it has been observed that transmission can occur by contact with clothing, sheets and personal items of infected people (pérez-cano, 2013). it is found with high prevalence in prisons, brothels and similar places (ragne et al., 1995). in addition, the socieconomic status and disaster situations are factors in the transmission (díaz 2006). information on reports of pubic lice is less frequent than head or body lice, yet their epidemiology is important due to the correlation with the appearance of other sexually transmitted diseases (stds) and these adapt to a sedentary lifestyle in pubic hair, body hair, groin, perianal region and sometimes in eyelashes (newsome et al., 1979; rundle, 1993; klaus, shvil & mumcougly, 1994; hernández-contreras et al., 2001; mimouni et al., 2001, pierzchalski et. al., 2002; bingel 2005; flinders & deschweinitz 2005; pakeer et al., 2008; yagoob 2015; tang & ran 2017; lin li 2018). according to mumcuoglu (2015), p. pubis infection is more frequent in adults than in children. veraldi, pontini & nazzaro (2018), reports it on children's eyelashes and eyebrows and nazzal et al., (2019), indicates phthiriasis palpebrarum (eye infestation) as rare disease. case report we describe a case of infestation by pthirus pubis in a 46-yearold adult man. the patient presented in our department due to pruritus in the left eye for 3 weeks. the skin test found small yellowish-brown ecks attached to the eyelashes. brown or white eggs or nits containing nymphs were observed, these were rmly attached to the base of the eyelash hair. adults were seen grabbing the hairs of the eyelashes with claws or inserted in the eyelid and sucking blood. the adult females of p. pubis found are semi-transparent. the patient reports that approximately 1 month after his return from a trip to austria in a tourist area, he felt severe itching in his left eye. the patient did not have a history of any std, or known infestation in any other part of his body. slit lamp biomicroscopy revealed multiple eggs attached to the eyelashes along with eight insects moving in the margin of the top line of the eyelash and much secretion accumulated in the tear. examination of insects under light microscopy revealed translucent crawsh, wingless, with three pairs of legs and claws. insect sizes were between 2 and 5.5 mm, the species was conrmed as phthiriasis palpebrarum caused by pthirus pubis [figure 1]. for identication we rely on anane et al., 2013 & salavastru et al., 2017. the patient was successfully treated with mechanical removal of insects and nits together with the application of topical permethrin at 1%. figure 1. pthirus pubis. a. biomicroscopy of an adult's left eye. (scale bar= 10 mm). b. the arrow indicates, eggs attached to the patient's eyelashes. (scale bar= 10 mm). c. scanning electron microscopy of adults (500 µm). d. scanning electron microscopy of egg. (200 µm) e. drawing of an adult female. (scale bar= 0.5 mm). f. drawing of egg attached to an eyelash. (scale bar= 0.12 mm). phthiriasis palpebrarum (pthirus pubis): a case report in the dominican republic original research paper o. p. perdomo* instituto tecnológico de santo domingo (intec) área de ciencias básicas y ambientales av. de los próceres 49, 10602. santo domingo. dominican republic *corresponding author clinical research pthirus pubis, is a hematophagous and ectoparasite insect. we present the case of a 46-year-old male patient diagnosed with an eye infection. phthiriasis palpebrarum is reported for the rst time for the dominican republic. abstract keywords : human louse, pthirus pubis, dominican republic. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra a. pineda facultad de ciencias. escuela de microbiología y parasitología universidad autónoma de santo domingo santo domingo. dominican republic a. binet álvarez facultad de ciencias. escuela de biología universidad autónoma de santo domingo santo domingo. dominican republic 80 x gjra global journal for research analysis conclusion it is necessary to alert the health centers of the country and the medical schools of the universities to promote informative and educational efforts of this insect and the importance of monitoring these ectoparasites to assess emerging and modiable trends and behaviors in order to establish treatment and prevention measures. phthiriasis palpebrarum (ocular infestation) had never been reported in eyelashes in the dominican republic and is frequently misdiagnosed as blepharoconjunctivitis of bacterial or viral etiology. acknowledgements the authors thank queiroz portorreal of the instituto tecnológico de santo domingo (intec) for the assistance in scanning electron microscopy photography, the espaillat cabral institute for providing us with the photo of biomicroscopy, daniel ortega for the illustration of p. pubis and linda m. rodríguez guglielmoni of the english department of the university of puerto rico-mayagüez for the revision of the text. references 1. alarcón h, hinostroza d, santmaría, v. rev. cent. dermatol pascua. 2001; 10 (3): 130-4. 2. anane s, malek i, kamoun r & chtourou o. phthiriasis palpebrarum: diagnosis and treatment. j fr ophtalmol. 2013; 36, 815-819. 3. anderson al, chaney e. pubic lice (pthirus pubis): history, biology and treatment vs. knowledge and beliefs of us college students. int. j. environ. res. public health. 2009; 6: 592-600. 4. bignell c. lice and scabies. medicine. 2005; 33: 76-7. 5. díaz, jh. the epidemiology, diagnosis, management, and prevention of ectoparasitic diseas in travelers. j. trav. med. 2006; 13: 100-111. 6. flinders dc, deschweinitz p. pediculosis and scabies. am. fam. phys. 2004; 69: 341-8. 7. hernández-contreras n, isla garcía m, vega correa, e. infestación del cabello por pthirus pubis (anoplura: pediculidae). rev. cubana med. trop. 2001; 53 (1): 63-7. 8. ibarra j. lice (anoplura). in: medical insects and arachnids (editors, r. p. lane & r. w. crosskey).1993; pp 517-528, chapman & hall, london. 9. klaus s, shvil y, mumcougly ky. generalized infestation in a 3 ½ year old girl with the pubic louse. pediatr dermatol. 1994; 11 (1): 26-8. 10. lin li, md, xueying liu, bs, leixu, md, yonghong lu, md. jaad case reports. 2018; 4: 168-9. 11. mimouni d, grotto i, haviv j, gdalevich m, huerta m, shpilberg o. secular trends in epidemiology of pediculosis capitis and pubis among israeli soldiers: a 27–year follow-up. int. j. derm. 2001; 40:637-9. 12. mumcuoglu ky. pubic louse (pthirus pubis) infestation of the scalp in a 4 years old infant. cumhuriyet medical journal. 2015; 37 (3): 241-3. 13. nazzal rm, al antary, tm, al antary nt. a case report of human infestation with crab louse pthirius pubis (anoplura: pthiridae) from jordan. 2019; fresenius environmental bulletin 28 (7): 5695-7. 14. newsome jh, fiore jl, jr. hackett e. treatment of infestation with pthirus pubis: comparative efcacies of synergized pyrethrins and gamma-benzene hexachloride. sex. transm. dis. 1979; 6: 203-5. 15. pakeer o, john j, mohamed abdullah m, ahmad f, baharudin o. four cases of pediculosis caused by pthirus pubis linnaeus, 1758 (diptera: anoplura) from peninsular malaysia. 2008. tropical biomedicine 24 (2): 101-3. 16. pérez-cano h. pthrius pubis y phthiriasis palpebral. revista médica md. 2013; 5 (1): 49. 17. pierzchalski jl, bretl da, matson sc. pthirus pubis as a predictot for chlamudia infections in adolescents. sex. transm. dis. 2002; 29: 331-4. 18. ragne da, morsy ta, abdala hm, abou-gamra mm. in vitro control of pthirus pubis with our pediculocides: eurax. elimite, licid and benzamil. j. egypt soc. parasitol. 1995; 25 (3): 677-8. 19. rick fm, rocha gc, dittmar k, coimbra, cea, reinhard k, boches f, ferreira lf, araújo a. crab infestation in pre-columbian america. journal of parasitology. 2002; 88 (6): 1266-67. 20. rundle pa. pthirus pubis infestation of the eyelids. br. j. opthalmol. 1993; 77 (12): 815-6. 21. salavastru cm, chosidow o, janier m & tiplica gs. european guideline for the management of pediculosis pubis. j eur acad dermatol venereol. 2017; 31(9): 1425¬-8. 22. tang jq, ran x, ran yp. coverimage: dermoscopy in vivo for the life cycle of pthirus pubis. br j dermatol. 2017; 176: 279. 23. veraldi s, pontini p, nazarro g. pthirus pubis infestation of the scalp: a case report and review of the literature. korean j. parasitol. 2018; 56: 487-9. 24. yagoob g. a case report of human infestation with pubic louse (pthirus pubis) in sarab city, iran medical science and discovery. 2015; 2(3): 228-30. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 81gjra global journal for research analysis 15.bluetree 02.cdr type 2 diabetic patients are often treated with a combination of antidiabetic agents. the need to use drugs with different and complementary mechanisms of action frequently arises in daily clinical practice. there are several reasons to do this; namely, the disease itself is progressive, with the deterioration of glycemic control over time, and monotherapeutic attempts to achieve and maintain glycemic control often fail in the long 1run . some patients do not accept insulin treatment because of the fear of needles and injections, the fear that the complications of diabetes are caused by insulin, and other false beliefs, and are willing to take as many anti-diabetic pills. several pharmacological agents have been developed to treat patients with type 2 diabetes mellitus. they either improve insulin resistance (biguanides and thiazolid ine diones), stimulate insulin secretion from the �-cell (sulphonyl ureas and metaglinides), or decrease glucose absorption 2from the gut (α-glucosidase inhibitors) . metformin monot he rapy is initially recommended along with lifestyle modica tions (increased physical activity and weight loss) for glycemic management of type 2 dm. however, if glucose levels are not controlled in patients with type 2 diabetes, other classes of antidiabetic agents are then additionally required. coadministration of glimepiride and metformin has been 3used to achieve glucose control . combination therapy using sulfonylurea and metformin, which respectively promotes insulin secretion and improves insulin resistance, is an effective and complementary method that improves both of the main causes of type 2 diabetes and has been reported by ukpds and other clinical studies to be 4more effective than monotherapy of both drugs . metformin improves insulin resistance and is recommended as the rstchoice medication for newly diagnosed type 2 diabetes patients by most guidelines. glimepiride is a third-generation sulfonylurea that stimulates insulin secretion. unlike conventional sulfonylurea, glimepiride has high selectivity toward the pancreatic atp-sensitive potassium channel, increases glucose t ranspor t , and shows var ious extrapancreatic effects in muscle and fat cells. for these benets, glimepiride is prescribed as a primary monotherapy or additional medication when metformin monotherapy has failed. various trials have established the efcacy of the combination of metformin with glimepiride. kim et al. compared the efcacy and safety of early combination therapy with glimepiride/metformin to metformin up-titration in reducing glycated hemoglobin (hba1c) levels in korean type 2 diabetic patients inadequately controlled on low-dose metformin monotherapy. the study was a randomized, openlabel, parallel-group, multicenter study, 209 korean type 2 diabetic patients (hba1c 7.0–10.0%, on metformin 500–1,000 mg/day) received glimepiride/metformin xed-dose combination (g/m fdc) or metformin uptitration treatment (met up). the primary end-point was the change in hba1c from baseline to week 24. g/m fdc therapy provided signicantly greater adjusted mean decreases vs met up therapy in hba1c (-1.2 vs -0.8%, p < 0.0001), and fasting plasma glucose (-35.7 vs -18.6 mg/dl, p < 0.0001). a signicantly greater proportion of patients with g/m fdc therapy achieved hba1c <7% (74.7 vs 46.6%, p < 0.0001) at the end of the study. a modest increase in mean body weight occurred in the patients who were treated with g/m fdc therapy (1.0 kg), whereas a slight decrease was observed in the patients who were treated with met up therapy (-0.7 kg). it was concluded that glimepiride/metformin xed-dose combination therapy was more effective in glycemic control than metformin uptitration, and was well tolerated in type 2 diabetic patients inadequately controlled by low-dose 4metformin monotherapy in korea . ortiz et al., compare the efcacy of glimepiride/metformin combination versus glibenclamide/metformin for reaching glycemic control in patients with uncontrolled type 2 diabetes mellitus. a randomized, double-blind, multicenter clinical trial was performed in 152 uncontrolled type 2 diabetic patients. serum fasting and postprandial glucose, hemoglobin a1c (a1c), high-density lipoprotein cholesterol, and triglycerides were measured. each study group included 76 patients. no signicant differences in basal clinical and laboratory characteristics between groups were found. at the end of the study, a1c concentration was signicantly lower in the glimepiride/metformin group (p=.025). a higher proportion of patients from the glimepiride group (44.6% vs. 26.8%, pb.05) reached the goal of a1c b7% at 12 months of treatment. a higher proportion of hypoglycemic events were observed in the glibenclamide group (28.9% vs. 17.1%, pb.047). it was found that glimepiride/metformin demonstrated being more efcacious than glibenclamide/metformin at reaching the glycemic control goals with less hypoglycemic events in 5patients with uncontrolled type 2 diabetes mellitus . young park et al., compare the commonly prescribed oral antidiabetic drug (oad) combinations to use as add-on therapy with insulin glargine in patients with uncontrolled type 2 addition of voglibose to the dual combination therapy of glimepiride and metformin in the management of type 2 diabetes original research paper x 41gjra global journal for research analysis medicine volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr bharat gupta kalyan health care, m. r. complex, near bhuteshwar temple, bhuteshwar, mathura 281004 keywords : dr girish hiregaudar* vallabh clinic, ruikar colony, kolhapur,416005 *corresponding author dr lakshman jambgi ashirwad hospital head post harugeri -591220 dr kiran patil 501/502 vishal villa, plot no. 167, veer savarkar marg, shivaji park dadar west, mumbai-400028 dr mahesh p rdshiva speciality clinic, #212, ground floor, 4th cross, 3 main, dr shivaramkaranth road, hanumanthnagar bangalore-560019 42 x gjra global journal for research analysis diabetes despite submaximal doses of oads. 99 patients with inadequately controlled type 2 diabetes were randomly assigned on a 1:1:1 basis to receive insulin glargine, with xed doses of glimepiride, metformin, and glimepiride plus metformin. outcomes assessed included hba1c, the changes in fasting glucose levels, body weight, serum lipids values, insulin dose, and symptomatic hypoglycemia. after 24 weeks, hba1c levels improved from (mean ± sd) 8.5±0.9% to 7.7±0.8% (69.0±10.0 mmol/mol to 60.8±8.6 mmol/mol) with insulin glargine plus metformin, from 8.4±1.0% to 7.7±1.3% (68.8±10.6 mmol/mol to 61.1±14.4 mmol/mol) with insulin glargine plus glimepiride and from 8.7±0.9% to 7.3±0.6% (71.7±9.8 mmol/mol to 56.2±6.7 mmol/mol) with insulin glargine plus glimepiride plus metformin. the decrease in hba1c was more pronounced with insulin glargine plus glimepiride plus metformin than with insulin glargine plus metformin (0.49% [ci, 0.16% to 0.82%]; p = 0.005) (5.10 mmol/mol [ci, 1.64 to 8.61]; p = 0.005) and insulin glargine plus glimepiride (0.59% [ci, 0.13% to 1.05%]; p = 0.012) (5.87 mmol/mol [ci, 1.10 to 10.64]; p = 0.012) (overall p = 0.02). weight gain and the risk of hypoglycemia of any type did not signicantly differ among the treatment groups. it was concluded that the combination therapy of metformin and glimepiride plus glargine insulin resulted in a signicant improvement in overall glycemic control as compared with the 6other combinations . although the combination of a sulfonylurea with metformin is commonly used in clinical practice, however, when this potent combination is no longer able to provide acceptable glycemic control, the addition of an antidiabetic drug with a different 1mode of action may lead to improved metabolic control . the addition of the second agent usually lowers the mean hba1c level of 1.0 to 1.4% more than monotherapy when the baseline value is between 8.5% and 9.5%. thus by using dual therapy and when the hba1c is >9 it is not possible to achieve the desired hba1c target i.e. <6.5%. thus, it is proposed that a third agent with a different mechanism of action can be added to the existing dual therapy if the hba1c level achieved with two agents is 8.0% or less. it has been observed that postprandial glucose level plays a major role in complications, thus besides controlling the fasting glucose, it is very important to control the postprandial glucose level aggressively. thus a triple-drug combination is suggested that can specically control postprandial hyperglycemia by 7reducing intestinal glucose absorption . a combination of voglibose, metformin and glimepiride is one such combination. all three drugs act by different mechanisms and can control both fasting and postprandial glucose levels. voglibose is an alpha-glucosidase inhibitor, known for its ability to increase and prolong glucagon-like peptide-1 (glp1) secretion in t2dm subjects which shows inhibitory action on glucagon secretion and lowers fasting glucose levels. increased release of glp-1, which is an insulinotropic hormone, enhances insulin secretion and insulin sensitivity. it also delays the absorption as well as digestion of dietary polysaccharides by reversibly inhibiting carbohydrate digestive enzymes. voglibose has shown to improve glucose tolerance by inhibiting digestion, absorption of glucose from the intestine and decrease postprandial glucose without 8inducing over secretion of insulin . trials have established the efcacy of the combination of voglibose and metformin. oh et al., compared the efcacy and safety of a xed-dose combination of voglibose plus metformin (vogmet) with metformin monotherapy in drugnaïve newly-diagnosed type 2 diabetes mellitus. a total of 187 eligible patients aged 20 to 70 years, with a glycosylated hemoglobin (hba1c) level of 7.0% to 11.0%, were randomized into either vogmet or metformin treatments for 24 weeks. a change in the hba1c level from baseline was measured at week 24. the reduction in the levels of hba1c was −1.62%±0.07% in the vogmet group and −1.31%±0.07% in the metformin group (p=0.003), and signicantly more vogmet-treated patients achieved the target hba1c levels of <6.5% (p=0.002) or <7% (p=0.039). glycemic variability was also signicantly improved with vogmet treatment, as estimated by m-values (p=0.004). gastrointestinal adverse events and hypoglycemia (%) were numerically lower in the vogmet-treated group. moreover, a signicant weight loss was observed with vogmet treatment compared with metformin (−1.63 kg vs. −0.86 kg, p=0.039). it was concluded that vogmet is a safe antihyperglycemic agent that controls blood glucose level effectively, yields weight loss, and is superior to metformin in terms of various key glycemic parameters 9without increasing the risk of hypoglycemia . faruqui., carried out post-marketing surveillance (pms), non-randomized, open, non-comparative, mono-centric study. the drug administered was a xed-dose combination of voglibose 0.2 mg; glimepiride, 0.5 mg, and metformin 500 mg sustainedrelease (sr). fifty type 2 diabetic patients were given a xeddose combination twice daily with major meals for 3 months. baseline value was recorded for glycated hemoglobin (hba1c), fasting plasma glucose (fpg) and postprandial blood glucose/hyperglycemia (pphg) level. it was found that there was a signicant decrease from baseline in hba1c value 10.6 ± 1.3 vs. 6.6 ± 0.4 (p< 0.0001), fpg levels 208.33mg/dl vs. 118.06 (p< 0.0001), and pphg levels 360.14 mg/dl vs. 168.36, (p< 0.0001) after 3 months of treatment. the combination was found to be effective in controlling both fasting and postprandial glucose levels and was well tolerated. investigator commented that the use of triple-drug combination is a good option in the management of type 2 diabetes which controls both fasting as well as postprandial 10blood glucose and ultimately hba1c values . conclusion metformin has been the mainstay and rst-line treatment for the management of type 2 diabetes. however, the management of type 2 diabetes often requires a combination of antidiabetic agents. for the successful management of both insulin resistance and � cell dysfunction, there arises a need for combination therapy with agents having complementary mechanisms of action. the outcome of clinical trials like ukpds laid the basis of usage of metformin along with glimepiride. to further maintain glycemic control, a triple combination of voglibose and metformin & glimepiride has been proposed. trials have conrmed the efcacy and safety of this triple combination, though large scale trials are needed. used wisely, with adequate medication counseling, triple fdcs provide effective glycemic control in a safe, welltolerated, and economic manner. references 1. sharma ak, srinivasan bp. triple verses glimepiride plus metformin therapy on cardiovascular risk biomarkers and diabetic cardiomyopathy in insulin resistance type 2 diabetes mellitus rats. eur j pharm sci. 2009;38(5):433-444. doi:10.1016/j.ejps.2009.09.004 2. derosa g, putignano p, bossi ac, et al. exenatide or glimepiride added to metformin on metabolic control and on insulin resistance in type 2 diabetic patients. eur j pharmacol. 2011;666(1-3):251-256. doi:10.1016/j.ej phar.20 11.05.051 3. shin kh, kim se, yoon sh, et al. pharmacokinetic comparison of a new sustained-release formulation of glimepiride/metformin 1/500 mg combination tablet and a sustained-release formulation of glimepiride /metformin 2/500 mg combination tablet in healthy korean male volunteers: a randomized. clin ther. 2011;33(11):1809-1818. doi:10.1016 /j.clin thera .2011 .10.003 4. kim h soon, kim d man, cha b soo, et al. efcacy of glimepiride/metformin xed-dose combination vs metformin uptitration in type 2 diabetic patients inadequately controlled on low-dose metformin monotherapy: a randomized, open label, parallel group, multicenter study in korea. j diabetes investig. 2014;5(6):701-708. doi:10.1111/jdi.12201 5. gonzález-ortiz m, guerrero-romero jf, violante-ortiz r, et al. efcacy of glimepiride/metformin combination versus glibenclamide/metformin in patients with uncontrolled type 2 diabetes mellitus. j diabetes complications. 2009;23(6):376-379. doi:10.1016/j.jdiacomp.2008.09.002 6. park cy, kang jg, chon s, et al. comparison between the therapeutic effect of metformin, glimepiride and their combination as an add-on treatment to insulin glargine in uncontrolled patients with type 2 diabetes. plos one. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 2014;9(3). doi:10.1371/journal.pone.0087799 7. c. rao aaf. efcacy and safety of oral triple drug combination (voglibose, glimepiride and metformin) in the management of type 2 diabetes mellitus. int j curr res rev. 2013;5(16):20-26. 8. ghadge aa, kuvalekar aa. controversy of oral hypoglycemic agents in type 2 diabetes mellitus: novel move towards combination therapies. diabetes metab syndr clin res rev. 2017;11:s5-s13. doi:10.1016/j.dsx.2016.08.009 9. oh tj, yu jm, min kw, et al. efcacy and safety of voglibose plus metformin in patients with type 2 diabetes mellitus: a randomized controlled trial. diabetes metab j. 2019;43(3):276-286. doi:10.4093/dmj.2018.0051 10. faruqui aa. safety and efcacy of fixed dose combination of voglibose, glimepiride and metformin in indian type 2 diabetes mellitus patients. adv diabetes metab. 2016;4(3):49-54. doi:10.13189/adm.2016.040302 x 43gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra background scrub typhus is an acute undifferentiated febrile illness and could be life threatening. causative agent is orientia tsutsugamushi, an obligate intracellular bacteria which is transmitted by larval trombiculid mite, which is the reservoir in 1vertebrate host. scrub typhusis prevalent in the south eastern asia and the western pacic. approximately one million cases 2are reported annually. scrub typhus often goes undiagnosed due to its varied clinical symptoms and lack of a denitive 3protocol for its diagnosis. it is considered a differential diagnosis in patients with acute febrile illness which is associated with hepatic dysfunction, thrombocytopenia, renal 4impairment, altered sensorium, pneumonitis or ards. it is characterized by eschar at the site of the bite, fever, headache, myalgia and gastrointestinal symptoms including nausea, vomiting and diarrhea.gastrointestinal presentations such as acute acalculous cholecystitis, duodenal ulcer perforation, 5peritonitis and gastric ulceration can occur. pancreatitis occurs in scrub typhus when it is complicated by pancreatic abscess or multiorgan failure and along with other confections.scrub typhus cause widespread endothelial cell invasion leading to vasculitis and perivasculitis of small blood 6vessels leading to acute pancreatitis. aim and objectives 1) to study involvement of pancreas in scrub typhus patients. 2) to study the relation between elevated serum amylase and lipase levels with the severity of scrub typhus. 3) to corelate evidence of pancreatitis in usg and elevated serum amylase and lipase levels in scrub typhus patients. materials and method this study was conducted from june 2018 to december 2018 in the department of medicine in geetanjali medical college and hospital, udaipur. study consisted of 26 adult patients admitted with signs and symptoms suggestive of scrub typhus. a detailed clinical history and clinical examination was done. scrub typhus was diagnosed by rapid immunoch romatographic assay. all these patients were investigated for routine blood tests like complete blood counts with peripheral smear, liver and renal function tests, serum amylase, lipase, urine routine and ultrasonography of abdomen. patients having other illnesses like recent intrabdominal surgery, ercp, gall stone disease, alcoholics, renal failure, carcinoma of lung or breast and patients on drugs such as sulfonamides, valproic acid, art, estrogen were excluded. pregnant females and patient having other co-infections like malaria, dengue, enteric fever, uti and septicemia were also excluded. results among 26 adult patients diagnosed as scrub typhus, 16 were males and 10 were female showing male preponderance. 8 out of 26 patients (30.7%) were of age group between 31 to 40 year. out of various presenting symptoms, fever was present in 22 patients (84.6%) being the most common symptom. other symptoms were abdominal pain in 18 patients (69.2%), vomiting in 16 patients (61.5%), diarrhea in 8 patients (30.8%), nausea in 14 patients (53.8%), bodyache in 17 patients (65.4%), jaundice in 13 patients (50.0%), altered sensorium in 2 patients (7.6%), diarrhea in 30.7% and bleeding manifestation in form of hematuria and blood in stool in 8 patients (30.8%). mean duration of symptoms was 7 days. raised serum amylase was seen in 15 patients (57.6%) and serum lipase in 11 patients (42.3%). on ultrasonographic examination of abdomen, bulky pancreas and presence of peripancreatic uid was seen in 5 patients (19.2%). out of these, 4 patients had high serum lipase and amylase. 14 (53.8%) patients had hepatic involvement in form of elevated serum sgot, sgpt, bilirubin (direct bilirubinemia), alkaline phosphatase and hepatomegaly on usg. there was elevated serum creatinine, urea and blood urea nitrogen along with decreased urine output in 5 (19.2%) patients suggesting renal involvement, in which 4 patients required hemodialysis support. 8 (30.8%) patients had hypotension and required vasopressor support to maintain blood pressure. there was pulmonary involvement in 4 patients (15.4%) in form of bilateral crackles, bilateral x-ray inltrates, hypoxia and required mechanical ventilatory support. out of 26 patients 4 (15.4%) had multiorgan dysfunction. central nervous system (cns) dysfunction was observed only in two patients. pancreatic involvement in scrub typhus original research paper mistry abhishek resident, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india x 53gjra global journal for research analysis general medicine background scrub typhus is transmitted by infected larva of trombiculid mite in areas of heavy scrub vegetation during rainy season. it is characterized by eschar at the site of the bite, fever, maculopapular rashes and local and/or generalized lymphadenopathy. pancreatitis with scrub typhus has been described when it is complicated by pancreatic abscess, multiorgan failure with other confections. method26 adult scrub typhus patients were studied at geetanjali medical college and hospital, udaipur, rajasthan. scrub typhus was diagnosed by rapid immunochromatographic assay along with routine blood tests, serum amylase, lipase and ultrasonography of abdomen. resultsamong 26 scrub typhus positive patients, 16 were male and 10 were females with mean age of 50 years. fever and abdominal pain were most commonly observed symptom, with mean duration of 7 days. 11 (42.3%) patients had raised serum lipase and 15 (57.6%) had raised serum amylase levels. on usg of abdomen 5 (19.2%) patients had evidence of pancreatitis out of which 4 had high serum lipase and amylase. 14 (53.8%) patients had multiorgan dysfunction of which 3 patients died. conclusionthis observation highlights the importance of pancreatitis as an uncommon & serious complication, where prompt diagnosis and early management can be lifesaving. abstract keywords : pancreatitis, scrub typhus. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra pathak praharsh* resident, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india *corresponding author kumawat d. c. professor and head, department of general medicine, geetanjali medical college and hospital, udaipur, rajasthan, india 54 x gjra global journal for research analysis discussion orientia tsutsugamushi is the causative agent of scrub typhus, transmitted by infected larva of trombiculid mite or chiggers in mostly during rainy season. the incubation period is 6 to 21 days. the onset is characterized by fever, headache, myalgia, cough and gastrointestinal symptoms such as nausea, vomiting, abdominal pain, diarrhea which occurring in 7varying frequency. the most useful diagnostic clue is an eschar formation at the site bitten by the mite of size about 5 – 820mm. abdomino pelvic involvement is characterized by splenomegaly and hepatomegaly. pathological ndings in the liver include hepatic congestion, periportal inammation 9and peripheral necrosis. gallbladder thickening may also be seen in patients with scrub typhus and could be due to acute vasculitis with perivasculitis similar to that seen in liver. the diagnosis of scrub typhus depends on clinical suspicion and appropriate laboratory investigations. although the disease is self-limiting, an early, accurate and prompt diagnosis is necessary to reduce the mortality and morbidity. laboratory diagnosis of scrub typhus was previously by weil10felix agglutination reaction. currentlyserological tests are indirect immunouorescence, indirect immunoperoxidase and elisa. other rapid detection kits like rapid immunochr 11omatography and dipsticks are also available. pancreatitis is mainly diagnosed by elevated serum amylase, lipase and imaging modalities. serum lipase has a higher sensitivity and specicity up to 82%-100%. in addition, lipase levels peak early and last longer, returning to normal only after about six to eight days. imaging modalities include ultrasonography which is a quick and easy-to-perform test on hemodynamically stable and unstable patients. computer tomography (ct) scanning, although better at delineating pathology of acute pancreatitis. chrispal a. et. al. in their large-scale study of 398 patients of acute febrile illness, 189 were scrub typhus positive. eschar was evident in 45.5% patients and primary presenting symptoms were headache, vomiting and myalgia. out of these 13.8% presented with shock and hepatic transaminases were elevated in 95.2% of patients. various complications were observed such as ards (29.7%), renal failure (29.7%), 12alteredsensorium (24.4%), and shock (38.4%). by wang nc, et. al., pancreatitis with scrub typhus has been described when there is pancreatic abscess with multiorgan involvement 13or with coinfection with leptospirosis. in a retrospective study of 623 patients with scrub typhus, the presenting manifestations were fever, headache, nausea and vomiting, shortness of breath and eschar formation.myocarditis, pericarditis, meningoencephalitis, glomerulonephritis,acute kidney injury, acute respiratory distresssyndrome andacute acalculous cholecystitis, are some uncommon complica 14tionsof scrub typhus reported in the literature. atif shaikh iqbal ahmed,et. al. in their case series of seven patients diagnosed as scrub typhus with acute pancreatitis, mean serum lipase and amylase levels were 1,509 u/land434 u/l 15respectively. conclusion scrub typhus is a tropical disease, underdiagnosed mainly due to presentation as a nonspecic febrile illness. pancreatitis is a serious and unusual complication of this disease. this observation highlights the importance of pancreatitis as an uncommon complication, where prompt diagnosis and early management can be lifesaving. references 1. traub r, wisseman cl jr. the ecology of chigger-bornerickettsiosis (scrub typhus). j med entomol 1974;11: 237–303 2. wu km, wu zw, peng gq, et al. radiologic pulmonary ndings, clinicalmanifestations and serious complications in scrub typhus. experiences from ateaching hospital in eastern taiwan. int j gerontol2009; 3:197–264. 3. gavin c.k.w. koh, maudi rj, paris dh, newton pn, blacksellsd. review: diagnosis of scrub typhus. am j trop med hyg mar2010; 82(3):368 – 370 4. m.vivekanandan, a. mani, y.s. priya, aj singh, s jayakumar, s. purty. outbreak of scrub typhus in pondicherry. japi jan 2010;58: 24 – 28. 5. yang ch, young tg, peng my, hsu gj. unusual presentation of acute abdomen in scrub typhus: areport of two cases. zhonghua yi xuezazhi 1995; 55:401–4. 6. ahmed as, kundavaram ap, sathyendra s, et al. acutepancreatitis due to scrub typhus. j glob infect dis 2014;6: 31–34 7. narendra rathi, akanshka rathi. rickettsial infections: indianperspective, indianpediatr 2010; 47: 157 – 164. 8. mathai e, rolain jm, verghese gm et al. outbreak of scrub typhus in southern india during the cooler months. ann n yacadsci2003; 990:359 – 364. 9. rakendra singh. clinical manifestations and complications of scrub typhus. jkscience. april – jun 2010; 12 (2): 76 – 78. 10. pradutkanchana j, silpapojakul k, paxton h, pradutkanchanas, kelly dj, strickmand.comparative evaluation of four serodiagnostic tests for scrub typhus in thailand. t roy soc tropmed h jul 1997; 91 (4): 425428 11. gurung s, pradhan j, bhutia p y. outbreak of scrub typhus in the north east himalayan region-sikkim: an emerging threat. indian j med microbiol 2013; 31:72–4.) 12. chrispal, a. scrub typhus: an unrecognized threat in south india clinical prole and predictors of mortality. tropical doctor. 2010;44(3): 13. wang nc, ni yh, peng my, et al acute acalculous cholecystitis and pancreatitis in a patient with concomitant leptospirosis and scrub typhus. j microboil immunol infect 2003; 36(4): 285-287). 14. varghese gm, trowbridge p, janardhanan j, et al. clinical prole and improving mortality trend of scrub typhus in south india. int j infect dis 2014; 23:39–43. 15. ahmed ai, paul prabhakar ak, sathyendra s, abraham oc. acute pancreatitis due to scrub typhus. j global infect dis 2014; 6:31-4 volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 1: symptoms at the time of presentation symptoms total (n=26) percentage (%) fever 22 84.6 abdominal pain 18 69.2 vomiting 16 61.5 diarrhea 8 30.8 nausea 14 53.8 body ache 17 65.4 jaundice 13 50.0 bleeding manifestation 8 30.8 altered sensorium 2 7.7 table 2: percentage of patients having elevated serum amylase and lipase no. of patients (n=26) % normal s. amylase 11 42.3 normal s. lipase 15 57.7 elevated s. amylase 15 57.7 elevated s. lipase 11 42.3 elevated s. amylase and s. lipase 11 42.3 table 3: involvement of other systems no. of patients (n=26) % renal failure 5 19.23 hepatic failure 14 53.85 cardiovascular failure 8 30.77 acute respiratory distress syndrome 4 15.38 central nervous system 2 7.7 multi organ dysfunction 4 15.38 introduction hypertension is a disorder of circulatory regulation.sustained hypertension causes accelerated atherosclerosis with coronary artery disease,heart failure,stroke and renal failure.if untreated,approximately 50 % of patients develop heart disease,33% develop stroke ,10-15 % develop renal failure. microalbuminuria(ma) is dened as urine albumin excretion(uae) in the range of 30-300 mg/24h,is seen in patients with established hypertension and is a predictor of higher risk of cardiovascular and renal dysfuntion.in 1976,parving et al highlighted the relation between microalbuminuria and severity of hypertension.leoncini g,studied association of microalbuminuria in 345 patients of asymptomatic hypertension and presence of subclinical organ damage.detection of uae could be the best index of an increased global cardiovascular risk in a given patient hypertension affects the heart by increasing afterload causing the lvh (left ventricular hypertrophy)and stiffening of the left ventricle ultimately leading to increase in the left ventricular mass.lvh is the most common abnormality in patients with hypertension and signicant marker of subclinical cardiovascular disease.positive correlation between ma and lvh has been documented in few studies,one such by hitha et al in south india studied relationship between ma and target organ damage in hypertension.hypertension accelerates atherosclerosis and also independently causes vascular damage affecting large and small vessels.this study was undertaken to determine the prevalence of ma in hypertension and to examine its correlation with severity of hypertension,lvh. materials and methods study population this study is conducted among 100 hypertensive(essential hypertension)patients attending general medicine department outpatient clinic and ward at sree balaji medical college and hospital,chennai collabarative deparments: department of cardiology,radiology study period july 2018 to august 2019 ethical concern the project was approved by the ethical comitee study type prospective analysis study sample size 100 cases inclusion criteria 1. hypertensive patients(both male and female) with bp>140/90mmhg 2. age more than 30 years exclusion criteria 1. patients with renal disease 2. diabetes mellitus 3. chronic heart failure 4. ischemic heart disease 5. cerbero vascular disease 6. patients with urinary tract infections 7. pregnancy 8. patients with obstructive uropathy conict of interest :nil financial support :nil methodology patients who were admitted and attending the general medicine department who fullled the inclusion criteria were included in the study.patients fullling the exclusion criteria were excluded from the study.investigations were sent and study of the correlation between microalbuminuria and retinopathy ,lipid profile in patients of essential hypertension original research paper dr.papaiah nirmal pudota m.b.b.s,(m.d) general medicine objective: to detect the correlation of microalbuminuria in 100 hypertensive patients with retinopathy and lipid prole methods: we performed a prospective analysis study of 100 patients visiting balaji medical college and hospital,chennai.inclusion criteria :hypertensive patients with bp>140/90 mmhg and age more than 30 years.exclusion criteria:patients with renal disease,t2dm,ischemic heart disease,cva,pregnancy.microalbuminuria was measured using the dip stick test ,dened as having uae in the range of 30-300mg/24h results:100 patients were involved in the study fullling the criteria.30 out of 100 patients had microalbuminuria. 21 males out of 45 were found to have microalbuminuria and 9 out of 25 females were found to have microalbuminuria.serum levels of cholesterol,triglycerides,and uric acid in patients with microalbuminuria were higher than the levels in those with normal uae(urine albumin excretion),and hdl(high density lipid) levels in patients with ma(microalbuminuria)were lower than levels in patient with normal uae.on performing fundus examination in the study patients ,13 out of 22 patients with grade ii retinopathy had microalbuminuria and 8 out of 13 with stage iii retinopathy had microalbuminuria ,5 out of 9 with stage iv had ma,and only 2 out of 43 patients with normal fundus had ma.so,stage ii,iii,ivof retinopathy patients had more frequency of microalbuminuria compared to patients with normal fundus. therefore screening of fundus is a must for patients having ma,so if we could detect ma early,end organ damage could be prevented by appropriate clinical management conclusion : hypertension is one of the most common global diseases causing signicant mortality and morbidity.therefore proper screening and assessment is required to identify patients at risk.patients with microalbuminuria have increased chances of developing retinopathy compared to those without.so, screening for microalbuminuria must be considered to be part of initial work up in every hypertensive patient and those with ma must be screened regularly for fundus along with appropriate clinical management. abstract keywords : volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 36 x gjra global journal for research analysis corellations were made accordingly labaratory investigations 1. clinial blood pressure was recorded using sphygmo manometer with standard size cuff on 2 to 3 occasions atleast to 10 min apart. 2. microalbuminuria estimation was done using immuno turbidemetric two point assay when a urine specimen is mixed with the reagents,albumin in the specimen combines with the anti human albumin antibody in the reagent to yield an insoluble aggregate that causes increased turbidity in the solution.the absorbance of the reaction turbidity is proportional to the concentration of albumin in the specimen ,and can be measured optically using spectrophotometer. 3. fasting lipid prole 4. fundus examination by opthalmoscope results frequency of ma in 100 essential hypertensive patients is found to be 30% frequency of microalbuminuria in 100 hyperte nsive patients-30% relation of microalbuminuria with age mean age of the patients is around 60 with ma and without ma is around 45.thus,age showed a signicant positive correlation with ma in the study.patients with higher age group 60 and above patients have increased prevalence of miccroalbuminuria.studies support this characteristic that ma prevalence increases with age.in our study we found ma to be present in 66% of the males and some support more prevalence in males but some studies do not support this correlation.as such,therefore sex of the patient doesn't correlate with increased prevalence of ma(microalbuminuria) fundus changes and microalbuminuria p value at 0.0005 .highly significant totally out of the 30 patients with microalbu minuria 13 belong to stage ii retinopathy and 8 belong to stage iii retinopathy and 5 to stage iv retinopathy.only 4,2 from stage i(out of 13) and 2 f r o m n o r m a l f u n d u s ( o u t o f 4 3 ) h av e microalbuminuria correlation between ma and lipid prole comparision between lipid profile and ma p value 0.0005 highly significant f-favourable lipid prole nf-not favourable lipid prole discussion hypertension is one of the most global diseases causing burden worldwide and is one of the most common cause of morbidity and mortality.along with diabetes,it is the most common disease affecting the end organs of the body.hypertension affects almost every organ in the body.in order to detect the end organ damage,patients usually will not present with symptoms unless severely affected.mostly they remain asymptomatic .so to know how can we detect the damage early.so that we can prevent the complications of hypertension.100 patients with essential hypertension presenting to our hospital were looked for age,sex,duration of hypertension ,ecg lipid prole and were screened for the end volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra microalbuminuria frequency percent a 70 70.0 p 30 30 total 100 100 age count % ma total a p upto 40 years count % 9 12.9% 0 0.0% 9 9.0% 41-50 years count % 14 20.0% 7 23.3% 21 21% 51-60 years count % 19 27.1% 9 30.0% 28 28.0% 61-70 years count % 20 28.6% 10 33.3% 30 30.0% above 7o years count % 8 11.4% 4 13.3% 12 12% total count % 70 100.0% 30 100.0% 100 100.0% fundus count % ma total a p i count % 11 15.7% 2 6.7% 13 13.0% ii count % 9 12.9% 13 43.3% 22 22.0% iii count % 5 7.1% 8 26.7% 13 13.0% iv count % 4 5.7% 5 16.7% 9 9.0% n count % 41 58.6% 2 6.7% 43 43.0% total count 70 100.0% 30 100.0% 100 100.0% lipid pofile count % ma total a p f count % 56 80.0% 7 23.3% 63 63.0% nf count % 14 20.0% 7 76.7% 37 37.0% total count % 70 100.0% 30 100.0% 100 100.0% x 37gjra global journal for research analysis organ damage and this study focused on fundus examination, correlating with the respective department.patients were included based on the inclusive and exclusion criteria as described above in present study,it was observed that out of 100 cases with hypertension,retinopathy noted in 57 patients ,and normal in 43 patients .13 patients had stage 1 retinopathy,22 with stage ii,13 with stage iii,9 with stage iv.13 of 22 patients with stage ii had ma,5 of 9 with stage iv had ma,8 of 13 with stage iii had ma,2 of 43 patients with normal fundus had ma .p value is <0.01 which is highly signicant. hence this study shows a positive correlation between the microalbuminuria and prevalence of retinopathy(p value <0.01).hypertensive patients with ma were 10 times more likely to develop retinopathy than patients with normal uae. keith wegner baker classication of retinopathy severe retinopathy can cause visual eld defects and blindness conclusions our study demonstrated the presence of ma (microalbu minuria) in a signicant number of newly detected and untreated patients of essential hypertension. furthermore, ma had a statistically signicant relationship with retinopathy. these ndings imply an underlying vascular relationship between ma and retinopathy. therefore,screening of all recently diagnosed patients of essential hypertension for ma may be a reasonable strategy to predict the presence of ongoing vascular damage, and retinal damage . financial support:nil conicts of intrest:there are no conicts of intrest references 1. systemic hypertension :mechanism and diagnosis in braunwalds heart disease.a text book of cardiovascular medicine 2. brantsma ah,bakker sj.urinary albumin excretion as a predictor of development of hypertension in the general population 3. pontremoli r,leoncini g,ravera m,ratto e,et al.microalbuminuria, cardiovascular,and renal risk in primary hypertension 4. cardio vascular diseases harrisons textbook of medicine 5. bigazzi r,bianchi s,nenci r.increased thickness of the carotid artery in patients with essential hypertension and micro albuminuria. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 38 x gjra global journal for research analysis introduction: bupivacaine is a local anesthetic that is largely used for spinal anesthesia, mainly as a hyperbaric or plain solution [1,3]. controversy exists regarding the predictability of the levels of analgesia achieved with isobaric solution when compared to hyperbaric [4–6]. virtually local anesthetics used for spinal anesthesia are mostly available as hyperbaric solutions and it is well established that the addition of dextrose to increase the specic gravity of the solutions alters the anesthetic proles [1, 3, 7, 8]. density varies inversely with temperature. the actual change in density with temperature cannot be predicted with different solutions. the temperature of local anaesthetic rapidly equilibrates with the core temperature of the csf (37-38°c). in order to determine accurately the baricity that dictates the spread of local anaesthetic, the density of csf and the density of the local anaesthetic must be measured at 37-38°c [8]. even though hyperbaric and isobaric solutions have been extensively studied until now, the comparison of these two solutions from the same manufacturer without any adjuvant for sab is not yet reported. this study aimed to compare the onset of anesthesia and duration of action of isobaric and hyperbaric bupivacaine 0.5% for sab. aims and objective: 1. to determine the effectiveness of hb compared to ib for sa in patient undergoing surgeries of the lower body assessed as success rate of sa. 2. to determine the onset time, duration of blockade and regression of spinal block, compared between hb and ib for sa in patients undergoing surgeries of the lower body. material and method: the medical ethical committee approved this study. sixty patients with asa i and ii, undergoing elective lower abdominal surgeries with the estimation in duration of no longer than 120 minutes were enrolled. this study was conducted in i.q city medical college and multispecialty hospital, durgapur, west bengal, from march to july 2019. exclusion criteria included patient's refusal to participate in the study, coagulopathy, anticoagulation therapy, presence of cutaneous infection at the site of the planned puncture, or systemic infection, untreated hypovolemia, progressive cardiomyopathy class iii, chronic renal failure receiving hemodialysis, peripheral neuropathy, autonomic dysfunction, history of lumbar surgery making needle puncture impossible, grossly deformed vertebral column, increased intraabdominal girth secondary to an expanding tumor, a mass or ascites, pregnancy, and allergy to local anesthetics. drop-out was made when the surgery was more than 120 minutes and severe hemodynamic instability, total spinal, allergic reaction, failed block, and the conversion to general anesthesia took place. preoperatively, physical examinations and supportive investigations (i.e., routine laboratory, ecg, and chest x-ray) were made one day prior to surgery. patients were randomized with sealed envelope method into two groups; group i received isobaric bupivacaine, while group ii received hyperbaric bupivacaine. neither anesthesiologist performing sab or collecting perioperative and postoperative data nor the patients were aware of the used solution. after monitoring, preanesthetic hydration which consisted of 10� ml/kg of a crystalloid solution was infused over 20–30�min via an 18-gauge cannula. after injection of spinal anesthetic drug, uids were administered on the basis of changes in arterial pressure and urinary output. blood loss was replaced with a crystalloid solution on a 3:� l basis until estimated or measured hematocrit reached 35%; further losses were replaced by blood. soon after proper sterility and disinfection procedure, sab was performed using midline approach in the sitting position, in the l3-4 interspace with 25�g quincke spinal needle (b-braun, melsungen, germany) with the tip heading toward the head (cephalad). a clearconstant ow of cerebrospinal uid (csf) leakage from spinal needle indicated a correct position of needle tip in the subarachnoid space. in all patients, 20�mg (4�ml) of either comparison of intrathecal use of isobaric and hyperbaric bupivacaine during lower abdomen surgery in i.q city medical college and multispeciality hospital, durgapur, west bengal, india original research paper dr. dilip kumar bhowmik associate professor, department of anaesthesia.shri ramakrishna institute of medical sciences & sanaka hospital x 1gjra global journal for research analysis anaesthesiology background: bupivacaine is an amide local anaesthetic used in hyperbaric and plain forms administered as spinal anesthesia. it is the most commonly used local anaesthetic for spinal anesthesia (sa). there are two forms of commercially available bupivacaine; isobaric bupivacaine (ib): a formulation with a specic gravity or density equal to cerebro spinal uid and hyperbaric bupivacaine (hb): a formulation with density heavier than cerebro spinal uid. it is widely believed that the choice between isobaric bupivacaine and hyperbaric bupivacaine formulations alters the block characteristics for the conduct of surgery under spinal anesthesia. aims and objective: the aim of this study was to systematically review the comparative evidence regarding the effectiveness and safety of the two formulations when used for spinal anesthesia for adult and to compare the use of isobaric and hyperbaric bupivacaine during lower abdomen surgery and their outcome. methods and material: sixty patients who underwent lower abdominal, hips, and lower extremity surgeries were randomized into two groups. group i received 20�mg of 0.5% isobaric bupivacaine, while group ii received 20�mg of 0.5% hyperbaric bupivacaine. injection was made intrathecally in midline position at l3-4 interspace in sitting position. result: six patients were dropped out due to failed block and the duration of surgery being longer than 120 minutes. the remaining 54 patients (27 each groups) followed all the study procedure. patients in both groups were comparable. surgery lasted for 83 ± 19minutes in group i and 77 ± 19 minutes in group ii (p = 0.23). conclusion:isobaric produced more rapid onset and longer duration when compared to hyperbaric bupivacaine. abstract keywords : isobaric bupivacaine, hyperbaric bupivacaine, spinal anesthesia. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. mohammad zakiuddin* professor & head, department of physiology madhubani medical college, madhubani, bihar. *corresponding author 2 x gjra global journal for research analysis 0.5% isobaric or hyperbaric bupivacaine solution (buvanest, kalbe farma, jakarta, indonesia) was injected without barbotage in the speed of 0.2�ml/sec. immediately after the injection, the patients were turned back to the horizontal supine position and a pillow was placed under the head for the rest of the study. statistical analysis: data were analyzed using spps 20.0 software. results were expressed as mean ± standard deviation (sd). continuous variables analyzed with student t-test, while the chi-square test was used to compare discrete variables. p < 0.005 were considered signicant, and exact values are given when < 0.001. result: six patients were dropped out due to failed block and the duration of surgery being longer than 120 minutes. the remaining 54 patients (27 each groups) followed all the study procedure. patients in both groups were comparable, as in the demographic data (table 1). surgery lasted for 83 ± 19minutes in group i and 77 ± 19 minutes in group ii (p = 0.23). table 1: demographic data. mean ± sd. group i: isobaric; group h: hyperbaric; sap: systolic arterial pressure; map: mean arterial pressure; dap: diastolic arterial pressure; asa: preoperative status based on the american society of anesthesiologists. table 2: block characteristics. mean ± sd. group i:isobaric; group ii : hyperbaric sensory and motor blockade: the measured sensory blockade and motor blockade are the onset and duration (table 2). the onset of sensory blockade was signicantly shorter in group i when compared to group ii (p< 0.001). duration of sensory block was the time measured from the time of the highest block for the regression to the s2 dermatome, which is signicantly longer in group i compared to group h (p< 0.001). the onset of motor block was also shorter in group i than group h (p < 0.001), while the duration of motor block, the time measured from the achievement of bromage 3 until regression to bromage 0, was longer in group i when compared to group ii (p < 0.001). discussion: this study showed that isobaric bupivacaine produced more rapid onset of anesthesia and longer duration of action when compared to hyperbaric bupivacaine. in our study, the only variable was baricity, since dose, volume, and concentration were kept constant and even both solutions are produced by the same manufacturer. the isobaric bupivacaine (buvanest 0.5%) used in this study is an isotonic bupivacaine hcl 5mg/ml, while the hyperbaric bupivacaine (buvanest spinal 0.5% heavy) is an isotonic bupivacaine hcl 5 mg/ml and dextrose monohydrate 80mg/ml. baricity inuenced the distribution of local anesthetic solution in the csf. it is dened as the ratio of density (mass/volume) of local anesthesia solution's density compared to csf density in 37°c. thus, baricity inuences local anesthetic spread and block height since gravity causes hyperbaric solutions to ow downward in the csf, whereas hypobaric solutions tend to rise. in contrast, gravity has no effect on the distribution of truly isobaric solution [1, 8, 9, 10]. in our study, isobaric showed more rapid onset of anesthesia and longer duration of action than hyperbaric. another important nding is that there was a lower blockade with hyperbaric solutions, which is consistent with previous studies [2, 4, 6, 11, 12], while other studies also proposed that hyperbaric solutions may be more suitable to reach the higher thoracic dermatomes as opposed to their plain (i.e., isobaric) [5, 6]. however, only by comparing similar volumes and doses can this difference be accurately assessed. the reasons for this differential effect are speculative, but it could be explained by the properties of the two drugs in relation to gravity and the mass movement of csf as a result of the postural changes [1, 11, 13]. gravity will tend to keep the hyperbaric solution near the lowest point of the thoracic curve (t4/t5) in the supine position and to resist attempts to move it further in a cranial direction. this tendency could be further assisted by the viscosity of the hyperbaric solution, preventing it mixing with the csf [1, 2, 5–14]. the plain solution, however, mixing freely with csf, has neither gravitational nor viscous effect to constrain its movement within the displaced csf. conclusion: in conclusion, isobaric bupivacaine produced more rapid onset and longer duration compared to hyperbaric bupivacaine. references : 1. t. taivainen, m. tuominen, and p. h. rosenberg, “spread of spinal anaesthesia using various doses of plain 0.5% bupivacaine injected at the liv-v interspace,” acta anaesthesiologica scandinavica, vol. 33, no. 8, pp. 652–655, 1989. 2. p. vichitvejpaisal, o. svastdi-xuto, and s. udompunturux, “a comparative study of isobaric and hyperbaric solution of bupivacaine for spinal anaesthesia in caesarean section,” journal of the medical association of thailand, vol. 75, no. 5, pp. 278–282, 1992. 3. n. solakovic, “comparison of hemodynamic effects of hyperbaric and isobaric bupivacaine in spinal anesthesia,” medicinski arhiv, vol. 64, no. 1, pp. 11–14, 2010. 4. r. martin, c. frigon, a. chrétien, and j.-p. tétrault, “onset of spinal block is more rapid with isobaric than hyperbaric bupivacaine,” canadian journal of anaesthesia, vol. 47, no. 1, pp. 43–46, 2000. 5. h.-k. king, “spinal anesthesia for cesarean section: isobaric versus hyperbaric solution,” acta anaesthesiologica sinica, vol. 37, no. 2, pp. 61–64, 1999. 6. a. jankowska and y. veillette, “comparison of differential blockade during spinal anesthesia using isobaric vs hyperbaric lidocaine 2%,” canadian journal of anaesthesia, vol. 47, no. 2, pp. 137–142, 2000. 7. n. solakovic, “level of sensory block and baricity of bupivacaine 0.5% in spinal anesthesia,” medicinski arhiv, vol. 64, no. 3, pp. 158–160, 2010. 8. a. c. p. lui, t. z. polis, and n. j. cicutti, “densities of cerebrospinal uid and spinal anaesthetic solutions in surgical patients at body temperature,” canadian journal of anaesthesia, vol. 45, no. 4, pp. 297–303, 1998. 9. g. hocking and j. a. w. wildsmith, “intrathecal drug spread,” british journal of anaesthesia, vol. 93, no. 4, pp. 568–578, 2004. 10. m. g. richardson and r. n. wissler, “density of lumbar cerebrospinal uid in pregnant and nonpregnant humans,” anesthesiology, vol. 85, no. 2, pp. 326–330, 1996. 11. e. kalso, m. tuominen, and p. h. rosenberg, “effect of posture and some c.s.f. characteristics on spinal anaesthesia with isobaric 0.5% bupivacaine,” british journal of anaesthesia, vol. 54, no. 11, pp. 1179–1184, 1982. 12. j.m. malinovsky, g. renaud, p. le corre et al., “intrathecal bupivacaine in humans: inuence of volume and baricity of solutions,” anesthesiology, vol. 91, no. 5, pp. 1260–1266, 1999. 13. m. p. vercauteren, h. c. coppejans, v. l. hoffmann, v. saldien, and h. a. adriaensen, “small-dose hyperbaric versus plain bupivacaine during spinal anesthesia for cesarean section,” anesthesia and analgesia, vol. 86, no. 5, pp. 989–993, 1998. 14. b. gunaydin and e. d. tan, “intrathecal hyperbaric or isobaric bupivacaine and ropivacaine with fentanyl for elective caesarean section,” journal of maternal-fetal and neonatal medicine, vol. 23, no. 12, pp. 1481–1486, 2010. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra group-i group-ii p age (years) 38 ± 14 38 ± 9 0.90 sex (male/female) 18/9 17/10 0.32 weight (kg) 57 ± 8 60 ± 6 0.20 height (cm) 158 ± 7 159 ± 6 0.63 sap (mmhg) 131 ± 11 128 ± 10 0.21 dap (mmhg) 79 ± 9 81 ± 7 0.47 map (mmhg) 97 ± 9 97 ± 6 0.95 asa (i/ii) 16/1 18/9 0.30 group-i group-ii p onset (minutes) sensory 4.8 ± 2.2 7.5 ± 2.2 <0.001 motor 4.1 ± 2.1 6.4 ± 2.4 <0.001 duration (minutes) sensory 276 ± 30 163 ± 22 <0.001 motor 266 ± 32 163 ± 24 <0.001 introductioncervical cancer is the third most common cancer in women worldwide with global estimates of 529,800 new cases and 1275,100 deaths in 2011 . developing countries have higher incidence of cervical cancer cases and deaths occur because of lack of effective screening procedures, socioeconomic 2challenge, pattern of healthcare delivery and social factors . cervical cancer is the second most common cancer in india in women accounting for 22.86% of all cancer cases in women 3and 12% of all cancer cases in both men and women . rural women are at higher risk of developing cervical cancer as 4compared to their urban counterparts . cervical cancer is the third largest cause of cancer mortality in india accounting for 5nearly 10% of all cancer related deaths in the country . concurrent chemoradiotherapy (ccrt) is the mainstay treatment for locally advanced carcinoma of the cervix. various chemotherapeutic agents are used along with radiation. several studies have shown the superiority of platinum based therapy, combined with radiation. based on these premises the concomitant administration of radiotherapy plus weekly cisplatin may be considered as a reasonable standard of care. however despite the benets obtained with the addition of platinum based chemotherapy the cure rates of locally advanced squamous cell carcinoma have reached a plateau [6,7]in recent years . radiation with weekly cisplatin yields promising results nephrotoxicity becomes limiting factor especially in patients with parametrial involvement in whom renal function is already compromised . that's-why we need to study and observe outcome and toxicity with carboplatin, an analogue of cisplatin, with similar mechanism of action and less nephrotoxicity. carboplatin: its mechanism of action is mediated by the formation of platinum dna adducts. since 1999, carboplatin, an analogue of cisplatin, with a similar mechanism of action, has been used with radiation therapy in much institution for the treatment of locally advanced cervical carcinoma. mechanisms that underlie the interaction between the drugs and radiation therapy may include inhibition of the tumors sublethal damage repair systems and an increase in the 8radio-sensitivity . material methods inclusion criteria biopsy conrmed , locally advanced unresectable , stage iib – iiic ajcc 8th , cervix cancer , kps > 60 % , age > 20 years < 69 years , exclusion criteria patient not willing to give informed consent , age more than 79 years , biopsy inconclusive , metastatic tumours study design observational , randomised , prospective carried out at govt. mahatma gandhi memorial medical college , indore , madhya pradesh , india in the year 2018-2019. total 35 biopsy proven cases of cancer cervix received carboplatin ( auc 2 weekly ) as concurrent chemotherapy patients were treated upto 46 gy in 20 fractions using external beam radiotherapy , 5 fractions per week , 2.3 gy per fraction followed by hdr brachytherapy 7.5 gy per fraction weekly for three weeks. statistics all statistical calculations were done using spss 20 ,toxicity assessment toxicity criteria were by rtog/ eortc. response evaluation complete response (cr) was dened as the complete absence of disease 6 weeks. partial response (pr) was dened as a reduction of disease by at least 50% in the sum of all measurable products of the longest perpendicular outcome and toxicity of concurrent chemotherapy with carboplatin along with radiation in locally advanced carcinoma of the cervix original research paper dr preety jain associate professor dept of radiation oncology m.g.m. medical college indore m. p. , india oncology keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr vikas pal* pg third year dept of radiation oncology m.g.m. medical college indore m. p. , india *corresponding author dr manish verma assistant professor dept of radiation oncology m.g.m. medical college indore m. p. , india dr pranjil mandloi senior resident dept of radiation oncology m.g.m. medical college indore m. p. , india dr anshika gupta pg third year dept of radiation oncology m.g.m. medical college indore m. p. , india dr garima ulkey pg third year dept of radiation oncology m.g.m. medical college indore m. p. , india dr priyanka ahirwar pg second year dept of radiation oncology m.g.m. medical college indore m. p. , india dr prabhakar gupta pg second year dept of radiation oncology m.g.m. medical college indore m. p. , india 60 x gjra global journal for research analysis diameters of measurable tumor masses for at least 6 weeks, with no growth of other lesions or appearance of new lesions. stable diseases (sd)was dened as reduction in lesion by less than 50%, or increase by less than 25%. progressive disease (pd) was dened as an increase by at least 25% of tumor lesions or appearance of new lesions. observation and results out of 35 patients 18 patients in between 51-60 yrs of age,15 patients 61-69 yrs of age, 2 patients were 41-50 yrs of age. 7 cases were stage iib , 12 cases belongs to stage iiia, 10 cases were stage iiib and rest 6 cases belongs to stage iiic. patient characteristics (table 1 ) response in the present study disease assessment after concurrent chemoradiotherapy complete response seen in 31 patients and partial response seen in 3 patients and 1 patient reports stable disease. none patient presented with progressive disease. table2 response toxicity hematological toxicity grade 3 observed in 26 patients and grade 4 toxicity in 2 patients. grade 3 skin reaction observed in 27 patients and grade 4 skin reaction seen in 4 patients. renal toxicity observed grade 1 in 23 patients only. nausea and vomiting notice in 18 and 14 patients ,grade 2 and grade 3 respectively table 3 toxicity discussion denitive concurrent chemoradiotherapy is the standard treatment of the advance stage carcinoma of cervix (7). cisplatin and 5 fu were the drugs commonly used in combination with radiotherapy (9)(10)(11) . despite good response their use is restricted by their toxicities . situation is further worsened by the presence of hydronephrosis in patients suffering from ca cervix iii b so we studied effects and toxicities of carboplatin as concurrent chemotherapy in locally advanced cancer cervix. in our study we used weekly carboplatin at a dose of 100 mg/m2 as a radiation sensitizer in patients at auc2 as had been recommended and were also used in other studies (8). in our study most patients received 5 cycles of weekly carboplatin . complete response was seen in 31 (88 % ) patients and partial response was seen in 3 (8.5 %) patients and 1 patient reported stable disease. none patient presented with progressive disease. all these results were comparable in terms of efcacy to the studies evaluating the response rates using cisplatin as concurrent chemotherapy which is standard of care (7) (9) (10). in our study grade 3 and grade 4 hematologic toxicity were observed in 74 % and 5 % cases respectively which was a matter of concern but was managed aggressively with blood and blood products. radiation to pelvic bone marrow could be a contributing factor to this. grade 3 skin toxicity was seen in 77 % percent cases and 11 percent cases had grade 4 skin reaction. poor hygiene could be a contributing factor in this , as all the patients belonged to low socioeconomic status and illiterate background incidence of renal toxicities were low as only grade 1 (65 %) renal toxicity was observed this was very low as compared to standard regimen containing concurrent cisplatin chemotherapy. carboplatin is known to have very low nephrotoxicity. incidence of nausea vomiting were similar to standard regimens. conclusion carboplatin was administered to the patients of cancer cervix along with radiation. myelosuppression was the major toxicity observed but was manageable , outcomes were similar to standard protocol. this study concludes that carboplatin can also be used as radiosensitizer in locally advanced cancer cervix references 1. jemal a, bray f, center mm, ferlay j, ward e, forman d. global cancer statistics. ca cancer j clin 2011;61:1–22. 2. rose pg, bundy bn, watkins eb, thigpen jt, deppe g, maiman ma, clarkepearson dl, insalaco s. concurrent cisplatin-based chemoradiation improves progression free and overall survival in advanced cervical cancer: results of a randomized gynecologic oncology group study. n engl j med. 1999;340(1144):53 3. http://screening.iarc.fr/doc/who_india_ccsp_guidelines_2005.pdf 4. karthigeyan, k.; cervical cancer in india and hpv vaccination.;2012; indian j med paediatr oncol.; 33(1): 7–12 5. world health organisation. the global burden of disease: 2004 update geneva, who, 2009b. 6. rotman m, pajak tf, choi k, clery m, marcial v, grigsby pw, cooper j, john m. prophylactic extended-eld irradiation of para-aortic lymph nodes in stages iib and bulky ib and iia cervical carcinomas: ten-year treatment results of rtog 79-20. jama. 1995 aug 2;274(5):387-93. 7. rose pg, ali s, watkins e, thigpen jt, deppe g, clarke-pearson dl, insalaco s. long-term follow-up of a randomized trial comparing concurrent single agent cisplatin, cisplatin-based combination chemotherapy, or hydroxyurea during pelvic irradiation for locally advanced cervical cancer: a gynecologic oncology group study. journal of clinical oncology. 2007 jul 1;25(19):2804-10. 8. higgins rv, naumann wr, hall jb, haake m. concurrent carboplatin with pelvic radiation therapy in the primary treatment of cervix cancer. gynecologic oncology. 2003 jun 30;89(3):499-503 9. whitney cw, sause w, bundy bn, malfetano jh, hannigan ev, fowler jr wc, et al. randomized comparison of uorouracil plus cisplatin versus hydroxyurea as an adjunct to radiation therapy in stages iib–iva carcinoma of the cervix with negative para-aortic lymph nodes: a gynecologic oncology group and southwest oncology group study. j clin oncol 1999;17(5):1339–48. 10. eifel pj, winter k, morris m. pelvic irradiation with concurrent chemotherapy versus pelvic and para-aortic irradiation for high-risk cervical cancer: an update of radiation therapy oncology group trial (rtog) 90–01. j clin oncol 2004;22(5): 872–80. 11. peters iii wa, liu py, barrett ii rj, gordon jr w, stock rj, berek js, et al. cisplatin, 5uorouracil plus radiation therapy are superior to radiation therapy as adjunctive therapy in high-risk, early-stage carcinoma of the cervix after radical volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra patient characteristics number total patients 35 age 20 – 30 years nil age 31 – 40 years nil age 41-50 years 2 age 51 – 60 years 18 age 61 – 69 years 15 stage iib 7 iiia 12 iiib 10 iiic 6 response (n= 35) cr 31 pr 2 sd 1 pd 0 toxicity cases hematological toxicity grade 3 26 grade 4 2 skin reaction grade 3 27 grade 4 4 renal toxicity grade 1 23 nausea & vomiting grade 2 18 grade 3 14 x 61gjra global journal for research analysis introduction sepsis is a leading cause of mortality and morbidity in neonates, particularly in developing countries like india where neonatal deaths contribute 70% to the total under ve mortality rate, and about 30% of all neonatal deaths are attributed to severe bacterial infections (1,2). approximately 750,000 deaths from neonatal sepsis occur annually worldwide and 99% of these take place in developing countries settings.(3). there is an inverse relationship between the incidence of neonatal sepsis and birth weight(4,5). the world health organization currently recommends ampicillin or cloxacillin (if the staphylococcal infection is suspected) and gentamicin for the empiric treatment of suspected neonatal clinical sepsis (6). however, thirdgeneration cephalosporins, particularly cefotaxime, are also commonly utilized. late-onset neonatal sepsis is usually caused by neonatal intensive care units (nicus)-acquired pathogens and changes in antimicrobial susceptibility patterns necessitate a regular review of antibiotics regimen. grampositive organisms, particularly coagulase-negative staphylococcus and group b streptococci, are major causative agents of late and early-onset neo-natal sepsis, respectively.(7,8) . various studies done in different nicus showed that the incidence of infection was predominantly with gram-positive microorganisms around 60% and coagulasenegative staphylococcus was the predominantly isolated pathogen. they also reported that gram-negative microorganisms, mainly escherichia coli, klebsiella sp., and pseudomonas aeruginosa, accounted for 38% of isolated organisms(9) and over 90% of the gram-negative organisms were susceptible to gentamicin and amikacin(9). the united kingdom's health protection agency's national bacteremia surveillance also reported that over 95% of organisms causing neonatal sepsis were susceptible to gentamicin with either fucloxacillin or amoxicillin and amoxicillin with cefotaxime(10). due to the difculties in a prompt diagnosis of los, losassociated h igh r isk o f mor tal i ty and longterm neurodevelopmental sequelae, the symptoms of neonatal sepsis being nonspecic, differentiating between neonatal sepsis and the symptoms of prematurity is often difcult, empirical antibiotic treatment is initiated on suspicion of los. neonatologists prescribe broad-spectrum antibiotics under the assumption that neonatal sepsis exists, even after a negative result on initial blood culture. as the evidence for the most suitable empirical antibiotics for late-onset neonatal sepsis is lacking; therefore, there are no consensus guidelines on an antibiotic regimen. consequently, the empiric treatment of lateonset neonatal sepsis differs between nicus and among countries. in our unit, cloxacillin and amikacin are the commonly used antibiotics for the empiric treatment of lateonset sepsis. however, cefotaxime with ampicillin is also used occasionally. on account of the increased survival of preterm neonates and their more extended hospitalization, late-onset sepsis will continue to be a challenge. in this study, we c o m p a r e d t h e d i f f e r e n c e i n m o r t a l i t y b e t w e e n cloxacillin–amikacin and cefotaxime–ampicillin regimens in neonates with neonatal sepsis. we hypothesize that on account of better bacterial susceptibility to amikacin, empirical treatment of very low birth weight (vlbw) neonates with an amikacin-based regimen would result in lower mortality. methods : this study was carried out in the nicu of gb pant hospital, a tertiary hospital in kashmir. we retrieved the medical records of consecutively admitted vlbw neonates with rst episodes of late-onset sepsis between march 2014 and april 2016. only vlbw neonates (<1,500 g) with suspected late-onset neonatal infection were eligible for inclusion. we dened late-onset sepsis as sepsis occurring after 72 hours of birth. demographic data including birth weight, gestational age, and sex were extracted, in addition to data regarding comorbid conditions such as intraventricular hemorrhage, necrotizing enterocolitis, hypoxic-ischemic encephalopathy, patent ductus arteriosus, and periven-tricular leukomalacia. we also extracted data regarding sedative and inotropic drug treatment during hospitalization; invasive respiratory support (ie, intubation) during hospitalization; the types of antibiotics received; the number of courses and the duration of antibiotics; and the number of days of hospitalization and the out-come of treatment. study design it is a retrospective cohort study and identied 2 treatment cohorts. the primary cohort was neonates receiving empiric comparison between two commonly used emperic antibiotoc regimens in neonatal sepsis original research paper sheikh quyoom hussain registrar, department of paediatrics, gb pant hospital, government medical college srinagar , india. x 79gjra global journal for research analysis medical science background: neonatal sepsis remains a major cause of morbidity and mortality and warrants the immediate start of appropriate empiric treatment. thus, this study compared the effectiveness of the 2 antibiotic regimens (cloxacillin–amikacin or cefotaxime–ampicillin) among neonates with late-onset neonatal sepsis. methods: we conducted a retrospective cohort study comparing mortality between 2 treatment cohorts of very low birth weight neonates with late-onset sepsis, who had received amikacin–cloxacillin or cefotaxime–ampicillin between march 2014 and april 2016. 32 neonates were selected in each group after proper matching. results: we identied a total of 150 neonates from the hospital's record. we included 32 neonates each in the amikacin–cloxacillin and cefotaxime–ampicillin groups. intraventricular hemorrhage, necrotizing enterocolitis, birth weight, and gestational age were signicantly associated with mortality (p < 0.05). the risk of mortality was signicantly higher in neonates receiving empiric cefotaxime and ampicillin than those receiving amikacin and cloxacillin . conclusions: in our center, amikacin–cloxacillin combination therapy was associated with lower mortality in very low birth weight neonates with late-onset sepsis compared with cefotaxime–ampicillin therapy. abstract keywords : juvera gul wani* registrar, department of gynecology and obstetrics, lal ded hospital srinagar, india. *corresponding author roshi baghat registrar, department of paediatrics, smgs hospital, government medical college jammu, india volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 80 x gjra global journal for research analysis amikacin and cloxacillin for suspected ate-onset sepsis. the l comparison cohorts were neonates receiving empiric cefotaxime and ampicillin for suspected late-onset sepsis. a 1:1 propensity score matching of the 2 treatment groups to the nearest neighbour using the birth weights, gestational ages, need for respiratory support (received ventilatory support during hospitalization), was carried out. the primary outcome of this study was the all-cause mortality during the rst 120 days of life or discharge. defnitions clinical (suspected) sepsis: the exact denition of suspected neonatal sepsis remains vague. as the clinical features of sepsis may be infuenced by strong pro-infam-matory cytokines, clinicians rely on clinical features in their decision to suspect sepsis and start antimicrobial agents(11,12,13). conrmed (proven) sepsis: detection of a pathogen (positive culture) in otherwise sterile body uid, in addition to clinical and laboratory signs of sepsis(11,12,13) early-onset sepsis: sepsis caused by pathogens transmitted vertically from mother to infant occurring in the rst 3 days of life(11,12,13). late-onset sepsis: sepsis caused by horizontally acquired pathogens that occurs after 3 days of an infant's life.(11,12,13) blood sample for culture: we use standardized culture techniques to reduce false-negative results by taking 1-ml blood sample via venipuncture before starting antibiotics. statistical analysis the baseline characteristics of both treatment groups were compared using chi-square and independent t tests where appropriate. results: table 1 table 2 microrganisms recovered from culture we identied a total of 150 vlbw neonates who had received empiric amikacin–cloxacillin or cefotaxime–ampicillin for late-onset sepsis. thirty-six cases had reports of isolated microorganisms. the commonly isolated organisms include staphylococcus epidermidis (21 cases), acinetobacter baumannii (3 cases), and enterobacter cloacae (3 cases) (table 2), e. coli (2 cases), candida sp. (1 case). one hundred and eighteen neonates received amikacin–cloxacillin, whereas 32 received cefotaxime–ampicillin. the median duration of hospitalization among the patients was 42 ( 31–71) days, and the duration of antibiotics during hospitalization was 23 (iqr: 9–26) days. the neonates received an average of 3 courses of antibiotics during hospitalization. after 1:1 matching of neonates in both treatment groups, we included 32 neonates each in the amikacin–cloxacillin and cefotaxime–ampicillin groups. of those included in the study, 54.7% (35/64) were females. the mean gestational age of all the neonates in the study was 27.4 weeks, and the mean birth weight was 918g. the risk of mortality was signifcantly higher among neonates who received empiric cefotaxime and ampicillin compared with those who received amikacin and cloxacillin (hazard ratio: 2.91, 95% condence interval: 1.17–7.30, p = 0.023) discussion in this study, we found a lower risk of mortality among neonates receiving empiric amikacin–cloxacillin for lateonset neonatal sepsis, compared with cefotaxime–ampicillin treatment. cloxacillin, cefotaxime, and ampicillin are generally protective for gram-positive bacteria and amikacin and cefotaxime for gram-negative organisms. however, cefotaxime may not always provide sufcient gram-negative antibacterial coverage, with only about 75% of the enterobacteriaceae other than e. coli and 46% of the pseudomonas spp. susceptible in the united kingdom.14 several studies have reported an increased risk of fungal infection, death, and neurodevelopmental delay with starting cefotaxime in the rst few days of life.15,16 clark et al reported a higher mortality rate among infants who had received cefotaxime in the rst week of life, compared with gentamicin.16 resistance to cefotaxime is increasing on account of extended-spectrum beta-lactamase infections, commonly by a. baumannii, k. pneumonia, and e. coli.17 coagulase-negative staphylococci (cons) are the most frequent bacteria isolates in late-onset neonatal sepsis.. although cons are often susceptible to vancomycin, targeted empiric therapy with vancomycin is usually reserved for neonates with the highest risk of severe infections.11 an ideal antibiotic combination regimen should cover the most frequently isolated organisms, without causing selection pressure for antibiotic resistance. the strategies adopted by various nicus to prevent and treat late-onset neonatal sepsis may inuence the pattern of bacteria, causing sepsis in the r e s p e c t i v e u n i t s . f o r e x a m p l e , t h e u s e o f cefotaxime–amoxicillin in an nicu may increase the risk of cefotaxime resistance to gram-negative organisms. thus, with ampicillin–cefotaxime, gram-negative bacteria like enterobacter spp. may ourish following the elimination of normal intestinal ora. these organisms may degrade cefotaxime and cause cefotaxime-resistant invasive infections.. it is noteworthy that the selection of antibiotics in this study was not informed by a change in practice over time; rather, it was based on the hospital guidelines premised on the factors mentioned earlier. the rst-line empiric treatment for late-onset sepsis in our center is a combination of amikacin and cloxacillin. consequently, more neonates received this regimen compared with ampicillin–cefotaxime. this study, to our knowledge, is among the rst to compare empiric amikacin–cloxacillin with cefotaxime–ampicillin for lateonset neonatal sepsis.. however, the study is limited by the small sample size, which limits the generalizability of the volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra amikacin+ cloxacillin (32) cefotaxime+ ampicillin (32) p mean ga, wk (sd) 27.4 (2.7) 27.0 (3.3) 0.585 mean birth weight,g (sd) 937.6 (323.8) 898.3 (388.1) 0.639 male (%) 17 (53.1) 12(37.5) 0.054 pda (%) 15 (46.8) 20 (62.5) 0.268 ivh (%) 16 (51.9) 19 (59.3) 0.409 pvl (%) 3 (11.1) 0(0) 0.299 nec (%) 20 (62.5) 15 (46.8) 0.273 hie (%) 0 (0) 2 (6.2) 0.552 positive blood culture (%) 13 (40.6) 5(15.6%) 0.02* no. deaths (%) 9(28.1) 16 (50%) 0.097 invasive respiratory support 22 (68.75) 26 (81.25) 0.715 median hospital stay (d) 42 (iqr: 18–79) 23 (iqr: 5–74) median days on antibiotics 17 (iqr: 9–30) 13 iqr: 3–25) amikacin+cloxacillin cefotaxime+ampicillin staphylococcus epidermidis (13 cases), staphylococcus haemolyticus (1 case), staphylococcus lugdunensis (1 case), staphylococcus capitis (1 case), acinetobacter baumannii (1 case), enterobacter cloacae (2 cases), e. coli (1 case staphylococcus epidermidis (8 cases) pseudomonas aeruginosa (2 cases) klebsiella (1 case) acinetobacter baumannii (2 cases) enterobacter cloacae (1 case) e. coli (1 case) candida sp. (1 case ndings. hence, the result should be interpreted with caution. furthermore, we do not maintain a central line-associated bloodstream infection database at our center. thus, we are unable to account for the effect of these infections on mortality. in conclusion, amikacin–cloxacillin combination therapy was associated with lower mortality in neonates with late-onset sepsis at our nicu, compared with cefotaxime–ampicillin. other important inuences that can impact mortality need to be investigated in future studies.. to control the misuse of antibiotics, institutions need to develop clearer guidelines based on antibiotics prevalence and susceptibility patterns. conflict of interest : none references 1. registrar general of india (2016).sample registration syatem statistics report 2016,new delhi :registrar general of india. 2. national family health survey 4 (2015-16),n ational fact sheet, 2016. 3. waters d, jawad i, ahmad a, lukšic i, nair h, zgaga l, et al. aetiology of community-acquired neonatal sepsis in low and middle income countries. j glob health. 2011;1:154–170 4. bizzarro mj, raskind c, baltimore rs, et al. seventy-ve years of neonatal sepsis at yale: 1928–2003. pediatrics 2005;116:595–602. 5. shim gh, kim sd, kim hs, et al.trends in epidemiology of neonatal sepsis in a tertiary center in korea: a 26-year longitudinal analysis, 1980–2005. j korean med sci 2011;26:284–9. 6. fuchs a, bielicki et al.antibiotic sepsis use for the neonates and children.2016 evidence update.who reviews 2016 7. van den hoogen a, gerards lj, verboon-maciolek ma, fleer a, krediet tg. long-term trends in the epidemiology of neonatal sepsis and antibiotic susceptibility of causative agents. neonatology 2010;97:22-8. 8. leal ya, álvarez-nemegyei j, velázquez jr, rosado-quiab u, diegorodríguez n, paz-baeza e, et al. risk factors and prognosis for neonatal sepsis in southeastern mexico: analysis of a four-year historic cohort followup. bmc pregnancy childbirth 2012;12 9. al mouqadad mm,alaklobi et al. a retrospective cohort study patient chart review of neonatal sepsis investigating responsible microorganisms and their susceptibility. j clin neonatal. 2018:7 141-145 10. russel ab, sharland m, improving antibiotic prescribing in neonatal units, time to act. arch dis child fetal neonatal ed.2012 11. wynn jl. de�ning neonatal sepsis. curr opin pediatr. 2016;28:135–140 12. metsvaht t, ilmoja ml, parm ü, et al. comparison of ampicillin plus gentamicin vs. penicillin plus gentamicin in empiric treatment of neonates at risk of early onset sepsis. acta paediatr. 2010;99:665–672 13. hornik cp, fort p, clark rh, et al. early and late onset sepsis in very-low-birthweight infants from a large group of neonatal intensive care units. early hum dev.2012;88(suppl 2):s69–s74 14. muller-pebody b, johnson ap, heath pt, et al; icap group (improving antibiotic prescribing in primary care). empirical treatment of neonatal sepsis: are the current guidelines adequate? arch dis child fetal neonatal ed. 2011;96:f4–f8. 15. de man p, verhoeven ba, verbrugh ha, et al. an antibiotic policy to prevent emergence of resistant bacilli. lancet. 2000;355:973–978 16. clark rh, bloom bt, spitzer ar, et al. empiric use of ampicillin and cefotaxime, compared with ampicillin and gentamicin, for neo-nates at risk for sepsis is associated with an increased risk of neo-natal death. pediatrics. 2006;117:67–74. 17. aliaga s, clark rh, laughon m, et al. changes in the inci-dence of candidiasis in neonatal intensive care units. pediatrics. 2014;133:236–242 x 81gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction : odontogenic cysts are a group of common lesions – thought to be of developmental origin that commonly involve the maxilla and the mandible and frequently cause destruction of these bones. these cysts are seldom discovered in young individuals since they frequently occur in individuals between 20 and 40 years of age. these cysts are discovered unexpectedly on routine radiographic examination since they are asymptomatic unless after an infection. on imaging, these cysts may appear unilocular with well circumscribed margins. infected cysts show ill-dened margins. histologically these cysts are lined by non-keratinized stratied squamous epithelium. various modalities of management from marsupialization to enucleation have been reported in literature. the common treatment for dc is enucleation followed by extraction of the involved tooth. in cases where the cyst is large, then the management is two staged which includes marsupialization to decrease the size of the osseous defect followed by enucleation and and extraction of tooth. enucleation is the choice of treatment whenever the cyst is small and saving the involved tooth is impossible. when diagnosed at a late stage, they are usually managed by enucleation and by the extraction of the involved tooth. case report : a 23 year old female presented to our opd with chief complaints of left sided facial pain, asymmetry for 7 years. patient has undergone surgery for the same 7 years back details of which were unknown. upon examination, patient had her all permanent teeth associated with over crowding and small cystic swelling over the gingiva-buccal sulcus above the incisors. ct pns was done which revealed dentigerous cyst in the left maxillary sinus causing left premaxillary bulge and intra osseus cyst in the right maxillary cavity. fig 1 showing facial asymmetry on the left side fig 2 showing small cystic swelling over the left gingiva buccal sulcus above the lateral incisor fig 3 ct pns coronal cut showing dentigerous cyst with unerupted tooth in right maxillary cavity based on the clinical and radiological evidence, a provisional diagnosis of dentigerous cyst was made. patient underwent complete excision of the cyst with removal of the uninterrupted tooth by a gingiva buccal incision. specimen was sent for hpe which revealed non-keratinized squamous epithelium suggestive of dentigerous cyst. post operative healing was satisfactory with no recurrence. infected dentigerous cyst with unerupted tooth original research paper prof. dr. m. k rajasekar dept of ent, sree balaji medical college, chennai ent dentigerous cysts are odontogenic cysts associated with crown of impacted or unerupted tooth. they commonly occur in middle aged individuals and are believed to originate from the epithelial remnants of tooth forming organs. dentigerous cyst can occur in the rst decade of life in some rare cases. they are usually diagnosed on imaging when evaluvated for delayed eruption. we hereby present a case of 23 year old female who came with complaints of right sided facial pain and asymmetry for 7 years associated with history of surgery for the same. patient was evaluated and underwent complete excision of the cyst along with removal of the impacted unerupted tooth. management options include conservative measures, enucleation , excision or marsupialization. this report throws light on how management of the dentigerous cyst by excision was the suitable treatment of choice for this patient. abstract keywords : unerupted tooth, dentigerous cyst, excision prof dr. sridhara narayanan* dept of ent, sree balaji medical college, chennai *corresponding author dr. pravilika dept of ent, sree balaji medical college, chennai volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 104 x gjra global journal for research analysis fig 4 &5 showing intra-op pictures. fig 6 showing excised cyst with unerupted tooth. discussion : dentigerous cyst also called as follicular cyst is a odontogenic cyst which is of developmental origin. the term dentigerous the literal meaning “tooth bearing.” the cyst is usually lined by epithelial cells which is derived from the enamel epithelium of the tooth forming organ. the etiology behind accumulation of exudate between the reduced enamel epithelium and the crom may be due to the pressure exerted by an erupting tooth on the follicle thereby leading to formation of cyst. odontogenic keratocyst, adenomatoid odontogenic tumor, and ameloblastic broma can mimic a dentigerous cyst. a suspicion of other lesions can arise when the follicular space is larger than 5 mm in diameter. another factor which could be triggering the cyst formation in addition to developmental origin is the periapical inammation of a non-vital deciduous teeth which are in proximity to the follicles of unerupted permanent successors.occasionally the dentigerous cyst may give rise to mucoepidermoid/ ameloblastoma/squmaous cell carcinoma. these cysts have the tendency to become large in size and can cause displacement of teeth or it may remain relatively small in a few cases. the age range varies widely, from 5 years to 57 years.[3] many dentigerous cysts are small asymptomatic lesions that are discovered serendipitously on routine radiographs. some may cause bony expansion that is usually painless until secondary infection occurs if they are large in size. early detection and management of these cysts is important to reduce morbidity as they can grow to varying sizes. three types of dentigerous cyst have been described radiographically: central type, in which the radiolucency surrounds just the crown of the tooth, with the crown projecting into the cyst lumen. in the lateral type, the cyst develops laterally along the tooth root and partially surrounds the crown, the circumferential type , the crown is surrounded by the cyst and the cyst contains the entire tooth .our case was a classic presentation of the circumferential variety. conclusion : dentigerous are the most common developmental cysts. early detection and prompt management is required to prevent the lesion from becoming an aggressive one causing gross expansion of bone with subsequent facial asymmetry, pain, displacement of teeth, and root resorption as it commonly involves young individuals. marsupialization can be the treatment of choice, whereas in the present case, excision was done taking into account the poor oral hygiene, cooperation and the socioeconomic status of the patient. the prognosis is good which are generally diagnosed by histopathology, recurrence being a rare nding. references : 1. delbem ac, cunha rf, afonso rl, bianco kg, idem ap. dentigerous cyst in primary dentitionreport of 2 cases. pediatr dent 2006;28:269-72. 2. naclério h, simões wa, zindel d, chilvarquer i, aparecida ta. dentigerous cyst associated with an upper permanent central incisor: case report and literature review. j clin pediatr dent 2002;26:187-92 3. management of a dentigerous cyst associated with inverted and fused mesiodens: a rare case report. patel k1, patel n, venkataraghavan k. 4. j. m. v. reyes, j. a. e. bermúdez, and y. e. g. ruisánchez, “dentigerous cysts: case report,” journal of advanced oral research, vol. 7, no. 1, 2016 5. d. w. anderson and d. evans, “dentigerous cyst of mandible presenting as sepsis,” the american journal of emergency medicine, vol. 32, no. 12, pp. 1561.e3–1561.e4, 2014. 6. an infected dentigerous cyst associated with an impacted permanent maxillary canine, inverted mesiodens and impacted supernumerary teeth. karthik rajaram mohan, balan natarajan, sudhaamani mani, yasmeen ahmed sahuthullah, arivukkadal vijaya kannan, and haritha doraiswamy. 7. browne rm. the pathogenesis of odontogenic cysts: a review. j oral pathol. 1975;4:31–46 volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 105gjra global journal for research analysis proximal tibial fractures with intraarticular extensions are 1very difcult to manage . complex biomechanics of weight bearing position, complex ligamentous stability and articular congruency are the main concerns to the surgeons in these type of fractures. the ideal treatment of high energy tibial plateau fracture is controversial. open reduction and internal xation with plate and screws method helps to achieve good anatomical 2reduction ,but devitalize the soft tissue and the rate of wound infection is high. to prevent this complication the trend of treatment is towards biological xation with minimal soft tissue damage which can be accomplished by mippo technique materials & methods this prospective study was conducted from november 2017 to june 2019. in this 30 patients of proximal tibial fractures extending to diaphysis,closed fractures, schatzker type 2 to type 6 and patient's age more than 18 years were included. patients with compound fractures, impending compartment syndrome, schatzker type 1 and patient's age less than 18 years were excluded from the study. the consent of the patient for anesthesia and surgery was obtained. patient was immobilized and adequate limb elevation was given. patient were placed in supine position, under mippo technique anterolateral approach skin incision was made in between gerdy's tubercle and anterior to head of bula. fascia was incised,indirect reduction of fracture was done by manual traction and reduction was maintained with reduction clamps. appropriate size locking compression locking plate was placed extra–periosteally and xed with kwires temporarily. alignment was checked and xed with both proximal and distal screw. depressed fragments were elevated in some cases;void lled with bone grafting, 6.5mmscrews were xed proximally and 5mm cortical locking screw was applied through multiple mini stab incisions. k wires were removed . ndpostoperatively wound was inspected at 2 post operative day. post-op x ray was taken. non-weight bearing and static stquadriceps exercises were started on the 1 post operative day .knee range of movements and quadriceps strengthening ndwere started from 2 post operative day . patient were followed at 6 weeks,3 months,6 months intervals 4for functional outcome by modied rasmussen criteria . results: in our 30 patients,the mean age group was 44.23years , 22 (73. 33%) patients were male 8 (26.66%)patients were female.12 patients had right side tibial plateau fracture,18 patients had left side tibial plateau fracture.road trafc accident was the most common mode of injury (26 patients).10 patient had schatzker type 2 fracture,12 patients had schatzker type 5, 8 patient had schatzker type 6 fracture.22 patients had knee range of movements > 120 degrees, 7 patients had >90120 degrees, 1 patient had knee range of movements of 80 degrees. in (gure 3 , 4) patient with schatzker type 6 with exion of > 120 degrees. the average time for bone union was 14.16 weeks .functional outcome of 30 cases of proximal tibial fractures is provided in table 1.functional outcome was divided into 4 categories based on modied rassmusen criteria,18 patients had excellent outcome ,9 patients had good outcome, 3 patients had fair outcome.there was no poor outcome in our study.27(90%) patients had acceptable outcome which are comparable with other studies complications were noted in 4 patients ,2 patients had knee stiffness,one patient had supercial skin infection,one patient had screw backout.(fig:5) table:1 minimally invasive percutaneous plate osteosynthesis for proximal tibial fractures-a prospective study original research paper mohammed irfankhan h post graduate department of orthopaedics ,sri venkateshwaraa medical college and research centre, puducherry , india orthopaedics introduction: proximal tibial fractures are most common in road trafc accidents,are difcult to manage due to limited soft tissue coverage. conventional method of plate and screws can devitalize soft tissue. to overcome such complications mippo technique is widely used. methods: the functional outcome of proximal tibial fractures in 30 patients treated by mippo technique has been evaluated. these patients were followed for 6 months postoperatively and assessed by modied rasmussen score. results: in our analysis of 30 patients ,18(60%) patients had excellent results, 9(30%) patients had good results, 3(10%)had fair outcome. discussion: fracture of proximal tibia involves lot soft tissue damage,this compromised soft tissue condition must be considered while treating them. mippo is more of biological xation with less soft tissue damage,hence wound healing is faster. abstract keywords : minimally invasive percutaneous plate osteosynthesis.,biological fixation,proximal tibia fractures. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra balasubramaniam r* prof. department of orthopaedics,sri venkateshwaraa medical college and research centre, puducherry, india *corresponding author manikandan a asst prof. department of orthopaedics, sri venkateshwaraa medical college and research centre, puducherry, india. functional interpretation (modied rasmussen criteria) no of patients percentage excellent 18 60 good 9 30 fair 3 10 poor 0 0 total 30 100 28 x gjra global journal for research analysis figure: 5 complication: screw back out. discussion: treatment of proximal tibial fractures are challenging due to limited soft tissue cover and even a small irregularity on articular surface in the joint leads to early arthritis ,instability 3and stiffness . there are various treatment options from closed reduction and casting to open reduction internal xation with plate and screws. open reduction and internal xation with plate and screws can cause extensive devitalization of soft tissue leading to delayed wound healing and infections. in our study we managed these fractures by minimally invasive percutaneous plate osteosynthesis (mippo). this technique is widely accepted for treatment for peri articular fractures in which we reduce and stabilize the facture without opening the fracture site with minimal incision providing favourable environment for fracture healing. in our study most of the patients were male who are in active age group as they involve in travel sports and motor riding activities. it shows high velocity nature of tibial plateau fracture.which 5can be compared with albuquere et al study . in our series of 30 patients 77.33% of patients had knee range of movements of >120 degrees.mean range of movements was 122.83 degrees which is comparable with changwug oh 6et al study . in our study we used modied rasmussen criteria for evalu ation of functional outcome. 90%of the patients had acce ptable outcome.which can be compared with hassain raza et 7 8al and neil rohra et al studies. in our study average time for bony union was 14.16 weeks. all the fractures united .there was no case of non union in our study. there were 4 complications noted in our study.two patients had knee stiffness due to poor follow up,which recovered after physiotherapy. one patient had supercial skin infection which resolved following antibiotics. one patient had screw back out . conclusion: mippo technique is simple and more effective compared to the conventional plating system.it is more of a biological xation with less soft tissue damage hence wound healing is faster. declaration of patient consent the authors certify that they have obtained all appropriate patients consent forms. in the form,the patients have given their consent for their images and other clinical information to be reported in the journal. the patients understand that name and initial will not be published and due efforts will be made to conceal their identity,but anonymity cannot be guaranteed. financial support and sponsorship: nil conflicts of interest: there are no conict of interest references: 1. campbells operative orthopaedics; fractures of lower extremity:tibial plateau 20942111 vol 3. 2. kenneth. a. egol and kenneth j koval , in: fracture of proximal tibia: chapter 50, rockwood and green’s “fracture in adults”, vol. 2, 6th edition, lippincott williams and wilkins. pp. 1999. 3. charles . m. court-brown, in: fracture of tibia and bula. chapter 52, rockwood and green’s “fracture in adults” , vol. 2, 6th edition, lippincott williams and wilkins, pp. 2080 4. schatzkar j, mcbroom r, bruce d. the tibial plateau fractures. toronto experience. clinorthop 1979;138:94. 5. albuquerque, rp e, hara r, prado j, schiavo l, giordano v, &amaralnp do.epidemiological study on tibial plateau fractures at a level i traumacenter. actaortopédicabrasileira. (2013): 21(2), 109-15. 6. chang-wug oh, jong-keon oh, hee-soo kyung et all. double plating ofunstable proximal t ibial fractures using minimally invasive percutaneousosteosynthesis technique. injury actaorthopaedica 2006; 77(3):524-530. 7. raza h, hashmi p, abbas k, hafeez k. minimally invasive plate osteosynthesis for tibial plateau fractures. j orthopaedic surgery. 2012;20(1):42–47 8. rohra n, suri hs, gangrade k. functional and radiological outcome of schatzker type v and vi tibial plateau fracture treatment with dual plates with minimum 3 years follow-up: a prospective study. j clindiagn res. 2016;10(5):rc05–rc10. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra figure: 1 figure: 2 figure: 3 figure: 4 pre op xray at 6 months x 29gjra global journal for research analysis introduction presence of appendicitis and pancreatitis in a patient is very rare and whether it is complication of pancreatitis resulting in appendicitis or two separate pathologies, is not known. there exists a possibility of spread of pancreatic inammatory exudates via the small bowel mesentery resulting in periappendicitis (1). we present a case of acute abdomen which was diagnosed to have both appendicitis and pancreatitis. case report 35 year old male with no known co morbidities presented with history of severe abdominal pain, loss of appetite, nausea and non bilious vomiting of one day duration. pain was sudden in onset, severe in nature localised in epigastric and right lumbar region. no history of fever or bowel and bladder complaints. the patient denied any history of alcohol consumption. on examination, vitals were within normal limits. abdomen was distended and had tenderness in epigastric and right lumbar region and bowel sounds were present. per rectal examination was unremarkable. patient had leucocytosis on haematological examination with raised serum amylase and lipase levels. ultrasound of the abdomen revealed fat stranding around body of pancreas and features of acute appendicitis (figure 1&2). abdominal computed tomography (ct) also revealed the evidence of complicated pancreatitis along with uid accumulation around the inamed appendix (figure 3&4). patient was managed conservatively to which he responded well and was discharged after 10 days of admission and is under regular follow up. figure 1 : usg showing fat stranding around pancreas figure 2: usg showing blind ending tubular non compressible structure figure 3 : cect abdomen showing pancreatitis figure 4: cect showing appendicitis & thickened gerota's fascia on right side discussion colonic complications of severe acute pancreatitis are quite uncommon and always occur in transverse colon and splenic exure (1). the incidence of such complications is approx 7% including infarction, infection and transverse colon and dual pathology of acute pancreatitis and acute appendicitis in a patient presenting with acute abdomen original research paper maj (dr) yogesh kukreja* graded specialist (general surgery), 153 general hospital * corresponding author general surgery presence of appendicitis and pancreatitis in a patient is very rare and whether it is complication of pancreatitis resulting in appendicitis or two separate pathologies, is not known. there is a requirement to study the association between the two. even the management of the same is not clear. we present a case of acute abdomen which was diagnosed to have both appendicitis and pancreatitis. abstract keywords : volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra maj (dr) ss choudhary graded specialist (radiodiagnosis), 153 general hospital maj (dr) rajat chawla graded specialist (internal medicine), 153 general hospital capt (dr) shreya srivastava medical ofcer, 153 general hospital 34 x gjra global journal for research analysis splenic exure stula, however not much has been reported about isolated involvement of the appendix as a complication of pancreatitis (2). according to the reports of rare cases, there is a possibility that appendicitis be a rare complication of pancreatitis (1,3,4). conclusion not much is known about the relationship between pancreatitis and appendicitis. the possibility is either of dual pathology or that the infection is spread from the pancreas to the colon or vice versa. further whether the patient should be managed conservatively or by surgical intervention should be further studied (1). references 1. hsia hc, shoung lk, wong dw. acute pancreatitis complicated with periappendicitis. zhonghua yi xue za zhi (taipei) 2002; 65:61921.[abstract] 2. alaqqad m, ram l, kannan p, abou al neaj m. pancreatitis complicated by acute appendicitis. hamdan med j 2015;8:161-4. 3. wasnik n, agrawal vp, khatri kr, khatri v. acute pancreatitis masquerading as acute appendicitis – a diagnostic dilemma. ijbar 2013 4. wasnik n, agrawal vp, khatri kr, khatri v. acute pancreatitis masquerading as acute appendicitis – a diagnostic dilemma. ijbar 2013; 4. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 35gjra global journal for research analysis introduction laryngocele is a cystic dilatation of the saccule of the larynx and it is generally lled with air. if communication between the cyst and the laryngeal lumen is occluded, uid may accumulate within the sac. a mucous retention cyst may also arise from the mucus gland of the saccule of the larynx, in which case it is lled only with mucus and not air and is called a saccular cyst. the incidence of laryngocele is 1 in 2.5 million population, hence it is rare. usually, males between 50 and 60 years of age are affected. since a laryngocele is mainly seen among glass blowers and trumpet players, an increase in intraluminal laryngeal pressure has been postulated as a possible mechanism. however, in the elderly, an underlying laryngeal carcinoma needs to be excluded. this case is unique in that the patient was neither a glass blower nor a trumpet player. besides, the excised specimen showed no evidence of malignancy. case report this is a case report of a 80-yearold farmer male who presented with the complaints of painless swelling in the upper left side of the neck for the past 1 year. it used to increase in size during coughing and straining. patient had past history of pulmonary koch’s for that complete akt taken. he is chronic bidi smoker. examination revealed a compressible swelling measuring 7 × 5 cm in the left anterior triangle of neck with normal overlying skin. it was non-tender, soft, cystic, uctuant and mobile. the swelling increased in size on coughing and on valsalva maneuver. indirect laryngoscopy was normal [figure 1]. figure 1: laryngocele on neck examination soft-tissue radiograph of neck (antero-posterior view) revealed an air-lled sac suggestive of external laryngocele [figure 2]. figure 2: external laryngocele on x-ray cect of neck conrmed the diagnosis following which the patient was taken up for excision of laryngocele. [figure 3]. figure 3: external laryngocele on cect neck procedure under general anesthesia with endotracheal intubation and aseptic precautions, a horizontal skin crease incision was made over the swelling. after raising skin aps and dissecting soft-tissues, the laryngocele was identied, separated from surrounding tissues and mobilized up to its neck as far as the thyrohyoid membrane. the neck was transected after securing it with a transxation suture to reduce the risk of recurrence. the skin was closed in layers after placing a drain. the post-operative period was uneventful and sutures were removed after 7 days. histopathologic examination conrmed laryngocele and excluded malignancy [figure 4] and [figure 5]. a rare case report of external laryngocele in farmer original research paper dr. nina m. shah associate professor & hou, department of general surgery, b.j.medical college, civil hospital, ahmedabad. general surgery keywords : dr. sandip lukhi* rd3 year resident, department of general surgery, b.j.medical college, civil hospital, ahmedabad. *corresponding author dr. siddharth tanti st1 year resident, department of general surgery, b.j.medical college, civil hospital, ahmedabad. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. hiral c. chauhan assistant professor, department of general surgery, b.j.medical college, civil hospital, ahmedabad. 64 x gjra global journal for research analysis figure 4: dissected fundus and neck. figure 5: transxed and cut end of neck. figure 6: conrmed by histopathology. discussion a congenital laryngocele, which causes respiratory distress in new borns, may be the result of a large ventricular appendix. an acquired laryngocele may develop as a result of an increase in intra-glottic pressure, such as that caused by excessive coughing, playing a wind instrument, glass blowing and after performing valsalva maneuver, or using ventricular phonation during speech. laryngoceles may extend internally into the airway or externally through the thyrohyoid membrane and they are termed internal if medial to the thyroid cartilage, or external if lateral to it. as the laryngocele expands and escapes laterally across the thyroid cartilage, the air-lled communication may become tenuous, even though pressure changes may still be transmitted through it; this accounts for the presence of a cough impulse and also increase in size with valsalva maneuver. depending on the size and duration, the swelling may present as internal, external or combined (mixed) internal and external laryngocele. the common presenting symptoms of internal or mixed laryngoceles are globus sensation, sore throat, cough, pain, snoring, increasing stridor, hoarseness, airway obstruction if the lesion is large, or in case of external laryngoceles, a visible or palpable mass in the neck. laryngoscopic examination may reveal a globular swelling in the laryngeal lumen or a submucosal fullness, but may miss the internal component of a mixed laryngocele if it is small and also due to rapid deation and ination. while it is often difcult to establish if a laryngeal cyst is congenital or acquired, a laryngocele must be differentiated from other laryngeal cysts, of which the true cysts may be classied as epithelial, oncocytic and tonsillar. epithelial cysts are the most common and include saccular cysts, whereas tonsillar cysts are mostly found in the region of the vallecula, epiglottis or pyriform sinus and bear resemblance to lympho-epithelial cysts of the oral cavity. oncocytic cysts are more common in the ventricle, are seen predominantly in the elderly, may be multiple in number, have higher rates of recurrence and generally behave like benign neoplasms, though the jury is still out on whether the oncocytic cells containing hypertrophied deeply eosinophilic mitochondria are the result of degeneration or neoplastic change. a laryngocele may coexist with other laryngeal diseases like recurrent respiratory papillomatosis, amyloidosis, rheumatoid arthritis, etc., and must not only be differentiated from, but may also be co-existent with, oncocytic cysts. computed tomography scan is the most accurate imaging method in dening spatial relationships between the laryngocele and laryngeal structures and extra-laryngeal soft-tissues, in differentiating the laryngocele from other cystic formations and in identifying the coexistence of a laryngeal malignancy. management includes observation, endoscopic resection, or resection through an external approach. marsupialization using co laser, may be done through an 2 endolaryngeal, endoscopic or microscopic approach for internal or mixed laryngoceles. the external cervical approach, with or without tracheotomy, may be employed for mixed and external laryngoceles. the neck, in case of an external laryngocele sac, should be dissected carefully in order to prevent damage to the neurovascular bundle which penetrates the thyrohyoid membrane at the site of exit of the external laryngocele. conclusion though rare, laryngocele should be considered in any patient presenting with a compressible neck swelling, even in the absence of known risk factors or associations. repeated and thorough laryngoscopic examination must be carried out to determine whether the laryngocele is internal, external or mixed so that appropriate treatment can be instituted. references 1. michael m, par ikh s. benign lar yngeal les ions . bal lenger 's otorhinolaryngology, head and neck surgery. 17 th ed. �cbs publishers & distributors pvt. ltd.; 2009. p. 880. 2. drozd m, szuber k, szuber d. the signicance of the valve mechanism in pathology of laryngocele. otolaryngol pol 1996;50:17-20. 3. dray tg, waugh pf, hillel ad. the association of laryngoceles with ventricular phonation. j voice 2000;14:278-81. 4. gallivan kh, gallivan gj. bilateral mixed laryngoceles: simultaneous strobovideolaryngoscopy and external video examination. j voice 2002;16:258-66. 5. pennings rj, van den hoogen fj, marres ha. giant laryngoceles: a cause of upper airway obstruction. eur arch otorhinolaryngol 2001;258:137-40. 6. akbas y, unal m, pata ys. asymptomatic bilateral mixed-type laryngocele and laryngeal carcinoma. eur arch otorhinolaryngol 2004;261:307-9. 7. zawadzka-glos l, frackiewicz m, brzewski m, biejat a, chmielik m. difculties in diagnosis of laryngeal cysts in children. int j pediatr otorhinolaryngol 2009;73:1729-31. 8. ramesar k, albizzati c. laryngeal cysts: clinical relevance of a modied working classication. j laryngol otol 1988;102:923-5. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 65gjra global journal for research analysis introduction heart disease complicates more than 1 percent of all pregnancies and now is leading cause of indirect maternal deaths-accounting of 20 percent of all cases. pregnancy comes as a temporary complication in the disease process of a patient with a cardiac lesion. prevalence of heart disease in pregnancy varies from 0.3%-3.5%. it is the fourth common cause of maternal mortality and one of the most important non obstetrical causes of maternal death. previously most women with diagnosed heart disease were advised to avoid pregnancy and labor and termination was advised. but in modern obstetrical practice, pregnancy in a patient with a heart disease is no longer an unacceptable hazard. joint management between the obstetrician and the cardiologist has improved the outcome of pregnancy and reduced maternal risks. the most common clinical features of cardiac lesions like breathlessness, pedal oedema , murmurs which mimic normal physiological changes in pregnancy posing a diagnostic difculty for obstetricians. in rst trimester nearly 30% increase in stroke volume due to ventricular remodeling and decrease in after load due to fall in systemic vascular resistance. later on increase in cardiac output is sustained by increase in heart rate of about 10-20 beats per minute. this increase in heart rate and cardiac output has deleterious effect on stenotic lesions. during labor, cardiac output increases by 45% above the pre labor level, with up to 500 ml of blood being pumped into circulation with uterine contraction. after delivery of the baby, caval compression is relieved and after placenta is delivered, another auto transfusion occurs from the placental sinusoids into maternal circulation, both increases the cardiac output and stroke volume 80% above baseline. in patient of cardiac disease, there is more chances of abortion, preterm delivery, fetal growth restriction and fetal death. the time to learn about identifying high risk factor pregnancy, different mode of deliveries, in such patients is prior to pregnancy. the management includes intensive care throughout pregnancy and also during labor and postpartum. the earliest signs of complication need to be watched for so, longer hospitalization period is always recommended in antenatal and even postnatal period. vigilance with combined efforts from the obstetrician, a physician and a cardiologist and is mandatory for successful course and outcome of pregnancies complicated by heart diseases. though heart disease is often a worrying problem, the study shows that outcome of pregnancy is generally satisfactory and majority of the patients with proper management achieve normal vaginal delivery after spontaneous onset of labor. aims and objective: ÿ to assess maternal and fetal outcome and prognosis in cases of cardiac disease in pregnancy. ÿ to assess effect of pregnancy on cardiac disease and effect of cardiac disease on pregnancy. material and method in this study, patient's detailed demographic information, diagnosis, course in the hospital, management and analysis of maternal and fetal outcome in 100 cases of cardiac disease in pregnancy was carried out in the department of obstetrics and gynecology in b.j. medical college civil hospital, ahmedabad at a tertiary care center from 01/08/2018 to 31/07/2019. inclusion criteria: ÿ patient with known case of rhd or diagnosed during present pregnancy. ÿ patient with congenital heart disease. ÿ patient with ischemic heart disease. ÿ patient with prosthetic heart valve and surgically corrected heart disease. ÿ patient with any cardiac disease. exclusion criteria: ÿ patient who is not willing to participate in study. ÿ all conditions mimicking heart disease were excluded. fetomaternal outcome in cardiac disease with pregnancy original research paper dr. lalit d. kapadia professor and hou, department of obgy, civil hospital, ahmedabad obstetrics and gynaecology background: heart disease is most important cause of maternal mortality. problems may arise due to hemodynamic burden and the hypercoagulable state of pregnancy. identifying women at high risk is an important aspect of care for women with heart disease. material and method: this prospective study is an analysis of maternal and fetal outcome in cases of cardiac disease in pregnancy was carried out in department of obstetrics and gynecology in civil hospital, ahmedabad. results: the prevalence of heart disease in present study is 0.67% which is more common in child bearing age. rhd is still a major group of heart disease in pregnancy among which mitral valve disease is the commonest. with increase in severity of nyha grade there is increase of chances of maternal morbidity and mortality. preterm labor is common in patients with cardiac diseases. conclusion: educating the community about the cardiac disease and its complications, need for early detection of cardiac lesion, close monitoring during antenatal period, intrapartum period and postpartum care play a vital role in achieving good feto– maternal outcome. use of prophylactic antibiotics, anti failure treatment during labor may bring down the incidence of infective endocarditis and cardiac failure during antenatal as well as puerperal period. abstract keywords : dr. pooja thummar* 3rd year resident, department of obgy, civil hospital, ahmedabad *corresponding author volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 48 x gjra global journal for research analysis results and discussion in our study ,out of total 14,708 deliveries during period 01/08/2018 to 31/07/2019 , there were 100 cases of pregnancy with cardiac disease and they were studied in terms of maternal and fetal outcomes. total 14708 patients were registered as indoor patients at our setup during the study period. prevalence of cardiac disease during the study was 0.67%. table 1: maternal age and heart disease study comparison of present study with other author study in present study out of 100 patients, 7 patients were from 1820-year age group, 49 patients were from 21-25 years of age group, 24 patients were 26-30 years' age group, while 20 patients were 31-40 years' age group. this suggests cardiac disease during pregnancy was more common in child bearing age group, because of majority of patient with cardiac disease was rst time diagnosed during antenatal, intrapartum or postpartum period. in the present study, total of 100 patients 96 patient delivered, while 2 patients underwent termination of pregnancy while one patient had spontaneous abortion and one patient had 2nd trimester iud. figure:2 etiological distribution in the present study out of 100 cases, 63 patients were found to have rheumatic heart disease. among all presentations of rheumatic heart disease, mitral stenosis is the predominant lesion. cardiomyopathies are being increasingly recognized, with three main types-dilated, restrictive and hypertrophic cardiomyopathy. with advances in surgical techniques, the prognosis of congenital heart disease has improved and majority have survived in adulthood. in the present study, the commonest lesion in congenital heart disease found during pregnancy was operated atrial septal defect in 11 patients. pregnancy is well tolerated unless pulmonary hypertension has developed, but this is uncommon. figure 3 : severity of heart disease according to nyha grade in present study most of the patients were in grade i and ii of nyha classication. with proper care and management normal labor and delivery were achieved in most of these patients. the patients of grade iii and iv were immediately hospitalized and need intensive care because as the grade increases, the maternal and fetal prognosis worsens. grade iii and iv patients had more chances of development of cardiac complications like congestive cardiac failure, pulmonary edema and many more. poor functional class iii-iv in addition to severity of the cardiac lesion is a signicant risk factor for both mother and child. out of 8 cases of grade iii and iv, 6 cases developed ccf. thus these patients of grade iii and iv patients present a challenge in obstetric management. hence multi disciplinary approach is needed for such patients. table 4: complications of heart disease total 32 patients developed complications. out of 100 cases 8 patient developed ccf,6 patients were developed pleural effusion and 6 patient developed pulmonary edema. none of the patient developed acute rheumatic fever probably due to improved and regular prophylaxis by inj. benzathine penicillin 1.2 mu im every 21 days which is very effective drug in preventing attacks of rheumatic fever. most of the patients who developed complications belonged to nyha grade 3 to 4 from the very beginning and thus this shows that as the functional grade increases the incidence of cardiac de compensation also increases. in developing countries like india, cardiac disease complicates 2% of pregnancies and contribute to 1/5 of all maternal death. those patient with a treated cardiac valvular lesion with prosthetic valve pose a special problem at time of delivery. these patients were at increased risk to develop complications like thrombosis, endocarditis. in such cases anticoagulant drugs are needed. as soon as pregnancy conrm switch from warfarin to lmwh to prevent teratogenicity upto 12 weeks. again covert to warfarin from 12 week to 36 week (maintain inr between 2.5 to 3.5 )and changed to lmwh after 36 weeks till 7 days postpartum. stop all anticoagulant before and after delivery for 24 hrs to prevent pph in mother and intracranial hemorrhage in baby. in present study one patient develop thrombosis. figure 5 : outcome of pregnancy according to the indication and condition of patients, the mode of deliveries was planned. out of 100 patients, 58patients had full term deliveries while in 38 patients pre term deliveries occurred. one patient had eissenmenger syndrome which was diagnosed at 16th week of gestation in which medical termination of pregnancy was done with volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra age group present study (%) pandey k. et al 25study(2016) <20= year 7% 28% 21-25year 49% 36% 26-30 year 24% 28% 31-40 year 20% 8% complications other congestive cardiac failure 8 pneumonia 2 pleural effusion 6 pulmonary edema 6 thromboembolism 1 maternal mortality 4 post-partum hemorrhage 4 cardiomyopathies 1 x 49gjra global journal for research analysis cardiologist's advise. out of two cases of tetralogy of fallot th one with 12 week of gestation were advised for termination & medical termination was done in these case. one patient with severe anemia and mitral stenosis had been diagnosed as 24 weeks of gestation iud which delivered spontaneously at our institute following admission to the labor room. table 6 : mode of deliveries in heart disease in the present study, out of total 96 deliveries, 47 were vaginal deliveries. amongst these 13 were instrumental delivery to cut ndshort 2 stage of labor. out of 13 instrumental delivery 7 were forceps delivery and 6 were ventouse delivery. vaginal delivery is better option than cesarean section for women with heart disease. the risk of bleeding, infection and thrombotic complications is less and vaginal delivery is not associated with anesthetic complications and acute shift in blood volume that happens during cesarean section. moreover 36 lower segment cesarean section were performed. all are done under general anesthesia. out of 36, only 4 lscs were done for cardiac indication as advised by cardiologist. fetal outcome in present study: in present study out of 100 fetuses, 86 were delivered live either pre term or full term, 10 babies were still born, 1 abortus iud and no case was remaining undelivered. table 7 : percentage of nicu admission in present study. in the present study, out of total 86 live birth , 34 babies were admitted in the nicu. among them, 8 babies were full term and 26 babies were preterm. it indicates that prematurity is the leading cause for nicu admission which is because of cardiac disease . neonatal mortality and its causes: neonatal mortality rate in the present study is 8.33%(n=8). there were multiple causes of neonatal mortality including prematurity, hyaline membrane disease, meconium aspiration syndrome and septicemia. in the present study, total 8 babies expired, out of them 5 babies expired due to prematurity and hyaline membrane disease, 2 babies expired due to meconium aspiration syndrome and septicemia and 1 baby expired due to congenital anomaly. in present study total 10 babies were still born and 8 babies expired after admission in nicu. total 96 viable pregnancy and 1 abortus in present study according to this perinatal mortality in present study is 18.75%. table 8 : maternal mortality in present study in present study 4 patients expired due to cardiac disease, one from pulmonary oedema, one from atrial fibrilation, one from congestive cardiac failure and one from eisenmenger disease. in our study period of 1 year, in our tertiary care center total 112 maternal mortality occurred ,out of that only 4(3.57%) maternal mortality were due to cardiac disease. these shown that close monitoring and proper management in antenatal, intrapartum and postpartum period may decrease maternal mortality in cardiac disease with pregnancy. conclusion the results of our study indicate that heart disease forms a substantial proportion of medical illness complicating pregnancy. cardiac disease in the pregnant women pose a challenging task to the obstetrician, the physician, the cardiologist and to the neonatologist. but the majority of pregnancies complicated by heart disease are uneventful with a favorably good outcome for both the mother and the fetus if appropriate antenatal and medical care is availed. this study conclude that rheumatic heart disease is still a predominant cardiac lesion affecting pregnancy and its outcome. early detection, treatment like benzathine penicillin and diuretics, proper follow up and correction prior to pregnancy shall improve outcome and decrease in maternal mortality and morbidity. failure to systematically search for cardiac disease in pregnant women has led to late diagnosis and high rates of fatal complications. therefore, effective screening for cardiac disease in pregnant women is warranted. use of prophylactic antibiotics, anti failure treatment during labor may bring down the incidence of infective endocarditis and cardiac failure during antenatal as well as puerperal period. educating the community about the cardiac disease and its complications, need for early detection of cardiac lesion, close monitoring during antenatal period, intrapartum period and postpartum care play a vital role in achieving good feto–maternal outcome. references 1. surge d, blake s, mcdonalad d et al. ‘pregnancy complicated by maternal heart disease’ at the national maternity hospital, dublin:1969-1978 2. michel peter “experience of chf in pregnancy” 1874, 2nd edition 124:126 3. angus macdonald “on the bearing of chronic disease of the heart upon pregnancy & parturition” 1877, 1st edition 150:156 4. uelen, p m richardson, b t le roux et al. “pericardiectomy in pregnancy” thorax 1970;25:627-630 5. michael de swiet “editorial note pregnancy and heart valve replacement” international journal of cardiology impact factor:4.04 06/1984;5(6):741-743 6. cesar a esteves, auristela i o ramos, sergio l n braga et al. “effectiveness of percutaneous balloon mitral valvotomy during pregnancy”am j cardiol 1991;68:930-934 7. jessup m, brozena s “heart failure” n engl j med 2003 may 15;348(20):200718 8. nassar ah, hobeika em, abd essamad hm et al “pregnancy outcome in women with prosthetic heart valves” am j obstet gynecol 2004 sep;191(3):1009-13 9. oron g, hirsch r, ben-haroush a et al “pregnancy outcome in women with heart disease undergoing induction of labour” bjog 2004 jul;111(7):669-75 10. fernando arias, shirish n daftary, amarnath g bhide “practical guide to high-risk pregnancy & delivery” a south asian perspective 3rd edition . volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra mode of delivery no of patients percentage % vaginal delivery 1.vaginal delivery 2.assisted vaginal delivery -forceps -vacuum 47 07 06 48.9% 7.2% 6.25% lscs 36 37.5% total 96 100 nicu admission no. of baby percentage full term 8 8.33% preterm 26 27% cause of death no. of patient pulmonary oedema 1 atrial fibrilation 1 primary pulmonary hypertension leading to congestive cardiac failure 1 eisenmenger disease 1 50 x gjra global journal for research analysis introduction current lifestyle and stress factors have continued to increase the burden of chronic kidney diseases (ckd) ascribed to hypertension, diabetes, genetic factors and infections. progressive ckd is associated with a wide range of complications including cardiovascular (cv) diseases, hypertension, anemia, bone disorders and dyslipidemia [1]. association of hypertension and ckd is a vicious cycle, interlinked with each other. it damages the arteries with loss of arterial elasticity, resulting in arterial stiffness (as), vascular dysfunction and nally cv events [2,3]. its treatment involves a combination of antihypertensive drugs belonging to different classes that reduce bp [4,5], thus discharging the stiff arterial components causing a decrease in as resulting a drop-in pulse wave velocity (pwv) [6,7]. thus, as is measured in terms of pwv. vascular aging (va) and as are prominent features of patients with ckd [8,9]. scientic studies report stiffer arteries in dialysis patients than non-uremic [10]. the major causative factor of as in these patients is bp rather than renal function. mechanisms involved in as in ckd patients is complex and still under research, however, studies suggest that dialysis stimulates chronic inammation and oxidative stress, adversely affecting the arterial wall resulting in arterial stiffening and vascular impairment [11-13]. oscillometric technique is used currently to detect as and central hemodynamics. it is reliable, reproducible and inexpensive; suitable for community-based intervention programs. it measures aortic pressure, bp, pwv and augmentation index (ai). it is an important diagnostic means supporting the management of hypertensive patients with improved compliance. research suggest greater than 40% patients on dialysis die due to cv diseases. covic et al. [14] demonstrated that pwv and ai increase as the coronary vessels are affected adversely suggesting it to be an independent prognostic factor for cv morbidity and mortality. the vascular measurements guide to initiate the specic therapy through individual risk classication and hemody namics data [15]. literature reports a strong association between pwv and as with hypertension especially in elderly. evaluating as is a well-established diagnostic tool, hence, endorsed by hypertension guidelines. studies suggest, early treatment measures can reverse as that could help in preventing hypertension and accompanying clinical conditions [16-18]. limited studies are conducted in indian population to determine the occurrence and prole of as and va in patients with ckd on dialysis with associated hypertension. this study is aimed to investigate the severity of as and va by measuring pwv in these patients using oscillometric device to determine the trend in indian population. this study can help establish the ckd stage at which as and va become apparent in renal patients and their role in cv events. methods and materials this was prospective study conducted at a tertiary care center. patients of either sex with a diagnosis of ckd on dialysis and with associated hypertension were included in the study. the detailed medical history and demographic details [age, sex, body mass index (bmi), bp] were collected for each patient. central blood pressure (cbp) and as were measured using the ®mobil-o-graph pwa (i.e.m. gmbh, stolberg, germany). this device is a commercially available branchial oscillo metric ambulatory bp monitor and has been validated according to british hypertension society and european society of hypertension recommendations [19]. a common cuff was centered to the left upper arm. cuff size was chosen according to the circumference of the mid upper arm. mobil®o-graph pwa provides information about peripheral bp, vascular age, ai and pwv. the primary outcomes of this study were pwv, ai, as of large evaluation of vascular aging and arterial stiffness in patients with chronic kidney disease and associated hypertension original research paper dr. geeta sheth associate professor, department of nephrology, grant government medical college and sir j. j. group of hospitals, mumbai, maharashtra, india x 41gjra global journal for research analysis nephrology background: patients with chronic kidney disease (ckd) on dialysis have high risk of cardiac diseases. vascular aging (va) and arterial stiffness (as) are the major determinants of cardiovascular events. the present study assessed the parameters of va and as by oscillometric device in patients with ckd and associated hypertension. materials and methods: a prospective study was conducted in patients with ckd on dialysis with associated hypertension. central blood pressure (bp) and as were measured using the mobil-o-graph® pwa. it provides information about peripheral bp, vascular age, augmentation index and pwv. this validated device is a commercially available branchial oscillometric ambulatory bp monitor. statistical analysis was performed using chi-square, sample t and mann whitney u test. results: a total of 303 patients with a mean age of 50.70 years were included in this study. the mean age was signicantly higher in patients with large arteries of abnormal as (64.05 years) (p<0.001). the mean va was signicantly higher in patients with average large arteries than normal large arteries (p<0.001). a signicant association was observed between large normal, average and abnormal as in peripheral systolic bp, pulse pressure, mean arterial bp and pulse wave velocity (pwv, [p<0.001]). signicant increase in trend in va and pwv were observed with increasing age (p<0.001). a signicant association was observed between pwv and body mass index, va, as and peripheral and central bp (p<0.001). conclusion: the overall observation suggests an increasing trend in oscillometric measurement of pwv, va, ai with increase in the severity of as. theses parameters are indicative of cardiac events associated with ckd. abstract keywords : augmentation index, blood pressure, cardiovascular, oscillometric, pulse wave. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. shahid ansari* senior registrar, department of nephrology, grant government medical college and sir j.j. group of hospitals, mumbai, maharashtra, india *corresponding author 42 x gjra global journal for research analysis and small arteries and va and secondary outcomes were central and peripheral bp. statistical analysis statistical analysis was performed using statistical package for the social sciences (spss) version 23.0. analysis of categorical variables using chi-square test and continuous variables using independent sample t-test and one-way anova were done. correlation analysis between as and va were done using spearman's correlation coefcient (nonparametric test was used because data were not normally distributed). comparative analysis of quantitative parameters in patients with as was performed using mann whitney u test (not normally distributed data) or independent sample t-test (normally distributed data). results a total of 303 patients diagnosed with ckd on dialysis associated with hypertension were included in this study. the mean age was 50.70 years and there was a prevalence of men (n=203; 67%). demographic and clinical characteristics are summarized in table 1 table 1. demographic and clinical characteristics of partic ipants arterial stiffness small and large arteries were categorized into normal (<27 and <6.9), average (28-40 and 7-8.2) and abnormal (>40 and >8.3) as (table 2). volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra characteristics total (n=303) age (years) 50.70 (14.23) sex, n (%) men 203 (67) women 100 (33) bmi (kg/m2) 23.39 (4.66) peripheral blood pressure (mmhg) systole 128.58 (20.50) diastole 86.70 (16.09) pulse pressure (mmhg) 43.18 (12.23) heart rate per minute (bpm) 83.44 (16.92) mean arterial bp (mmhg) 105.58 (17.44) augmentation index (%) 25.98 (12.49) pulse wave velocity (m/s) 7.64 (1.72) vascular age 52.74 (14.06) central blood pressure (mmhg) systole 118.57 (19.49) diastole 87.46 (18.48) arterial stiffness small arteries 25.76 (12.64) large arteries 7.64 (1.72) data represented as median (sd), unless otherwise specied. bmi, body mass index; bp, blood pressure. table 2. arterial stiffness wise analysis parameters arterial stiffness p-value normal average abnormal small large small large small large small large age (years) 35.5 (11-69) 36.33 (10.44) 52 (28-61) 51.74 (6.10) 64.00 (45-81) 64.05 (7.12) a, >0.05 b,c a, 0.001 b, c sex, n (%) men women 77 (72.6) 29 (27.4) 48 (53.3) 42 (46.7) 78 (72.9) 29 (27.1) 2bmi (kg/m ) 23.51 (4.91) 22.45 (11.72-67.21) 22.98 (4.07) 23.93 (16.53-33.30) 23.94 (4.99) 23.23 (16.44-37.83) 0.518 a 0.012 , b 0.562 c,0.042 vascular age (years) 51.66 (14.06) 37.00 (22.00-75.00) 53.22 (13.85) 53.00 (37.00-61.00) 51.60 (15.54) 62.00 (0.00-86.00) a, >0.05 b,c <0.001 a b0.013 , c0.024 peripheral bp systole (mm hg) 124.93 (18.05) 119.00 (16.57) 133.91 (21.16) 129.83 (16.81) 131.5 (26.35) 137.02 (22.86) <0.001 a, b,c a, b 0.001 c0.027 diastole (mm hg) 84 (52-143) 80 (52-125) 88 (58-126) 85.00 (58.00143) 81 (63-164) 88.00 (60.00-164.00) a0.005 , b0.130 , c0.871 <0.001 a,c b0.099 pulse pressure (mmhg) 41.2 (12.39) 38.5 (11-127) 45.08 (10.69) 42 (24-67) 47.4 (14.07) 46 (24-87) a, >0.05 b,c <0.001 a, b,c heart rate (bpm) 77.5 (13.98) 86.06 (19.02) 88.57 (15.45) 82.34 (16.31) 98.76 (20.50) 81.74 (14.91) <0.001 a, b,c a, >0.05 b,c mean arterial bp (mmhg) 97 (59-142) 97 (59-142) 105(65-163) 105 (65-163) 110 (43172) 110 (43-172) a0.002 , b0.264 , c0.525 <0.001 a, b c0.028 augmentation index (%) 19 (-10-27) 24.74 (14.01) 33 (28-40) 26.35 (11.17) 45 (41-90) 26.90 (11.95) <0.001 a, b,c a, >0.05 b,c pwv (m/s) 7.47 (1.68) 5.85 (4.10-6.90) 7.91(1.71) 7.55 (7-8.20) 7.64 (1.89) 9.3 (8.3-12.4) a, >0.05 b,c <0.001 a, b,c central bp (mmhg) systole 109 (63-152) 110.12 (15.51) 119(84-171) 120.52 (15.20) 123(18-197) 125.30 (23.00) <0.001 a, >0.05 b,c <0.001 a, c, b0.212 mean age was signicantly higher in patients with large arteries of abnormal as (64.05 years) compared to normal (36.33 years) and average as (51.74 years) (p<0.001). in abnormal large as, va was higher compared to normal and average large as (p<0.024). also, the mean va was signicantly higher in patients with average large arteries than normal large arteries (p<0.001). a signicant association was observed between large normal, average and abnormal as in peripheral systolic blood pressure (sbp), pulse pressure, mean arterial bp and pwv (p<0.001). increase in severity of small and large as showed a signicant increase in pwv. as the severity of as increased in small arteries, there was a signicant increase in heart rate and ai (p<0.001). age group wise analysis mean bmi was higher in patients with age group of 31-60 years. patients with age more than 60 years had bmi between the patients with age group of 10-30 years and 31-60 years (p=0.005). signicant increase in trend in va and pwv were observed with increasing age (p<0.001). arterial stiffness was comparable between normal, average and abnormal small arteries among age groups (table 3). a signicant association was observed between large as and age (p<0.001). table 3. age group wise analysis mean peripheral sbp was lower in 31-60 years (50 mmhg) and more than 60 years (66 mmhg) age group of patients compared to 10-30 years (122.5 mmhg) age group of patients. whereas, peripheral diastolic blood pressure, pulse pressure, cbp and drug treatment were comparable among all age groups. heart rate per minute was signicantly lower in patients with more than 60 years of age (79.17 per min) compared to patients with age group 10-30 years (87.89 per min) (p=0.026). a positive correlation was observed between age and pwv, va and larger as (p<0.001). pwv was positively correlated with age, va, pulse pressure (p<0.001). augmentation index and va were directly related to va and large as, respectively (table 4). table 4. correlation analysis between arterial stiffness and vascular age x 43gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra diastole 80 (52-125) 81.00 (84-127) 85 (58-143) 88.83 (59-198) 88 (60-164) 89.00 (62-150) a0.005 , >0.05 b,c a0.002 , b0.001 , c0.137 data represented as mean (sd), unless otherwise specied. statistical analysis: one-way anova (for normally distributed dataindependent sample t-test, for not normally distributed datamann whitney u test). a, normal vs. average; b, average vs. abnormal; c, normal vs. abnormal. bmi, body mass index; bp, blood pressure; pwv, pulse wave velocity. parameters group i group ii group iii p value (10-30 years) (n=38) (31-60 years) (n=186) (>60 years) (n=79) sex, n (%) men women 33 (86.8) 5 (13.2) 116 (62.4) 70 (37.6) 54 (68.4) 25 (31.6) 2bmi (kg/m ) 21.97 (11.72-29.52) 23.36 (15.06-67.21) 23.15 (16.90-36.65) 0.005 vascular age (years) 27 (22-37) 51 (0-75) 67 (46-86) <0.001 normal 12 (35.30) 82 (44.10) 26 (32.90) 0.200 average 9 (26.50) 54 (29.00) 32 (40.50) abnormal 13 (38.20) 50 (36.90) 21 (26.60) arterial stiffness small arterial stiffness, n (%) 0.677 normal 18 (47.4) 109 (58.6) 44 (55.70) average 15 (39.5) 56 (30.10) 28 (35.4) abnormal 5 (13.20) 21 (11.30) 7 (8.90) large arterial stiffness, n (%) normal 37 (97.4) 68 (36.6) 1 (1.3) <0.001 average 1 (2.6) 86 (46.2) 3 (3.8) abnormal 32 (17.2) 75 (94.9) peripheral bp systole (mmhg) 122.5 (97-175) 50 (31-60) 66 (61-81) a0.304 , b0.983 , c0.305 diastole (mmhg) 83.5 (52-120) 85 (54-164) 85 (60-126) a0.209 , b0.465 , c0.522 pulse pressure (mmhg) 43 (14-127) 41 (11-77) 41 (24-87) a0.608 , b0.288 , c0.907 heart rate (bpm) 87.89 (23.16) 84.33 (16.18) 79.17 (14.23) a0.698 , b0.068 , c0.026 mean arterial bp (mmhg) 102 (73-145) 104 (59-172) 119 (63-197) pwv (m/s) 5.28 (0.69) 7.26 (1.13) 9.63 (1.06) a,<0.001 b,c central bp (mmhg) systole 113.00 (85.00158.00) 119.00 (63.00197.00) 117.00 (18.00177.00) 0.176 diastole 84.94 (16.75) 88.29 (20.70) 86.69 (12.92) 0.933, b,c1.000 data represented as mean (sd), unless otherwise specied. statistical analysis: one-way anova (for normally distributed dataindependent sample t-test, for not normally distributed datamann whitney u test)a, group i vs. group ii; b, group ii vs. group iii; c, group i vs. group iii. bmi, body mass index; bp, blood pressure; pwv, pulse wave velocity. parameter 1 parameter 2 correlation coefcient p value age (years) pwv 0.911 <0.001 vascular age 0.942 large arterial stiffness 0.911 peripheral systole bp (mmhg) peripheral diastole bp 0.742 <0.001 pulse pressure 0.611 mean arterial bp 0.917 pwv 0.401 central systole bp 0.931 central diastole bp 0.771 large arterial stiffness 0.401 pulse wave analysis a signicant increase in pwv was observed as the age increased (p<0.001). a signicant association was observed between pwv and bmi, va, as and peripheral bp and cbp (p<0.001). a signicantly higher pwv (9.7-12 m/s) was observed in patients with abnormal va (48.60%) (table 5). table 5. pulse wave velocity wise analysis vascular age patients with average and abnormal va showed a signicantly higher pwv as compared to patients with normal va (p<0.001). augmentation index was signicantly higher in patients with abnormal va than with normal and average va (p<0.031). there is a signicant correlation of large as with va. patients with abnormal va displayed a signicantly higher cbp and peripheral bp (table 6). table 6. vascular age wise analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 44 x gjra global journal for research analysis peripheral diastole bp (mmhg) peripheral systole bp 0.742 <0.001 mean arterial bp 0.918 pwv 0.313 central systole bp 0.817 central diastole bp 0.980 large arterial stiffness 0.313 pulse pressure (mmhg) peripheral systole bp 0.611 <0.001 mean arterial bp 0.409 pwv 0.314 central systole bp 0.543 large arterial stiffness 0.314 hrt (bpm) augmentation index 0.532 <0.001 small arterial stiffness 0.538 mean arterial bp (mmhg) pwv 0.392 <0.001 central systole bp 0.941 central diastole bp 0.928 large arterial stiffness 0.392 pwv (m/s) vascular age 0.935 <0.001 central systole bp 0.382 central diastole bp 0.311 augmentation index (%) vascular age 0.934 <0.001 vascular age (years) large arterial stiffness 0.935 <0.001 central systole bp (mmhg) large arterial stiffness 0.369 <0.001 statistical analysis: spearman's correlation coefcient. bp, blood pressure; hrt, heart rate, pwv, pulse wave velocity. abnormal 12 (11.30) 17 (10.50) 4 (11.40) large arterial stiffness, n (%) <0.001 normal 106 (100.0) average 90 (55.6) abnormal 72 (44.4) 35 (100.0) augmentati on index 24.74 (14.01) 26.36 (11.33) 27.97 (12.71) 0.357 peripheral bp systole (mmhg) 116 (65.16) 130.5 (87-202) 137 (112-201) <0.001 diastole (mmhg) 80.73 (13.47) 89.74 (10.95) 90.73 (14.4) <0.001 pulse pressure (mmhg), median (range) 38.50 (11.00 127.00) 43.50 (24.00-69.00) 48.00 (33.00-87.00) <0.001 heart rate (bpm) 86.06 (19.02) 81.87 (15.31) 82.71 (16.73) a0.142 , b1.000 , c0.926 mean arterial bp (mmhg), median (range) 97.00 (59.00142.00) 107.00 (43.00172.00) 111.00 (87.00159.00) <0.001 central bp (mmhg), median (range) systole 109.00 (63.00152.00) 120.50 (18.00197.00) 124.00 (102.00177.00) <0.001 diastole 81.00 (-84.00127.00) 88.00 (59.00150.00) 91.00 (67.00128.00) <0.001 data represented as mean (sd), unless otherwise specied. statistical analysis: one-way anova (for normally distributed dataindependent sample t-test, for not normally distributed datamann whitney u test). a, normal vs. average; b, average vs. abnormal; c, normal vs. abnormal. bmi, body mass index; bp; blood pressure. parameters pulse wave velocity (m/s) p value normal (<7) average (7-9.7) abnormal (9.7-12) age (years) 36.33 (10.44) 55.85 (7.45) 70.34 (5.73) <0.001 sex, n (%) 0.026 men 77 (72.6) 98 (60.5) 28 (80.0) women 29 (27.4) 64 (39.5) 7 (20.00) 2bmi (kg/m ), median (range) 22.45 (11.72-67.21) 23.90 (16.53-37.83) 22.51 (16.44-35.25) a0.003 , b0.063 , c0.850 vascular age (years) 38.36 (10.84) 57.67 (6.88) 73.52 (4.81) <0.001 normal 61 (59.80) 59 (36.40) <0.001 average 22 (21.60) 55 (34.00) 18 (51.40) abnormal 19 (18.60) 48 (29.60) 17 (48.60) small arterial stiffness, n (%) normal 70 (66.00) 86 (53.10) 15 (42.90) average 24 (22.60) 59 (36.40) 16 (45.70) 0.060 parameters vascular age p value normal (n= 120) average (n=95) abnormal (n=84) age (years) 52.00 (23.00-70.00) 53.00 (24.00-81.00) 52.50 (20.00-81.00) 0.050 sex, n (%) men 77 (72.6) 98 (60.50) 28 (80.00) 0.437 women 29 (27.4) 64 (39.5) 7 (20.00) 2bmi (kg/m ) 22.67 (15.06-33.30) 23.51 (15.23-34.85) 22.96 (16.44-67.21) 0.120 discussion prevalence of ckd in india is an emerging cause of morbidity and mortality due to the accompanying complications. hypertension is another rampant health issue, the incidence of which increases with age and is also associated with ckd. the characteristic risk factors of ckd including va and as are being emphasized in medical science due to the prognostic value in early detection and prevention of cardiac diseases associated with ckd. the standard method used to assess as is pwv that in turn predicts va. it is strongly associated with age and bp wherein arterial elasticity is reduced, subsequently increasing the vascular stiffness [20,21]. apart from ckd, arterial stiffness is a predictor of cardiovascular diseases [22] and also associated with type i diabetes along with its complications such as renal, cardiovascular, retinal diseases and autonomic neuropathy. managing pwv using antihypertensives reduces associated mortality [23]. evidences reveal that aortic stiffness is signicantly higher in patients with ckd than in hypertensives, regardless of analogous age and bp. several investigators have conducted studies determining an increase in aortic stiffness in haemodialysis patients suggesting it to occur due to a rise in calcium levels of the arterial wall [24,25]. townsend et al. conducted a study to determine whether as has an impact on ckd progression and concluded that as increases in patients with ckd and impaired renal function than the healthy population, thus helping to identify the high-risk patients and implement early intervention to prevent death [26,27]. this study represents a population with a very wide age range of 11-81 years and men preponderance. the present study revealed higher as in patients with a higher mean age. the mean va was higher in patients with average large as. increase in severity of large and small as showed a signicant increase in pwv. the 2013 european guidelines for the management of hypertension and cv disease prevention in clinical practice recommended that aortic pwv be used to assess target organ damage [28]. nevertheless, the main drawback of pwv measurement is the difculty to accurately record in peripheral artery disease and obese patients. in the present study a positive correlation was observed between pulse pressure, mean arterial bp, pwv and as which is in accordance with the reported literature [29]. age and bp have a greater impact on as than gfr, however, as is strongly associated with altered renal function. a similar investigation by wang et al. assessed the severity of as in 102 patients with ckd by using pwv to evaluate associated risk factors. pwv values in patients with ckd stages 1 to 2 and the age-matched control group were similar and an increasing trend was observed in pwv corresponding to progression in ckd stage (p<0.0001) [30,31]. sigrist et al. conducted a study comprising, a total of 134 patients, of which 60 were on haemodialysis, 28 on peritoneal dialysis, and 46 with stage 4 ckd. it was observed that patients with stages 4 and 5 ckd showed a signicant calcication over 24 months which is associated with as and mortality [32]. lilitkarntakul et al. determined that pwv increased linearly as renal function deteriorated, however, age and mean arterial bp are the strongest factors of as in patients with ckd. similarly, the present study showed a signicant association between age and large as with a signicant increase in va and pwv (p<0.001) as the age progressed [33]. takenaka et al. [34] reported that ai showed a positive correlation with age and weight, and negatively to height and heart rate and suggested ai to be a risk factor of progression of non-diabetic ckds. however, in this study heart rate showed a strong positive correlation with ai as well as a signicant increase occurred in ai as the small as and va increased. in the present study, mobil-o-graph was employed to determine the prole of as and va in terms of pwv that was in accordance with the studies conducted by salvade et al. and solanki et al. [35,36] demonstrating the instrument usage to assess pwv in patients with renal impairment and hypertension. in dialysis population, mobil-o-graph was used to determine pwv and test its sensitivity for va and pulse pressure. it was observed to be more sensitive for va than pulse pressure. the present study showed a signicant association between pwv with age, bmi, va, as and peripheral and cbp. previous investigations reveal that pwv predicts early cv aging in young rst-degree relatives of hypertensives. it is dependent on age, strongly associated with brachial bp and foresees upcoming cardiac diseases including hypertension [37]. this technique aids to identify the progression of disease, detection of co-morbidities and shape up the treatment with x 45gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra small arterial stiffness, n (%) normal 70 (66.00) 86 (53.1) 15 (42.9) average 24 (22.6) 59 (36.4) 16 (45.7) 0.060 abnormal 12 (11.3) 17 (10.5) 4 (11.4) large arterial stiffness, n (%) normal 106 (100) average 90 (100) <0.001 abnormal 72 (44.4) 35 (100) pwv (m/s) 6.90 (1.38) 8.01 (1.67) 8.40 (1.68) a<0.001 ,c augmentati on index (%) 23.94 (13.47) 24.91 (11.63) 29.68 (11.1) a0.004 b,c0.031 peripheral bp systole (mmhg) 113.00 (65.00133.00) 130.00 (97.00144.00) 150.00 (87.00202.00) <0.001 diastole (mmhg) 77.00 (52.0099.00) 86.00 (65.00126.00) 100.00 (71.00164.00) <0.001 pulse pressure (mmhg) 36.00 (11.00127.00) 41.00 (30.0067.00) 50.50 (35.0087.00) <0.001 heart rate 79.50 (5.10121.00) 83.00 (47.00161.00) 86.00 (52.00124.00) 0.282 mean arterial bp (mmhg) 93.00 (43.00114.00) 106.00 (87.00123.00) 122.00 (100.00172.00) <0.001 central bp (mmhg) systole 104.50 (63.00127.00) 120.00 (102.00133.00) 137.00 (18.00197.00) <0.001 diastole 76.20 (17.52) 87.78 (8.80) 103.97 (15.22) <0.001 data represented as median (sd), unless otherwise specied. statistical analysis: one-way anova (for normally distributed dataindependent sample t-test, for not normally distributed datamann whitney u test). a, normal vs. average; b, average vs. abnormal; c, normal vs. abnormal. bmi, body mass index; bp; blood pressure. new medical interventions for enhanced results. limitations of the study one potential limitation of this study is the connement to patients with ckd; thus, these ndings might not be applicable to the general population or those with other chronic conditions. this is a single center study with moderate sample size. another limitation is absence of biochemical investigation. conclusion the overall observation suggests an increasing trend in oscillometric measurement of pwv, va, ai with an increase in the severity of as. further a positive association of pwv, va and as with aging indicates the role of these parameters to detect and improve cv risk prediction associated with ckd. references 1. bello ak, alrukhaimi m, ashuntantang ge, basnet s, rotter rc, douthat wg, et al. complications of chronic kidney disease: current state, knowledge gaps, and strategy for action. kidney int suppl (2011). 2017; 7(2):122-9. 2. ecobici m, stoicescu c. arterial stiffness and hypertension which comes rst? maedica (buchar). 2017; 12(3):184-90. 3. calhoun da, jones d, textor s, goff dc, murphy tp, toto rd, et al. resistant hypertension: diagnosis, evaluation, and treatment. a scientic statement from the american heart association professional education committee of the council for high blood pressure research. hypertens. 2008; 51:1403-19. 4. buffet l, ricchetti c. chronic kidney disease and hypertension: a destructive combination. us pharm. 2012; 37(6):26-29. 5. ku e, lee bj, wei j, weir mr. hypertension in ckd: core curriculum 2019. am j kidney dis. 2019; 74(1):120-31. 6. ong kt, delerme s, pannier b, safar me, benetos a, laurent s, et al. aortic stiffness is reduced beyond blood pressure lowering by short-term and longterm antihypertensive treatment: a meta-analysis of individual data in 294 patients. j. hypertens. 2011; 29(6):1034-42. 7. shahin y, khan ja, chetter i. angiotensin converting enzyme inhibitors effect on arterial stiffness and wave reections: a meta-analysis and metaregression of randomised controlled trials. atherosclerosis. 2012; 221(1):1833. 8. sarnak mj, foley rn: cardiovascular mortality in the general population versus dialysis: a glass half full or empty? am j kidney dis 2011; 58: 4-6. 9. kooman jp, kotanko p, schols am, shiels pg, stenvinkel p. chronic kidney disease and premature ageing. nat rev nephrol. 2014; 10(12):732-42. 10. lemos mm, jancikic a, sanches f, christofalo d, ajzen s, miname mh, et al. pulse wave velocity-a useful tool for cardiovascular surveillance in predialysis patients. nephrol dial transpl. 2007; 22(12):3527-32. 11. zanoli l, lentini p, briet m, castellino p, house a, london g, et al. jasn. 2019; 30(6):918-28. 12. desjardins mp, sidibé a, fortier c, mac-way f, marquis k, de serres s, et al. association of interleukin-6 with aortic stiffness in end-stage renal disease. j am soc hypertens. 2018; 12: 5-13. 13. miyata t, horie k, ueda y, fujita y, izuhara y, hirano h, et al. advanced glycation and lipid oxidation of the peritoneal membrane: respective roles of serum and peritoneal uid reactive carbonyl compounds. kidney int. 2000; 58:425-35. 14. covic a, haydar aa, bhamra-ariza p, gusbeth-tatomir p, goldsmith dj. aortic pulse wave velocity and arterial wave reections predict the extent and severity of coronary artery disease in chronic kidney disease patients. j nephrol. 2005; 18(4):388-96. 15. nilsson wadström b, fatehali ah, engström g, nilsson pm. a vascular aging index as independent predictor of cardiovascular events and total mortality in an elderly urban population. angiol. 2019; 70(10):929-37. 16. danninger k, hafez a, binder rk, aichberger m, hametner b, wassertheurer s, et al. high prevalence of hypertension and early vascular aging: a screening program in pharmacies in upper austria. j hum hypertens. 2019 [epub ahead of print]. 17. fry jl, al sayah l, weisbrod rm, van roy i, weng x, cohen ra, et al. vascular smooth muscle sirtuin-1 protects against diet-induced aortic stiffness. hypertens. 2016; 68(3):775-84. 18. oh, ys. arterial stiffness and hypertension. clin hypertens. 2018; 24:1-3. 19. franssen pm, imholz bp. evaluation of the mobil-o-graph new generation abpm device using the esh criteria. blood press monit. 2010; 15(4):229-31. 20. cefalu ca. theories and mechanisms of aging. clin geriatr med. 2011; 27(4):491-506. 21. rizzoni d, porteri e, boari ge, de ciuceis c, sleiman i, muiesan ml, et al. prognostic signicance of small-artery structure in hypertension. circulat. 2003; 108(18):2230-35. 22. cecelja m, chowienczyk p. role of arterial stiffness in cardiovascular disease. jrsm cardiovasc dis. 2012;1(4): cvd.2012.012016. 23. theilade s, lajer m, persson f, joergensen c, rossing p. arterial stiffness is associated with cardiovascular, renal, retinal, and autonomic disease in type 1 diabetes. diabetes care. 2013;36(3):715-21. 24. blacher j, guerin ap, pannier b, marchais sj, london gm. arterial calcications, arterial stiffness, and cardiovascular risk in end-stage renal disease. hypertens. 2001; 38:938-42. 25. haydar aa, covic a, colhoun h, rubens m, goldsmith dj. coronary artery calcication and aortic pulse wave velocity in chronic kidney disease patients. kidney int. 2004; 65:1790-94. 26. townsend r, anderson a, chirinos j, feldman h, grunwald j, nessel l, et al. association of pulse wave velocity with chronic kidney disease progression and mortality hypertens. 2018; 71(6):1101-07. 27. taal m, sigrist m, fakis a, fluck r, mcintyre c. markers of arterial stiffness are risk factors for progression to end-stage renal disease among patients with chronic kidney disease stages 4 and 5. nephron clin pract. 2007;107:c177c181. 28. authors/task force members, mancia g, fagard r, narkiewicz k, redon j, zanchetti a. 2013 esh/esc guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the european society of hypertension (esh) and of the european society of cardiology (esc). eur. heart j. 2013;34(28):2159-22. 29. ohya y, iseki k, iseki c, miyagi t, kinjo k, takishita s. increased pulse wave velocity is associated with low creatinine clearance and proteinuria in a screened cohort. am j kidney dis. 2006;47(5):790-7. 30. briet m, bozec e, laurent s, fassot c, london gm, jacquot c, et al. arterial stiffness and enlargement in mild-to-moderate chronic kidney disease. kidney int. 2006; 69:350-57. 31. wang mc, tsai, wc, chen jy, huang j. stepwise increase in arterial stiffness corresponding with the stages of chronic kidney disease. am j kidney dis. 2005; 45(3):494-501. 32. sigrist mk, taal mw, bungay p, mcintyre c. progressive vascular calcication over 2 years is associated with arterial stiffening and increased mortality in patients with stages 4 and 5 chronic kidney disease. clin j am soc nephrol. 2007; 2:1241-48. 33. lilitkarntakul p, dhauna, n, melvillea v, blackwell s, talwarc d, liebmana b, et al. blood pressure and not uraemia is the major determinant of arterial stiffness and endothelial dysfunction in patients with chronic kidney disease and minimal co-morbidity. atherosclerosis. 2011; 216: 217-25. 34. takenaka t, mimura t, kanno y, suzuki h. qualication of arterial stiffness as a risk factor to the progression of chronic kidney diseases. am j nephrol. 2005;25(5):417-24. 35. salvadé i, schätti-stählin s, violetti e, schönholzer c, cereghetti c, zwahlen h, et al. a prospective observational study comparing a non-operator dependent automatic pwv analyser to pulse pressure, in assessing arterial stiffness in haemodialysis. bmc nephrol. 2015; 16:62. 36. solanki jd, mehta hb, panjwani sj, munshi hb, shah cj. central hemodynamic and arterial stiffness by oscillometric pulse-wave analysis in treated gujarati euglycemic hypertensives: a case-control study. j family med prim care. 2019; 8(6):2047-54. 37. solanki jd, mehta hb, shah cj. pulse wave analyzed cardiovascular parameters in young rst-degree relatives of hypertensives. j res med sci. 2018; 23:72. 46 x gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra background: rabies, a neglected tropical zoonotic disease is caused by the 1rabies virus (lyssavirus genus, family rhabdoviridae). globally 95% human rabies' mortality can be attributed to rabid dog exposure. it is a 100% fatal disease & claims more 2than 59,000 human lives every year globally. one human life is lost every 15 minutes due to this deadly preventable disease. over 95% of the mortality happens in asia and africa, where canine rabies is enzootic. in india, about 20,000 human 3deaths occur each year by the bite of rabid dog. timely initiation of post exposure prophylaxis following an animal bite result in 100% preventability of this fatal disease. studies conducted in various parts of the globe have revealed a low level of awareness among the health care professionals in rabies post exposure prophylaxis. in a medical college setup in india, doctors pursuing their post-graduation are the rst one who attend these patients. so, this study was planned to assess the knowledge of postgraduate students working in pgims rohtak, regarding rabies and its prevention. objective: to assess the knowledge of postgraduate students of pgims, rohtak regarding rabies and its prevention materials & methods: study setting: this study was conducted in pgims, rohtak, a tertiary care hospital in haryana. post graduates of all 3 years from the department of medicine, surgery, paediatrics and community medicine were included in the study. study design: observational cross-sectional study. study sample: all the 120 postgraduates from the department of medicine (38), surgery(38), paediatrics (32) & community medicine(12) were included in the study. study tool: the knowledge was assessed using a pretested semi-structured self-designed questionnaire. results: most of the participants (85%) had less than 5 years' experience in clinical practice. most of them were clear about the transmission (77%) and infected material (67%) of rabies. rd2/3 participants (67%) were aware about correct preexposure prophylaxis. table 1: knowledge about rabies and pre-exposure prophylaxis: assessment of knowledge regarding rabies and its prevention among postgraduate medical students of pgims rohtak original research paper tarun kumar junior resident, deptt. of community medicine, pt. b.d. sharma pgims, rohtak community medicine background: rabies is a fatal viral zoonotic disease of public health importance. prevention forms the basis of management. this study was thus planned to assess the knowledge of postgraduate students working in pgims rohtak, regarding rabies and its prevention. methodology: a cross-sectional study was conducted among all postgraduate students, working in the departments managing cases of animal bite. the knowledge was assessed using a pretested semi-structured questionnaire. spss version 20 was used for analysis. results: more than 80% participants had knowledge about the standard wound management practices. only half of them were rdclear about the intradermal vaccination schedule. about 1/3 participant had knowledge about the categories of animal bite, immunoglobulin use i.e. its recommendation, site and dose of administration. conclusion: the current study revealed that the correct knowledge about animal bite management and anti rabies immunization was lacking among postgraduate students managing cases of animal bite. abstract keywords : rabies, knowledge, postgraduate students. kashish grover* senior resident, deptt. of community medicine, pt. b.d. sharma pgims, rohtak *corresponding author vinay junior resident, deptt. of community medicine, pt. b.d. sharma pgims, rohtak volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra anvesha junior resident, deptt. of community medicine, pt. b.d. sharma pgims, rohtak ginni agrawal junior resident, deptt. of community medicine, pt. b.d. sharma pgims, rohtak aashima senior lecturer, pdm dental college and research institute, bahadurgarh roopam kapoor post graduate student, pdm dental college and research institute, bahadurgarh statement correct response % of correct response transmission of rabies licks on intact skin 77% infected material for rabies saliva of the infected animal 67% licks on broken skin is which category category iii 22% abrasion without bleeding category ii 53% who should be given pre-exposure prophylaxis all (veterinary doctors, animal catchers, zoo keepers, quarantine ofcers, travellers from free areas) 5% 42 x gjra global journal for research analysis almost all the participants (98-100%) were clear about the wound toileting & its duration post animal bite and most of them (80-90%) knew that the wounds should not be dressed/sutured/cauterized unless absolutely required. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra no of doses of of arv for prep as per i/d regime three 67% dose of rabies for children same as adults 81.7% table 2: knowledge about rabies post-exposure prophylaxis: statement correct response % of correct response first step after animal bite wash with soap under running water 100% duration of wound toileting 10-15 min. 83% is dressing of wound necessary no 71.7% is suturing of wound necessary no 92% is cauterization of wound recommended no 95% no. of visits in i/m schedule 5 visits 60% no. of visits in i/d schedule 4 visits 76% immunoglobulins for which category of bite category iii 68.3% site of administration rig full dose into and around the wound site 23% respective dose of equine rig 40iu/kg 60% respective dose of human rig 20iu/kg 66% maximum dose for erig 3000iu 15% maximum dose of hrig 1500iu 22% only half of them were clear about the intradermal schedule and only 5% participants knew the difference in dose of intramuscular and intradermal schedule. about 33% participant knew about the category, dose, site of administration and maximum dose of immunoglobulin to be given to animal bite victims. discussion: the knowledge of 120 post-graduate medical students of pgims, rohtak regarding rabies and its prevention was assessed. the mean work experience of the participants in our study was lower than study conducted in different parts of 4north india and by holla et al in mangalore . majority of participants knew about the transmission (77%) and infected material of rabies (67%) which was lower than study conducted by holla et al in mangalore (91%). knowledge about the category of bite & pre-exposure prophylaxis was also lower when compared to other studies. all the participants were aware about the wound toileting method and most of them (83%) knew the appropriate duration of wound toileting which was signicantly higher as compared to different studies conducted by holla et al in 5mangalore, singh a et al in ambala . 28.3% pgs were unaware regarding dressing practices of animal bite wound which was similar to the study conducted in mangalore, whereas, it was 60% and 6% in studies conducted 6at nayak rk et al in belgaum and singh a et al in ambala. the knowledge regarding im (60%) & id (76%) schedule was also lower when compared to other studies. the knowledge about immunoglobulin site of administration (23%), dose/kg (60%), and maximum dose (15-22%) was lower when compared to other studies conducted in mangalore, ambala, and belgaum. conclusion: based on the results and discussion of the present study, it can be concluded that awareness of post graduate students of pgims, rohtak about rabies & its prevention is inadequate. to combat the disease and to improve the outcome frequent training and workshops for the newly admitted pgs should be arranged. references 1. world health organization. who | animal rabies [internet]. world health organization. world health organization; 2016 [cited 2019 apr 28]. available from: https://www.who.int/rabies/about/home_animal_rabies/en/ 2. world health organization. who | human rabies [internet]. geneva. world health organization; 2018 [cited 2019 apr 28]. available from: https:// www.who.int/rabies/about/home_human_rabies/en/ 3. sudarshan m, madhusudana s, mahendra b, rao n, ashwath narayana d, abdul rahman s, et al. assessing the burden of human rabies in india: results of a national multi-center epidemiological survey. india int j infect dis [internet]. 2007 [cited 2019 aug 15];11:29–35. available from: http://intl.elsevierhealth.com/journals/ijid 4. holla r, darshan b, guliani a, unnikrishnan b, thapar r, mithra p, et al. (2017) how familiar are our doctors towards rabies prophylaxisa study from coastal south india. plos negl trop dis 11(10): e0006032. https://doi. org/10.1371/journal.pntd.0006032 5. singh a, agarwal m, singh a, katyal r, joshi hs, khan s. knowledge about rst aid, wound management and vaccination for the cases of dog bite: a cross-sectional study among the students of a management and technology institute in western uttar pradesh. int j community med public health 2018;5:280-3. 6. nayak rk, walvekar pr, mallapur md. knowledge, attitudes and practices regarding rabies among general practitioners of belgaum city. al ameen j med sc i 2013; 6(3) :237-242 x 43gjra global journal for research analysis introduction dengue fever and dengue hemorrhagic fever is a very important vector borne illness in india. as per data from nvbdcp, there have been 101192 reported cases of dengue last year in india, of which there were 172 reported mortalities. various neurologic complications of dengue viral infection are rare but have been reported, including central and peripheral nervous system involvement. encephalopathy, encephalitis, se izures , mononeuropathy, polyneuropathy, and guillain–barré or miller-fisher syndromes have been associated. however, spinal cord involvement associated with dengue viral infection has been rarely reported. there have been very few previously reported cases of longitudinally extending transverse myelitis in association with dengue infection. case report a 53 year male presented to the emergency department of a tertiary care hospital with complaints of twitching (exor spasms and parasthesias) in both lower limbs along with imbalance of gait and difculty getting up from a supine and a sitting position since the past 15 days. the patient also gave a history of slipping of footwear and involvement of bowel and bladder in the form of decreased sensation and incontinence. t h e r e w a s n o h i s t o r y o f s l u r r e d s p e e c h / v i s i o n abnormalities/deviation of angle of mouth/seizure/memory impairment. the patient was hemodynamically stable on admission with cns examination suggestive of spastic weakness in both lower limbs (4 out of 5 according to mrc grading of power.) supercial reexes were normal, deep tendon reexes were exaggerated in both lower limbs. sensory examination was suggestive of impaired pain and temperature sensation and impaired sensation of ne touch upto the hip in both lower limbs. joint position sense was also impaired in both lower limbs. magnetic resonance imaging of the whole spine was suggest ive of a dif fuse i l l dened long segment intramedullary hyperintense signal on t2w involving dorsal spinal cord extending from level of inferior end plate of d7 vertebral body to the conus medullaris. it involved more than 2/3rd circumference to near complete involvement of the spinal cord in a few places. the signal was isointense on t1 images. the patient gave a history of fever with chills and rigors 1 month ago from which he recovered with supportive management. this episode of fever was serologically conrmed as dengue fever via a positive igm elisa study and with a positive ns1 antigen capture assay from 1 month ago. workup for other common causes( csf oligoclonal bands, serum igg, serum neuromyelitis optica antigen and csf neuromyelitis optica antibody ) for letm came out to be negative. ana by iif was negative. the patient was treated with supportive management and intravenous pulse therapy with methylprednisolone at a dosage of 1 g/day for 3 days and then was switched to oral prednisolone. the oral prednisolone dosage was started at 60 mg/day and then was tapered gradually over 4 weeks. the patient's bladder was catheterized for the rst week, and then the catheter was removed after intermittent clamping and bladder training. rehabilitation physical therapy exercises were done simultaneously with medical treatment. over the course of 2 weeks of hospital stay and 4 weeks of regular follow up the patient improved signicantly with return of normal power in lower limbs, normal bowel and bladder functions and return to activities of daily living with only minimal imbalance of gait while walking. discussion neurologic manifestations associated with dengue fever were considered very rare initially, but in the last 20 years there has been increasing recognition of the spectrum the neurologic manifestations. after a thorough search of the literature, we found very few reports of dengue illness associated with spinal cord involvement in the form of longitudinally extending transverse myelitis. our patient had typical history of dengue fever with a clinical history, rash, thrombocytopenia, leukopenia, and positive ns1 antigen and immunoglobulin m serologic ndings for dengue virus. with all these features on examination and imaging, the lack of any other important physical ndings and negative autoimmune workup, letm in this patient was probably post dengue infection. the patient responded very well to corticosteroid treatment, and the neurologic decit recovered almost completely by 6 weeks. a case of longitudinally extending transverse myelitis post dengue infection original research paper dr. ratnesh sharma 3rd year resident, dept. of general medicine, svpimsr, nhlmmc, ahmedabad. general medicine association of dengue fever with longitudinally extensive transverse myelitis is a rare neurological feature of dengue infection. we describe a 53 year old male who had a history of dengue fever ( serologically conrmed ) 1 month ago and in whom symptoms of longitudinally extending transverse myelitis developed 4 weeks after fever (post-infectious stage). magnetic resonance imaging conrmed the diagnosis of longitudinally extensive transverse myelitis involving dorso-lumbar cord upto the conus medullaris. our patient recovered with minimal residual neurological decit in the form of minimal gait imbalance after a six weeks course of corticosteroids and supportive management including physiotherapy. abstract keywords : dengue, longitudinally extending transverse myelitis, neurological manifestations of dengue dr. saif ali g. mansuri* 2nd year resident, dept. of general medicine, svpimsr, nhlmmc, ahmedabad. *corresponding author dr. dhara b. roy associate professor , department of general medicine, svpimsr, nhlmmc, ahmedabad volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 46 x gjra global journal for research analysis in our patient, myelitis developed in the acute postinfectious phase of dengue illness, similar to earlier case reports. it was also postulated that acute parainfectious dengue infection presents with spastic paralysis, whereas late-stage (postinfectious) dengue infection presents with spastic weakness, and our case had similar ndings of accid paralysis. usually, letm is associated with a poor prognosis; however, our patient showed a dramatic improvement in neurologic decit after treatment with corticosteroids and supportive physiotherapy. we were unable to determine the strain of dengue in our patient. however, it would be interesting to know the epidemiology for future such cases. conclusion even though transverse myelitis is a rare neurologic manifestation of dengue infection, manifesting mostly during parainfectious phases and sometimes after the infection has resolved, it is important that clinicians are aware of this entity. it is vital that clinicians look for dengue virus as a cause of transverse myelitis or other inammatory neurologic manifestations in patients presenting with typical dengue fever symptoms and living in or visiting dengue-endemic areas. references 1. tomar lr, mannar v, pruthi s, aggarwal a. an unusual presentation of dengue fever: association with longitudinal extensive transverse myelitis. perm j. 2015;19(4):e133–e135. doi:10.7812/tpp/15-019 2. malik s, saran s, dubey a, punj a. longitudinally extensive transverse myelitis following dengue virus infection: a rare entity. ann afr med. 2018;17(2):86–89. doi:10.4103/aam.aam_30_17 3. chanthamat n, sathirapanya p. acute transverse myelitis associated with dengue viral infection. j spinal cord med. 2010;33(4):425–427. doi:10.1080/10790268.2010.11689722 4. longo dl, fauci as, kasper dl, hauser sl, jameson j, loscalzo j. eds. harrison's principles of internal medicine, 20e. new york, ny: mcgraw-hill; 2018; p1504,1505 5. dengue/dhf situation in india, https:// nvbdcp. gov. in/ index 4. php?lang=1&level=0&linkid=431&lid=3715 6. bennett je, dolin r, blaser mj. mandell, douglas, and bennett's principles and practice of infectious diseases. philadelphia, pa :elsevier/saunders, 2015; p1882-1902 volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 47gjra global journal for research analysis introduction: water is abundantly found on earth. water is essential not only for humans but also for animals , plants and other living organisms . only 0.3% of total water of earth is available for human use. drinking water should be of high quality and constituents required for human health under prescribed limit .for the present study the amarpatan region of satna district of m.p is chosen and sample were collected ,analysed for only uoride ion concentration .in this area bore well water is major source for drinking purpose .fluoride ingested with water is almost completely absorbed and distributed rapidly throughout the body, with main retention in the bones and small portion in teeth . recommended value of uoride ion according to who is 0.5 to 1.0 ppm[3]. material and mathod : in present study to access the uoride content in drinking water samples collected from different sampling sites of amarpatan area of satna city during nov.2018 to april 2019.details of which are given in table no.1 table no.1 details of sampling stations water sample of bore wells were collected from above mentioned sampling stations of amarpatan area and deter mined uoride ion by zirconium alizarin-s method. in the acidic medium zirconium react with alizarin red –s to form complex, which is bleached on the addition of uoride ion and colour changes from red violet to yellow green [4]. 20ml of ltered sample is taken and sodium arsenite solution is added to remove residual chlorine. 5ml of zirconium alizarin solution added to the standards and samples solution mixed well immedietly and measured the absorbance after 20minutes at 520nm. result and discussion: the result of analysis of uoride ion content of water samples of borewells of amarpatan regions of satna district are given in the table 2 .from the table the uoride content ranges from 0.2 to 1.6ppm at different sampling stations .in the present study uoride concentration is found within the prescribed limit except ss1 and ss2. apart from rock forming mineral which on weathering can contribute to the uoride content in ground water the use of phosphoric fertilizer in agriculture and industrial efuent can enhance the concentration of uoride . table no.2 fluoride concentration of different borewells fluoride ion concentration in ppm analysis of fluoride concentration in the water of borewells of amarpatan area in satna district (m.p.) india original research paper prince soni department of chemistry aks university satna m.p. india 485001 shakti patel department of chemistry aks university satna m.p. india 485001 x 53gjra global journal for research analysis chemistry concentration of uoride should be within permissible limit as prescribed by organizations like icmr, who, bis. high concentration of uoride in drinking water causes uorosis and mottling of teeth. fluoride ions enters in ground water from geological formation. the absence or very low concentration of uoride ions causes dental carries in children's teeth. so it is necessary to nd out the concentration of uoride ion in water used for drinking purpose. in present study uoride ion concentration is determine by standard analytical procedures and found in the range from 0.2 to 1.6ppm at different sampling stations of amarpatan area in satna district during nov. 2018 to april 2019. abstract keywords : drinking water fluorosis, mottling of children teeth. deependra singh* department of chemistry aks university satna m.p. india 485001 *corresponding author shailendra yadav department of chemistry aks university satna m.p. india 485001 sujit dubey department of chemistry aks university satna m.p. india 485001 shafqat alauddin department of chemistry-s.n.c . azamgarh,u.p, india volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra sn. locality sampling stations owner of the borewell 1. nadan tola amarpatan ss1 makhan singh 2. jurmaniya amarpatan ss2 kamta yadav 3. purani basti ramnagar road ss3 om prakash saket 4. kharamseda road amarpatan ss4 rameshwer prasad sahu 5. amarpatan city ss5 neeraj agrawal 6. word no 12 lalpur amarpatan ss6 munni lal 7. khaas amarpatan ss7 shurendra prasad chaurasiya 8. rewa road amarpatan ss8 diwakar singh 9. chaturvedi colony amarpatan ss9 prabha devi pandey sn. sampling stations november-2018 january-2019 april-2019 1. ss1 1.1 0.95 1.0 2. ss2 1.6 1.5 1.3 3. ss3 0.2 0.3 0.3 4. ss4 0.5 0.5 0.6 5. ss5 0.8 0.7 0.8 6. ss6 1.0 0.95 1.0 7. ss7 0.3 0.4 0.5 8. ss8 0.4 0.4 0.3 9. ss9 0.5 0.6 0.5 54 x gjra global journal for research analysis acknowledgement :the authors are very thankful to chairman aks university satna, m.p. for providing fund and necessary facilities. references:1. khadsan, r. e.,(2007),analysis of uoride in borewells water of chikhli city, dist. buldana (m.s.), journal of ultra chemistry,3(1),p 93-95 2. handa, b. k. (1988), fluoride occurrence in natural water in india and its signicance, bhujal news, 3(2), p 3-7 3. who, international standards for drinking water, (1971), 3rd edition ,who, geneva 4. megregian, s., (1954) rapid spectrophotometric determination of uoride with zirconium eriochrome cyanine r lake, anal. chem 26, p 1167-s1166. 5. apha (1993), standard methods for the examination of water and waste water, 16th edition american public health association, washington for d.c. 2005. 6. shafqat alauddin, shailendra yadav (2016) study of uoride concentration in the ground water of atrauliya nagar panchyat area of azamgarh. ijeter volume 4, issue 1, january 2016. 7. handa b.k. (1975), geochemistry and genessis of uoride containing ground water in india groundwater, 13(3) p 275-281. 8. manivaskam, m. (1996), physico-chemical examination of water, sevage and industrial efuents pragati prakashan, 3rd edition p-83-88. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra references 1. park k. park's textbook of preventive and social medicine. 25th ed. jabalpur, india: bhanot publishers, 2019. pp. 285-97. 2. aidsinfo.unaids.org report on the global aids epidemic unaids publisher submitted on 4 dec 2019. 3. cook gc, zumla a. manson tropical diseases of medicine. 21st ed. chapter 20. in: hiv/aids with an emphasis on africa, gilks cf, eds. british council: elst with saunders; 2003, pp. 401-22. 4. fitzpatrick t, eisen az, wolff k, freedberg im, austen kf. fitzpatrick's dermatology in general medicine. 9th ed. chapter 206. in: oral candidiasis, klenk as, martin ag, heffernan mp, eds. usa: mc-graw-hill; 1993, pp. 2019.dddddd. 5. rautemaa r, rusanen p, richardson m, meunnan jh. optimal sampling site for mucosal candidiasis in oral cancer patients is the labial sulcus. journal of medical microbiology 2006; 55:1447-51. 6. anaissie, mcginnis, pfaller. clinical mycology. 1st ed. chapter 8. in: candida, dignani mc, solomkn js, elias j annaissie, eds. philadelphia: churchill livingstone publication ; 2003, pp. 7. singh k, khan s. candida species associated with candidiasis in immunocompromised patients. indian journal of microbiology 1999; 39: 1559. 8. sweet sp, cookson s, challacombe sj. candida albicans isolates from hiv infected and aids patients exhibit enhanced adherence to epithelial cells. j med microbiol 1995; 43: 452-7. 383-86. 9. koneman's color atlas and textbook of diagnostic microbiology. 6th ed. philadelphia: lippincott williams and wilkins publications; 2006, pp. 121624. 10. jagadish chander. text book of medical mycology. 2nd ed. new delhi: mehta offset pvt ltd. naraina ii, 2002. pp 212 31. 11. maria cd, joseph ss elias ja. clinical mycology. 1st ed. chapter 8. in: candida, dignani mc, solomkn js, elias j annaissie, eds. philadelphia: churchill livingstone publication ; 2003, pp. 195-239. 12. barlow aje aldersley. factors present in serum and seminal plasma which promote germ tube formation and mycelial growth of candida albicans. journal of general microbiology 1974; 82: 261-72. 13. maldarelli f. diagnosis of hiv infection. 6th ed. chapter 115. in: bennett's principles and practice of infectious disease, mandell, douglas, eds. pennsylvania: elsevier churchill living stone; 2005, 1: pp.1506-26. 14. ananthanarayan, paniker. textbook of microbiology. 9th ed. hyderbad: orient longman private ltd; 2009. pp. 582-96. 15. dybeel m, comors m, fauci as. the immunology of hiv infection. 61h ed. chapter 116. in: bennett's principles and practice of infectious disease, mandell, douglas, eds. pennsylvania: elsevier churchill livingstone; 2005; i: 1527-45. 16. http://www.avert.org/aidsindia.htm 17. sullivan d, coleman d. candida dubliniensis: characteristics and identication. journal of clinical microbiology 1998 ; 36(2):329-34. 18. report of hiv surveillance and hiv estimation in india. 2008. 19. http://stgl.karnic.in/ksps. 20. lango dl, anthony s, fauci s. the human retroviruses. 18th ed. in: harrison's internal medicine. usa: mcgraw-hill publications; 2009; 1: 1132-6. 21. wilkins egl. hiv and the human aids. 20th ed.: in: boon na, colledge nr, walker br, davidson's principles and practice of medicine, eds. philadelphia: churchill livingstone; 2006, 86-109. characterization of candida species in oral thrush in hiv seropositive patient original research paper dr. anubha tutor, department of microbiology, skmch, muzaffarpur. microbiology background and objective: globally 37.9 million people are infected with aids, india alone has 2.31 million patients with hiv infection. the virus targets the immune system and with waning immune system opportunistic infection appears. oral candidiasis is the most common opportunistic fungal infection. in hiv infection the isolation of non albicans from oral candidiasis is on a rise. hence it is not sufcient to identify candida albicans alone and is a must to identify other non-albicans species. hence the present study was undertaken to identify the isolates and correlate them to cd4+lymphocyte count. methods: the present study was conducted in the department of microbiology, skmch, muzaffarpur over a period of 6 month from january 2019– june 2019.the study included 100 hiv seropositive cases with oral candidiasis. sampling done with cotton tipped wooden swab, koh mount and gram stain done for demonstration of yeast like cells. isolation done on sda, ba. isolates were further processed by germ tube test, grown on cma, conrmation by fermentation and assimilation test done. cd4+ t cell count done. then later statistical analysis was done. results: samples from 100 patients yielded 113 isolates, specicity of gram's stain and koh mount was 76% and 64%, respectively. sda yielded 100% growth, germtube was positive in all c. albicans and c. dubliniensis cases. c. albicans was the most common species isolated (28.31%), followed by c. tropicalis (26.66%), c. guillermondii (17.69%), c. dubliniensis (10.61%),c. krusei (7.07%), c. parapsilosis (6.19%), c. kefyr (3.53%), least isolated species c. glabrata (0.88%). mean cd4+ t lymphocyte count was 125.28 – 78.45 cells/ul of blood.12 patients had multiple isolates with c. tropicalis as the most common of the 10 combinations. multiple species were isolated in patients with cd4+ cells < 150 cells/ (p < 0.05). present study showed 68.75% of c. albicans and 83.94% of non albicans as isolates from patients with cd4+ t lymphocyte count < 200 cells/ul of blood. oral candidiasis affects the patient compliance to art and nutritional intake. interpretation and conclusion: there is an increase in occurrence of non-candida albicans species in oral candidiasis and hence it is a must to speciate all isolates. occurrence of certain species may be a marker for decreasing cd4+ cell count. abstract keywords : oral candidiasis, speciation of candida, hiv seropositive,cd4+ t lymphocyte. dr. r.n. sharma* associate professor, department of microbiology, skmch, muzaffarpur *corresponding author dr. ranjeet kumar hod & associate professor, department of microbiology, skmch, muzaffarpur volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 6 x gjra global journal for research analysis introduction mi is dened by the demonstration of myocardial cell necrosis due to signicant and sustained ischemia. it is usually an acute manifestation of atherosclerosis-related coronary heart disease. mi results from either coronary heart disease, which implies obstruction to blood ow due to plaques in the coronary arteries or, much less frequently, to other obstructing mechanisms (e.g. spasm of plaque free arteries). the clinical presentation of mi varies from a minor coronary event to lifethreatening clinical situations or sudden death. those who survive the initial event are vulnerable to repeat attacks of mi. in 1958, fletcher rst reported the use of thrombolytic therapy for the management of ami [1]. subsequently several small trials reported the benet of streptokinase (sk) in the management of patients with ami [2-6]. newer agents including tissue plasminogen activators (tpa) such as alteplase, reteplase, tenecteplase (tnk) were developed subsequently. in the present era, thrombolytic therapy and primary percutaneous coronary intervention (ppci) has revolutionized the way patients with ami are managed resulting in signicant reduction in cardiovascular mortality [7,8]. the objective of both treatment strategies is to provide a rapid, complete, and sustained restoration of blood ow in the infarct-related coronary artery (ira) [9,10]. with this background we aim to study the complications of early and late throbolysis in mi patients. case study study area – department of general medicine, d y patil university school of medicine & hospital, nerul, navi mumbai. study population in patients who meet the inclusion and exclusion criteria. inclusion criteria: 1) patient admitted to dr d y patil hospital with chest pain lasting 20 mins or more with ecg sign compatible with mi (a) st elevation of 0.2 mv or greater in one of the precordial leads (b) 0.1 mv elevation in limb leads or both of the above 2. patient with 0.2 mv or greatest st segment depression in precordial leads compatible with posterior wall infarction exclusion criteria: ÿ age > 70 yrs ÿ previous treatment with streptokinase ÿ bypass surgery of the vessels corresponding to the infarct location ÿ recent trauma including traumatic resuscitation ÿ history of gi bleed, ulcer, hematuria or cva within three months ÿ pregnancy or menstruation sample size: by using convenience sampling the minimum sample size of 50 was arrived at using convenience sampling. [14] study design: observational prospective study study duration: 1 year methodology: after approval from the ethics committee and with written informed consent, a pilot study was conducted. based on the results of pilot study, sample size was calculated. after taking the detailed history and considering the symptomatology of patients presenting to the department of medicine. patients who presented with symptoms (chest pain, palpitations, sweating, dyspnoea, nausea, vomiting) within 4 hrs were labelled as early and those presented after 4 hrs were labelled as late. after admission the patients were undergone following ÿ detail clinical history ÿ thorough examination ÿ electrocardiography ÿ cardiac screen based upon above data the patients were diagnosed as st elevation mi. following standard treatment was given: oxygen via mask, analgesic, vasodilators such as sublingual nitroglycerine, with loading dose of aspirin (300mg), clopidogrel (600mg) and atorvastatin (80mg). patients fullling the inclusion criteria were then lysed with any of the thrombolytic agents like streptokinase, tenecteplase, alteplase. results table no. 1: distribution of patients according to time of lysis a study of complications of thrombolysis in myocardial infarction original research paper dr neha momale junior resident in dept of general medicine, d y patil hospital nerul, navi mumbai general medicine introduction: mi is myocardial cell necrosis due to signicant and sustained ischemia caused by obstruction to blood ow due to plaques in the coronary arteries. an early diagnosis and thrombolysis reduces complications and mortality. objective: to study the complications of thrombolysis in mi. methodology: observational prospective study in a tertiary care hospital where 50 pts (divided into two groups, depending upon the time of occurrence of symptoms into <4hrs and >4hrs) following the inclusion criteria were thrombolysed and were followed up. results: patients thrombolysed within 4 hrs had better outcome including medical management, lesser arrhythmias and overall mortality. conclusion: early diagnosis and thrombolysis in mi is important in decreasing the complications and mortality. abstract keywords : thrombolysis, myocardial infarction. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr varun shetty* associate professor in dept of general medicine, d y patil hospital, nerul, navi mumbai *corresponding author start time of thrombolysis frequency (n) percentage (%) less than 4 20 40 26 x gjra global journal for research analysis the above table depicts patients in which thrombolysis started after 4 hrs. more than started within 4 hrs. (30 vs 20) table no.2: distribution of patients according to compli cations (multiple response) the above table shows cardiac arrhythmias was maximum in number (12%) followed by cardiac failure (6%), recurrent mi (6%) and angina (4%) in complications. chart no. 1: distribution of patients according to compli cations table no. 3: comparison of complications between early and late thrombolysis (multiple response) the above table shows that comparison of complications between early and late thrombolysis which shows that angina, cardiac failure and recurrent mi were observed in late thrombolysis and only arrythmias seen in early thrombolysis patients. discussion the present study was prospective observational study in tertiary care hospital. in this, 50 patients fullling inclusion and exclusion criteria enrolled for the study. the basic aim of our study was to observe complications of early and late thrombolysis in mi. in this study out of 50 patients 30 patients were undergone thrombolysis after 4 hrs. i.e. late thrombolysis and 20 patients were undergone thrombolysis before 4 hrs i.e. early thromb olysis. it was observed that 6 patients had arrhythmia , 3 patients had cardiac failure and recurrent mi each and 2 patients had angina in follow up. it was observed that complications like arrhythmias, cardiac failure and recurrent mi was lesser in early thrombolysis patients. it concludes that early thrombolysis after onset of mi reduce myocardial damage and thus preserve part of the function of the left ventricle and improve patient survival. similarly, maarten l. slmoons also mentioned that thrombolysis in the rst hours after the onset of infarction has less complications and can reduce myocardial damage and thus preserve part of the function of the left ventricle and improve patient survival. in one other randomized trial [11,12] there was a similar improvement in survival, although left ventricular function and infarct size appeared unaltered [13]. the gissi trial showed that improvement in survival after thrombolysis was inversely related to the delay to treatment. in our study we conclude that early thrombolysis within 4 hrs after onset of mi having lesser complications than late thrombolysis. conclusion ÿ early thrombolysis showed less complications as compared to late thrombolysis ÿ it was observed that early thrombolysis within 4hrs after onset of symptoms is benecial. references: 1. serruys pw, wijns w, brand m v/d, et al. is translummal coronary angioplasty mandatory after, successful thrombolysis ? br heart j1983;50:257-65. 2. rentrop kp. thrombolytic therapy patient with acute myocardial infarction clrculahon 1985; 71’627-31 3. muller je. stone ph. markles je. braunwald e let's not let thegeme escape from the bottle-agam. n engl j med 1981; 304.1294-6. 4. swan hjc. editorial: thrombolysis in acute myocardial infarction treatment of the underlying coronary artery disease. circulation1982; 66:914-6. 5. hugenholtz pg, rentrop p. thrombolytic therapy for acute myocardial infarction quo vadls? a revlt:w of the recent literature eur heart j1982;3:395403. 6. roger wj. mantle ja, hood wp. et al. streptokinase in acute myocardial infarction. circulation 1983;68: 1051-61. 7. schroeder r. biammo g, von leitner er, et al intravenous short term infusion of streptokinase in acute myocardial infarction circulation 1983;67:536-48. 8. alderman el. jutzy kr. berte le, et al. randomized comparison of intravenous versus intracoronary streptokinase for myocardial infarction. am j cardiol 1984;54.14-9. 9. simoon, ml. wijns w. balakumaran k, et al. the effect of intracoronary thrombolysis with streptokmase on myocardial thallium distribution and left ventricular function assessed by blood-pool scintigraphy. eur heart j 1982.3:433-40. 10. fioretti p, simoons ml, serruys pw. brand m v/d, feb pw, hugenholtz pg. clinical course after attempted thrombolysis in myocardial infarction results of pilot studies and preliminary data from a randomized trial eur heart j 1982;3:422-32 11. kennedy jw, ritchie jl. davis kb. fritz jk western washington randomized trial of intracoronary streptokinase in acute myocardial infarction. n engl j med 1983;309.1477-82 12. kennedy jw. ritchie jl. davis kb. stadius ml, maynard c, fritz jk. the western washington randomized trial of intracoronary strep• tokmase trial in acute myocardial infarction. n engl j med 1985 ;312: 1073-8. 13. ritchie jl. davis kb, williams dl. caldwell j, kennedy jw. global and regional left ventricular function and tomographic radionuclide perfusion: the western washmgtonmtracoronary streptokinase in myocardial mfarctiontnal. circulation 1984;70:867-75. 14. s. k. lwanga, s. lemeshow. sample size determination in health studies. a practical manual. world health organization geneva 1991 volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra more than 4 30 60 total 50 100 outcome frequency (n) percentage (%) angina 02 04 cardiac failure 03 06 recurrent mi 03 06 arrhythmias 06 12 outcome early late total angina 00 02 02 cardiac failure 00 03 03 recurrent mi 00 03 03 arrhythmias 02 04 06 x 27gjra global journal for research analysis 67.dr. bishnu kant jha.cdr what is sez? variously known as free trade zones, special economic zones, bonded warehouse,free ports ,customs zones and maquiladoras , these are , in fact , exports promotion zones which are dened by international labour organization (ilo) as industrial zones with special incentives set up to attract foreign investors , in which imported material undergoes some degree of processing before begin re-exported. a special economic zone (sez) is thus a specically delineated duty free enclave , which is deemed to be foreign territory for the purposes of trade opperations and duties and tariffs. by offering privileged trading terms for manufacturing-based exports , sezs can attract investment and foreign exchange , spur employment and boost the development of improved technologies and infrastructure . the government of india enacted the special economic zones (sez) act 2005 , which came into effect from february 10 , 2006 .these act is being considered as a major step in india's foreign trade policy to provide an internationally competitive and hassle free environment in manufacturing , trading and services sectors and to attract foreign investments to usher in an export led growth of the economy. in east economies , like china , which launched sezs on a scale not seen previously , provided a platform for attracting fdi and not only supported the development of china's export oriented manufacturing sector , but also served as a catalyst for sweeping economic reforms that later were extended throughout the country. in southeast asia , malaysia was the rst asean country to adopt an epz program in 1971. it was followed by the philippines (1972), indonesia (1973) and thailand (1978) respectively. by the 1970s , zones of various kinds were multiplying , but with mixed results. never the less , their popularity increased over the years with the '' miracle of shenzhen " serving as beacon. there after ,special economic zones (sezs) have been recognized as an important mechanism for trade and investment promotion, creation of infrastructure , employment generation , promotion of regional development , increase in f o r e i g n e x c h a n g e e a r n i n g s , i m p r o v i n g e x p o r t competitiveness and transfer of skill & technology. india witnessed remarkable growth in number of formal , notied and operational approvals post enactment of sez act in 2005 , formal approvals have been granted for sitting up of 405 sezs , of which 329 have been notied and 32 have been given in principle approvals as on 31st december ,2016. while , 206 sezs are operational and around 4218 units are approved within the sezs as on 31 dec 2016. an appraisal of the functioning of sez in india original research paper dr. bishnu kant jha m.com, m.a (economics), ph.d l.n mithila university darbhanga x 39gjra global journal for research analysis commerce keywords : volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra countries government strategy towards sezs impact of sezs on economy economic benets india government pushed export promotion through *scal incentives *setup of asia's rst epz in kandla to overcome anti-export base followed by six more epzs *all geographically closed small industrial estates in port areas. *launch of new sez scheme through a comprehensive sez act to provide a signicant push to investment in sezs *extended scope of sezs to include services, manufacturing trading , reengineering and reconditioning. sezs accounted for *5% of exports 0.2% of employment in 2000 which grew to 26% and 4.2% , respectively , in 2014 special economic zones in india india was one of the rst in asia to recognize the effectiveness of the export processing zone (epz) model in promoting exports , with asias rst epz set up in kandla in 1965 with a view to overcome the shortcoming experienced on account of the multiplicity of controls and clearances; absence of world class infrastructure , an unstable scal regime and with view to attract larger foreign investment in india , the special economic zones ( sezs) policy was announced in april 2000 . india was one of the rst in asia to recognize the effectiveness of the export processing zone (epz) model in promoting exports , with asias rst epz set up in kandla in 1965 the second epz, seepz (santa cruz electronics exports processing zone) was set up in maharashtra in 1974 subsequently , the government set up four more zones namely nepz (noida export processing zone ) in uttar pradesh , mepz ( madras export processing zone) in tamil nadu ,cepz ( cochin export processing zone) in kerela , and feps ( falta export processing zone) in west bengal during the mid-eighties ; where as the vepz ( vishakhapatnam export processing zone) in andhra pradesh was commissioned in 1994 . surat epz became operational in 1998 in 2000 , the export import (exim) policy of india shifted towards a new scheme of special economic zone ( sezs ) under this scheme , epzs at kandla , santa cruz , cochin and surat were the second epz , seepz (santa cruz electronic export procesing xone ) was set up in maharashtra in 1974 converted into sezs in 2003, the other existing epzs at noida , fslta , chennai and vzag ( also know as vishakhapatnam ) were also converted into sezs in all , the epzs have progressed over four distinct phases over the last ve decades which are discussed briey below : investment and employment in sezs : investment in the sezs increased more than six times from 40 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra rs.77210 crores in 2007 08 to rs. 492312 crores as on 30th september 2008. investments in sezs have shown a positive growth rate over a period of time registering a compounded annual growth rate ( cagr) of 3.89% over a period of 10 years on the other hand sezs have witnessed four fold generation of employment from 336235 persons in 2007 -08 to 1996610 persons as on 30th september 2018. total employment generation has shown a positive growth rate over a period of time registering a compounded annual growth rate ( cagr) of 4.8% over a period of 10 years. export performance of sezs : exports from sezs have increased over 25 times from about rs.22840 crores in 2005-06 to about rs.581033 crores in 2017-18. the percentage share of sez exports in the total exports of the country in the year 2005-06 was only 5% in the year 2017-18 it stood at 29.71% ,this shows the impact of sezs on the exports of india. land acquisition the sez act also provides for a robust structure in terms of the land requirements and the project proposal being recommended by the appropriate state government to bring in the social not for the project and the same progress towards approval from the ministry of the commerce and industry for approval with terms and conditions. though the land remains under the control of the developer , the establishment of the units and the management of the land is under the jurisdiction of the development commissioner .sez lands cannot be sold as per sez rules any change in their land use is subject to the approval of the statutory authorities with relevant condition imposed on them. according to "the right to fair compensation and transparency in land acquisition, rehabilitation and resettlement act , 2013",there should be a transparent process followed for the purpose of the land acquisition for industrialization and development of essential infrastructural facilities and urbanization with the least disturbance to the owners of the land and other affected families and provide just and fair compensation to the affected families whose land has been acquired or proposed to be acquired or are affected by such acquisition and make adequate provisions for such affected persons for their rehabilitation and resettlement . initiatives taken for streamlining the functioning of sezs the following initiatives have been taken in recent years for implementation of the sez policy in the country and resolve issues there in : i) minimum land area requirement for setting up of new sezs has been reduced to 50% for multi product and sector specic sezs . ii) sectoral broad banding has been introduced to encompass similar / related areas under the same sector. iii) a new sector " agro based food processing " sector has been introduced to encourage agro based industries in sezs iv) dual use of facilities like social and commercial infrastructure by sezs and non sezs entities has been allowed in order to make sezs operations more viable. v) online processing of various activities relating to sez developers and units has been introduced for improving easy of doing business. conclusion the survey also observed the shortfall between the projections and actuals of exports/employment/investment in the sezs and found global slowdown, recession in the shipping industry, too many restrictions & frequent changes in policies as the major reasons for this shortfall. more often than not, expectations with regard to sezs are often inated; objectives are overstated and strategic planning remains inadequateresulting in stagnant development, unsustainable growth or low returns on investment. in addition, sez development programs should be integrated into the broader economic policy frame work and the national investment environment, and be ne-tuned to be consistent with the capacity of the government. sez programs should wider economic strategies as they evolve, supporting domestic investment in sezs and promoting linkages, training and upgrading along the value chain. at every stage, both the broader development program and the sezs need clear, consistent and credible political commitments at the highest levels of government. references 1. goswami, b. (2007) sez-lessons from china. retrieved may 30, 2013 2. govt. of india, ministry of finance, department of economic affairs, economic survey 2009-10 3. the nancial express new delhi, october 6, 2010 4. majumder, s (2003) ‘’sezs, go the chinese way’’, the business line, the hindu group of publications, mumbai, india introduction: renal biopsy is a widely used diagnostic tool all over the world which helps in correct evaluation of renal diseases and their prognosis which benets in identifying treatment strategies. renal biopsy observations from previous studies differ greatly and common factors which contribute to this variation are ethnicity, age characteristics of the population and the geographic location. advances in technology over time also impact this variation [1-4]. although several country specic renal biopsy registries available, there is no renal biopsy registry in india which might give information regarding overall spectrum of glomerular diseases. few indian studies have attempted to evaluate and report a wide range of glomerular diseases after renal biopsy; however, most of the studies include paediatric patients or adolescents [1, 5-7]. studies which include geriatric population are scanty [8]. there are limited indian studies demonstrating spectrum of glomerular diseases (gds) based on renal biopsy and most of them are from southern part. there is a paucity of data from western india. we believe that this will contribute to the literature. the present study aimed to assess spectrum of gds with the help of histopathological ndings in patients below 20 years to above 60 years. the objective of this study was to evaluate trend of gds in different age groups and to analyse the difference in pattern of gds based on gender. materials and methods: this cross-sectional study was conducted at grant medical college and sir jj group of hospitals, mumbai between october 2017 and august 2019. the present study included data of 189 patients who underwent renal biopsy. hematoxylin and eosin (h and e), periodic acid schiff, masson trichrome, were used to stain the specimen, and congo-red stain whenever necessary. all the biopsies were analysed through light microscopy and immunohistochemistry staining was performed using igg, igm, iga, c3, c4, and brinogen, and electron microscopy was used. as shown in ow chart histological ndings were divided into 4 categories after histopathological evaluation (figure 1). histopathological observations from renal biopsy: a single centre experience from maharashtra, india original research paper dr. geeta sheth associate professor, department of nephrology, grant government medical college and sir j. j. group of hospitals, mumbai, maharashtra, india dr. shweta manoharrao watane assistant professor, department of pathology, grant government medical college and sir j. j. group of hospitals, mumbai, maharashtra, india x 47gjra global journal for research analysis nephrology introduction: incidence of glomerular disease varies worldwide depending upon age, gender, and geographical region. understanding the aetiology is very important for management of these diseases. biopsy based technique helps in precise diagnosis and improved treatment outcomes. aim: this study aimed to classify glomerular diseases based on histopathological ndings of renal biopsies in patients below 20 years to above 60 years. materials and methods: this cross-sectional study was conducted at department of nephrology, grant medical college and sir jj group of hospitals, mumbai between october 2017 and august 2019 among patients who underwent renal biopsy. histological diagnosis was performed using light microscopy, electron microscopy and immunohistochemistry staining. histological ndings were divided into primary glomeruli disease (pgd), secondary glomeruli disease (sgd), tubulointerstitial disease (tid) and others. statistical analysis was done using one sample t-test to determine the differences in disease frequencies. results: total of 189 patients (102 men and 87 women) included were from age of 3-90 years. the mean (sd) age was 31.11 (16.05) years. the most common histological disease was pgd (48.67%) followed by sgd (33.33%) and tid (6.34%). incidence of sgd was more common in elderly patients (>60 years). among total population, incidence of focal segmental glomerulosclerosis (fsgs) (14.81%) and lupus nephritis (ln) (11.11%) were highest in pgd and sgd observed, respectively. incidence of diabetic nephropathy (dn) was highest (33.33%) in elderly population (>60 years). in pgd, incidence of membranous glomerulonephritis (mgn) was signicantly higher in men (87.5%) compared to women (12.5%) (p=0.001); however, in sgd, incidence of ln was signicantly common in women (85.71%) compared to men (14.29%) (p=0.015). conclusion: fsgs and ln were prevalent pgd and sgd, respectively. incidence of mgn was most common in men while, ln was prevalent in women who underwent renal biopsy. abstract keywords : diabetic nephropathy, elderly population, focal segmental glomerulosclerosis, lupus nephritis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. yogesh sadashiv thube* assistant professor in radiodiagnosis, department of radiodiagnosis, grant government medical college and sir j. j. group of hospitals, mumbai, maharashtra, india *corresponding author dr. shilpa domkundwar professor and hod, department of radiology, grant government, medical college and sir j. j. group of hospitals, mumbai, maharashtra, india dr. narendra m dedhia professor and hod, department of nephrology, grant government medical college and sir j. j. group of hospitals, mumbai, maharashtra, india 48 x gjra global journal for research analysis figure 1. flow chart of classication of histological ndings *crescentic gn / anti-neutrophil cytoplasmic antibody gn / antiglomerular basement membrane disease/deposition diseases. ain, acute interstitial nephritis; ctin, chronic tubulo interstitial nephritis; fsgs, focal segmental glomerul o scle rosis; gin, granulomatous interstitial nephritis; gn, glomerul onephritis; igan, iga nephropathy; mcd, mini mal changed disease; mgn, membranous glomeru lonephritis; pgd, primary glomeruli disease; sgd, secondary glomeruli disease; sle, systemic lupus erythematosus; tid, tubulointerstitial disease. statistical analysis the data were analysed using online statistics calculator. the frequencies of patients were expressed as percentages. one sample t-test was used to determine the differences in disease frequencies according to age group and gender in which biopsy was performed. a p <0.05 was considered statistically signicant. results a total of 189 patients were included in this study, of which 102 were men and 87 were women. the mean (sd) age was 31.11 (16.05) years with 47 patients (24.87%) below 20 years of age, 90 patients (47.62%) between 21-40 years of age, 40 patients (21.16%) between 41-60 years of age, and 12 patients (6.34%) above 60 years of age. the distributions of histopathological diagnoses are summ arized in (table 1) pgd (n=92, 48.67%) were the most common followed by sgd (n=63, 33.33%) and tid (n=12, 6.34%). till the age of 60, incidence of pgd and sgd were comparable. however, incidence of sgd was found to be more common in elderly patients (>60 years) (figure 2). incidence of pgd was in the range of 41.66% 50%. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra <20 years (n=47) 21-40 years (n=90) 41-60 years (n=40) >60 years (n=12) total (n=189) primary glomeruli disease fsgs 3 (6.38) 16 (17.78) 8 (20) 1 (8.33) 28 (14.81) mcd 12 (25.53) 5 (5.56) 0 (0) 0 (0) 17 (8.99) membranous gn 1 (2.13) 2 (2.22) 5 (12.5) 0 (0) 8 (4.23) mpgn 1 (2.13) 5 (5.56) 1 (2.5) 1 (8.33) 8 (4.23) iga nephropathy 1 (2.13) 6 (6.67) 1 (2.5) 0 (0) 8 (4.23) diffuse proliferative gn 2 (4.25) 4 (4.44) 0 (0) 0 (0) 6 (3.17) acute glomerulonephritis 1 (2.13) 1 (1.11) 3 (7.5) 0 (0) 5 (2.64) anca/anti gbm 0 (0) 2 (2.22) 0 (0) 1 (8.33) 3 (1.59) atypical haemolytic uraemia syndrome 1 (2.13) 1 (1.11) 0 (0) 0 (0) 2 (1.06) pauci-immune crescentic gn 0 (0) 1 (1.11) 1 (2.5) 0 (0) 2 (1.06) rpgn 1 (2.13) 0 (0) 0 (0) 1 (8.33) 2 (1.06) differential proliferative gn 0 (0) 1 (1.11) 0 (0) 0 (0) 1 (0.53) minimal mesangial gn 0 (0) 1 (1.11) 0 (0) 0 (0) 1 (0.53) crescentic mpgn 0 (0) 0 (0) 0 (0) 1 (8.33) 1 (0.53) secondary glomeruli disease ln 5 (10.64) 13 (14.44) 2 (5) 1 (8.33) 21 (11.11) dn 1 (2.13) 5 (5.56) 4 (10) 4 (33.33) 14 (7.41) sle 4 (8.51) 5 (5.56) 0 (0) 0 (0) 9 (4.76) focal proliferative lupus nephritis 2 (4.25) 1 (1.11) 0 (0) 0 (0) 3 (1.59) amyloidosis 0 (0) 0 (0) 2 (5) 1 (8.33) 3 (1.59) crescentic gn 0 (0) 1 (1.11) 1 (2.5) 0 (0) 2 (1.06) focal endocapillary proliferative gn 0 (0) 2 (2.22) 0 (0) 0 (0) 2 (1.06) pign 1 (2.13) 0 (0) 1 (2.5) 0 (0) 2 (1.06) hypertensive nephropathy 0 (0) 1 (1.11) 1 (2.5) 0 (0) 2 (1.06) membranous nephropathy 1 (2.13) 0 (0) 1 (2.5) 0 (0) 2 (1.06) psgn 1 (2.13) 0 (0) 0 (0) 0 (0) 1 (0.53) fibroid necrosis 1 (2.13) 0 (0) 0 (0) 0 (0) 1 (0.53) hiv/ hbsag/ hcv 0 (0) 0 (0) 1 (2.5) 0 (0) 1 (0.53) tubulointerstitial disease acute tubular necrosis 0 (0) 1 (1.11) 1 (2.5) 1 (8.33) 3 (1.59) focal necrosis 3 (6.38) 0 (0) 0 (0) 0 (0) 3 (1.59) renal cortical necrosis 0 (0) 1 (1.11) 2 (5) 0 (0) 3 (1.59) table 1. histopathological ndings figure 2. distribution of histopathological ndings accor ding to age group data represented as percentage of patients in each age group. pgd, primary glomerular disease; sgd, secondary glomerular disease; tid, tubulointerstitial disease. table 2. distribution of pathological ndings of renal biopsy based on sex x 49gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra cortical necrosis 0 (0) 2 (2.22) 0 (0) 0 (0) 2 (1.06) subcortical necrosis 1 (2.13) 0 (0) 0 (0) 0 (0) 1 (0.53) others 4 (8.51) 13 (14.44) 5 (12.5) 0 (0) 22 (11.64) data shown as n (%). anca, antineutrophil cytoplasmic antibodies; dn, diabetic nephropathy; fsgs, focal segmental glomerulosclerosis; gbm, glomerular basement membrane; gn, glomerulonephritis; hiv, human immunodeciency virus; hcv, hepatitis c virus; ln, lupus nephritis; mcd, minimal changed disease; mpgn, membranoproliferative glomerulonephritis; pign, post-infectious glomerulonephritis; rpgn, rapidly progressive glomerulonephritis; psgn, poststreptococcal glomerulonephritis; sle, systemic lupus erythematosus. histopathology men (n=102) women (n=87) p value primary glomeruli disease fsgs 19 (67.85) 9 (32.14) 0.053 mcd 10 (58.82) 7 (41.17) 0.470 membranous gn 7 (87.5) 1 (12.5) 0.015 mpgn 4 (50) 4 (50) >0.05 iga nephropathy 5 (62.5) 3 (37.5) 0.489 diffuse proliferative gn 2 (33.33) 4 (66.67) 0.426 anca/ anti gbm 3 (100) 0 (0) atypical haemolytic uraemia syndrome 2 (100) 0 (0) pauci-immune crescentic gn 1 (50) 1 (50) >0.05 rpgn 1 (50) 1 (50) >0.05 differential proliferative gn 0 (0) 1 (100) minimal mesangial gn 0 (0) 1 (100) crescentic mpgn 0 (0) 1 (100) acute glomerulonephritis 1 (20) 4 (80) >0.05 secondary glomeruli disease ln 3 (14.29) 18 (85.71) 0.001 dn 10 (71.43) 4 (28.57) 0.099 sle 2 (22.22) 7 (77.78) 0.079 psgn 1 (100) 0 (0) focal proliferative lupus nephritis 3 (100) 0 (0) crescentic gn 0 (0) 2 (100) fibroid necrosis 1 (100) 0 (0) focal endocapillary proliferative gn 1 (50) 1 (50) >0.05 pign 0 (0) 2 (100) amyloidosis 1 (33.33) 2 (66.67) 0.603 hypertensive nephropathy 2 (100) 0 (0) membranous nephropathy 1 (50) 1 (50) >0.05 hiv/ hbsag/ hcv 1 (100) 0 (0) tubulointerstitial disease acute tubular necrosis 3 (100) 0 (0) focal necrosis 0 (0) 3 (100) renal cortical necrosis 1 (33.33) 2 (66.67) 0.603 subcortical necrosis 1 (100) 0 (0) cortical necrosis 0 (0) 2 (100) others 16 (72.72) 6 (27.27) data shown as n (%). anca, antineutrophil cytoplasmic antibodies; dn, diabetic nephropathy; fsgs, focal segmental glomerulosclerosis; gbm, glomerular basement membrane; gn, glomerul onephritis; hiv, human immunodeciency virus; hcv, hepatitis c virus; ln, lupus nephritis; mcd, minimal changed disease; mpgn, membranoproliferative glome rulonephritis; pign, post-infectious glomerulonephritis; rpgn, rapidly progressive glomerulonephritis; psgn, poststreptococcal glomerul onephritis; sle, systemic lupus erythematosus. table 3. histological ndings of renal biopsies in this study and comparison with other published registries country india, present study india [1] india [5] india [6] india [7] india [9] india [10] korea [11] china [12] study site maharashtra west bengal chandigarh vellore tirupati tamil nadu kerala northeast china study period 2017-2019 2010-2012 2009-2012 1996-2015 2010-2012 2010-2016 2009-2016 1987-2014 2007-2016 number of patients 189 666 177 1740 137 231 271 345 2725 age group, years 3-90 5-48 13–19 ≤18 15-74 >60 11-80 5-18 ≥14 age in years, mean (sd) 31.11 (16.05) 28 (14.62) 16.2 (1.9) 12.8 (4.9) 37.99 (14.74) 64.2 (6.03) 41.98 (14.96) 9.7 (3.6) 41.24 (15.18) pgd 92 (48.67) 527 (79.13) 150 (84.75) 1321 (75.9) 137 (75.6) 210 (77.78) 266 (77.10) 2156 (79.12) majority of patients had fsgs in all the age groups. mcd was found in 12 patients below age of 20 years and in 5 patients between 21-40 years of age. mgn, mpgn, and igan was observed in eight patients each, while diffuse proliferative gn and acute gn were found in six and ve patients, respectively. in sgd, majority of patients had ln (11.11%), followed by dn (7.41%) and sle (4.76). focal proliferative ln and amyloidosis was observed in three patients each. tid, classied into acute tubular necrosis, anca/anti gbm, focal necrosis, renal cortical necrosis, were found in three patients each. male patients comprised the majority of the overall population (table 2). pgd was similar in men (50.98%) and women (49.02%). sgd observed were comparatively more in women (42.52%) than men (25.49%). incidence of fsgs was comparable between men (67.85%) and women (32.14%). incidence of mgn was signicantly higher in men (87.5%) than women (12.5%) (p=0.015). incidence of fsgs, mcd, igan, diffuse proliferative gn and acute gn were comparable between men and women. in sgd, ln was signicantly higher in women (85.71%) than men (14.28%) (p=0.001). dn and sle were found in 71.43% and 22.22% men and 28.57% and 77.78% women, respectively. however, there were no signicant difference observed in incidence of dn and sle between men and women. incidence of amyloidosis was comparable between men (33.33%) and women (66.67%). three male patients found with acute tubular necrosis and three female patients were found with focal necrosis. discussion: management and prognosis of glomerular diseases vary with patient age. early interventions help to reduce the prevalence and mortality associated with glomerular disease in these patients. the most common pgds that can cause end-stage renal disease are mcd and fsgs. renal biopsy is a safe and efcient procedure that aids in better understanding of histological pattern of glomerular disease, its prognosis and management. the present study was an attempt to add an evidence of a wide range of gd on the basis of histopathological observations post renal biopsy to the existing literature. this study included patients from a wide age range of 3-90 years and no previous study from india had evaluated patients from such a wide age group [1, 5-7, 9, 10]. generally previous similar studies included either paediatric, adult or elderly patient population alone, thereby providing age specic spectrum of histopathological diagnosis in patients undergoing renal biopsy (table 3) [1, 5-7, 9-12]. in the present study, the most common histological diagnosis was pgd (n=92, 48.67%) followed by sgd (n=63, 33.33%) and tid (n=12, 6.34%). these observations are in conco rdance with previously published literature [1, 5, 6]. present study observed comparable incidence of pgd across all age groups with decreasing trend according to increasing age. however, incidence of sgd was similar in age groups below 60 years and was more common in elderly patients (>60 years). these observations are suggestive of the fact that as age increases, there is an increased risk of sgd diagnosis. previous studies have established the relationship between increasing age and increased incidence of sgd [8,9,13]. incidence of fsgs (14.81%) and ln (11.11%) were highest in pgd and sgd observed, respectively, among total study population. these observations indicate fsgs and ln as the most prevalent gds in the present study. similar observations have been reported in several previously published literatures. a retrospective analysis of a large single centre paediatric renal biopsy cohort from south asia highlights important differences in the spectrum and trends of kidney disease compared to data from other regions. authors reported incidence of minimal change disease (21.2%) and ln (16.2%) was prevalent in primary and secondary gns, respectively. they further observed decrease in frequency of mcd and increase in frequency of fsgs and ln during the last 20 years [6]. a recently published indian study by gopaliah lr, et al. included 271 consecutive percutaneous kidney biopsies and evaluated the histopathologic pattern of renal biopsies from a tertiary care centre in south india. they reported the distribution of biopsy proven renal diseases among patients which highlighted pgd as the most common (77.78%) renal disease, followed by sgd (12.22%) and tid (10 %). the igan (23.33%) was the most common pgd followed by fsgs (13.70%) and dn (5.92%) and ln (5.18%) were the two most common biopsy-proven sgds [10]. these observations corroborate the present study ndings. a pakistani study published in 2010 reported that the fsgs was the leading histopathological diagnosis, found in 29% of pgd, followed by membranous gn (23.5%). in sgd, ln was most prevalent (44.1%), followed by amyloidosis (42.1%) and dn (8.1%) [14]. present study reported the incidence of dn was highest (33.33%) in elderly population (>60 years). a recently published study by su s, et al. reported slightly similar observations showing incidence of dn was highest in patients of age group 40-64 (64.3%) years and ≥65 years (16.7%) [12]. a previous study conducted over the period of 27 years comparing the pathological results of renal biopsy with clinical features in paediatric patients demonstrated pgd as the most common renal biopsy nding and iga nephropathy as the most common histopathological lesion [9]. another study by su et al. demonstrated mn as the most frequent pathological nding, however, igan was most commonly reported in other past literature [4, 12, 15, 16]. an indian study by golay et al. retrospectively analysed 666 patients of biopsy proven gd and reported mcd (20.12%) as the most common gd followed by fsgs (18.02%), ln (15.32%), membranous nephropathy (12.01%), and igan (8.11%). they further reported fsgs was the most common pgd in adults, mcd in children, and mn in the elderly patients and concluded that the spectrum of gd varies according to the area of study and changes over time [1]. a previously published study reported a signicant difference in incidence of membranous nephropathy and mcd between men and women. they observed signicantly higher male patients with diagnosis of membranous nephropathy and mcd as compared to female patients (p<0.001 and p=0.001, volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 50 x gjra global journal for research analysis fsgs 28 (14.81) 150 (22.58) 45 (25.42) 191(10.9) 9 (6.57) 16 (6.78) 37 (13.70) 11 (3.4) 73 (2.68) mcd 17 (8.99) 134 (20) 38 (21.46) 369 (21.2) 23 (16.79) 16 (5.92) 68 (21.3) 346 (12.69) sgd 63 (33.33) 139 (20.87) 27 (15.25) 323 (18.5) 41 (22.6) 33 (12.22) 46 (13.33) 417 (15.30) ln 21 (11.11) 102 (15.31) 19 (10.7) 282 (16.2) 43 (18.5) 14 (5.18) 5 (1.5) 115 (4.22) dn 14 (7.41) 1 (0.15) 1 (0.05) 33 (14.3) 16 (5.92) 42 (1.54) data shown as n (%), unless otherwise specied. dn, diabetic nephropathy; fsgs,focal-segmental glomerulosclerosis; ln, lupus nephritis; mcd, minimal change disease; pgd, primary glomeruli disease; sgd, secondary glomeruli disease. respectively). in sgd, ln was diagnosed in signicantly higher number of female patients as compared to male patients (p<0.001) [12]. these observations are in parallel with the present study. the present study had a limitation of shorter study duration of only two years. therefore, a longer duration study is required to evaluate the optimal pattern of renal diseases. conclusion: in overall patient population, fsgs and ln were the most common pgd and sgd, respectively, diagnosed based on histopathological observations. incidence of dn was highest in elderly population; whereas mgn was more common in men and ln was more common in women. references: 1. golay v, trivedi m, abraham a, roychowdhary a, pandey r. the spectrum of glomerular diseases in a single center: a clinicopathological correlation. indian j nephrol. 2013;23:168-75. 2. das u, dakshinamurty kv, prayaga a. pattern of biopsy-proven renal disease in a single center of south india: 19 years’ experience. indian j nephrol. 2011;21:250-7. 3. kurnatowska i, jêdrzejka d, mayska a, wgrowska-danilewicz m, danilewicz m, nowicki m. trends in the incidence of biopsy-proven glomerular diseases in the adult population in central poland in the years 1990-2010. kidney blood press res. 2012;35:254-8. 4. zhou fd, zhao mh, zou wz, liu g, wang h. the changing spectrum of primary glomerular diseases within 15 years: a survey of 3331 patients in a single chinese centre. nephrol dial transplant. 2009;24:870-6. 5. muthu v, ramachandran r, nada r, kumar v, rathi m, kohli hs, et al. clinicopathological spectrum of glomerular diseases in adolescents: a single-center experience over 4 years. indian j nephrol. 2018;28:15-20. 6. mohapatra a, kakde s, annapandian vm, valson at, duhli n, korula a, et al. spectrum of biopsy proven renal disease in south asian children: two decades at a tropical tertiary care centre. nephrology (carlton). 2018;23:1013-22. 7. modugumudi asn, venkata pb, bottla skv, kottu r, nandyala r, patnayak r, et al. a study of primary glomerular diseases in adults; clinical, h i s t o p a t h o l o g i c a l a n d i m m u n o  u o r e s c e n c e c o r r e l a t i o n s . j nephropharmacol. 2016; 5:91-7. 8. moutzouris da, herlitz l, appel gb, markowitz gs, freudenthal b, radhakrishnan j, et al. renal biopsy in the very elderly. clin j am soc nephrol. 2009;4:1073–82. 9. koshy pj, parthsarathy r, mathew m, prabakaran r, kuruvilla s, abraham g. interpretation of kidney biopsy in indian patients older than 60 years: a tertiary care experience. indian j nephrol. 2018;28:198–202. 10. gopaliah lr, sudakaran i, nalumakkal sv, narayanan r, vareed bm. spectrum of biopsy-proven renal diseases: a single center experience. saudi j kidney dis transpl. 2018;29:392-400. 11. lee sa, kim ms, kim sc, lee dy. clinical and pathological findings of renal biopsy in children: outcomes from a single center over 27 years. child kidney dis. 2017;21: 8-14. 12. su s, yu j, wang y, wang y, li j, xu z. clinicopathologic correlations of renal biopsy ndings from northeast china: a 10-year retrospective study. medicine (baltimore). 2019;98:e15880. 13. gupta p, rana ds. importance of renal biopsy in patients aged 60 years and older: experience from a tertiary care hospital. saudi j kidney dis transpl. 2018;29:140-4. 14. mubarak m, kazi ji, naqvi r, ahmed e, akhter f, naqvi sa, rizvi sa. pattern of renal diseases observed in native renal biopsies in adults in a single centre in pakistan. nephrology (carlton). 2011;16:87-92. 15. sugiyama h, yokoyama h, sato h, saito t, kohda y, nishi s,et al. japan renal biopsy registry and japan kidney disease registry: committee report for 2009 and 2010. clin exp nephrol. 2013;17:155–73. 16. chang jh, kim dk, kim hw, parks sy, yoo th, kim bs, et al. changing prevalence of glomerular diseases in korean adults: a review of 20 years of experience. nephrol dial transplant. 2009;24:2406–1. x 51gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction: liaison psychiatry is the branch of mental health that specializes in the interface between different medical specialties and mental health team, usually taking place in a hospital or medical setting. it also known as consultative psychiatry or consultation-liaison psychiatry (also, psychosomatic medicine). consults means when the primary care team has questions about a patient's mental health, or how that patient's mental health is affecting his or her care and treatment. the mental health team works as a "liaison" between the medical team and the patient. issues that happen include ability to consent to treatment, conicts with the primary care team, and the intersection of problems in both physical and mental health, as well as client who may report physical symptoms as a result of a psychological disorder. maternal mental health: maternal mental ill-health has a long-term effect on maternal wellbeing, family relationships and the mental health, social adjustment and attachment of the child during the rst critical years of life, therefore prevention, early diagnosis and intervention is vital. the mental health of the mother has a signicant effect on the health of her children during pregnancy but also throughout the child's life with a signicant inuence on foetal and early brain development. poverty and low socioeconomic status are associated with poor psychological and physical health when women come to pregnancy and are determinants of pregnancy outcome bringing about social disparities in pregnancy. mental health problems in pregnancy and the postnatal period are associated with adverse outcomes for the foetus and the baby as well as for the woman herself; for example, severe depression is associated with an increased risk of lower birth weight and premature babies, particularly for families affected by socioeconomic deprivation, self-harm and suicide. perinatal mental illness is complex and covers a range of conditions of varying severity including post-partum psychosis, mental ill-health and depression, perinatal obsessive compulsive disorders and anxiety. perinatal mental health problems perinatal mental health problems related studied in more than 90% of high income countries (hics), whereas information is available only for 10% of low and middle income countries (lmics). pregnant women and mothers of newborns experience signicant mental health problems range from 1:3 to 1:5, the most common of which are depression and anxiety states (e.g. 12.5 42% of pregnant women and, 12 50% of women of newborns in low and middle income countries (lmics) screen positive for symptoms of depression). suicide is one of the leading causes of pregnancy-related deaths (who report mmh2008). worldwide maternal mental health problems are considered as a major public health challenge. though maternal mortality still lies at the heart of maternal health indicators; for the post 2015 agenda for development goals, who is considering proposing healthy life expectancy (hle) and universal health coverage (uhc) related indicators as well. this imply stronger focus on mental health conditions in the integrated delivery of services for maternal and child health. the need is not just felt in high income countries. in fact, some educational and public health institutions in low and middle income countries have already initiated integrated maternal mental health programmes. these have been low cost interventions with the involvement of non generalized or community health providers. impact has been veried not only on mothers but also on growth and development of children. who is at risk of these disorders? almost all women can develop mental disorders during pregnancy and in the rst year after birth of baby. generally increase risks for specic disorders like low poverty, migration, extreme stress, exposure to violence (domestic, sexual and gender based), emergency and conict situations, natural disasters and low social support. effects of maternal mental disorders after birth on the mother and the infant after the delivery, the mother with depression suffers a lot and may fail to adequately eat, bathe or care for herself in other ways. this may increase the risks of ill health. the risk of suicide is also a consideration, and in psychotic illnesses, the risk of infanticide, though rare, must be taken into consideration. very young infants can be affected by and are highly sensitive to the environment and the quality of care, and are likely to be affected by mothers with mental disorders as well. severe or prolonged mental illness hampers the mother infant attachment, breastfeeding and infant care. what to do? maternal mental health can be integrated into general health care including women's health, maternal and child health care, reproductive health care and other relevant services. what is the evidence base? the national institute for health and care excellence (nice) clinical guidelines make recommendations for the recognition, assessment, care and treatment of mental health disorders in women during pregnancy and the postnatal period (up to one year after delivery). it includes advice on the care of women with an existing mental health disorder who are planning a pregnancy and on the organization of mental health services. it recommends that a clinical network should be established for perinatal mental health services managed by a coordinating board of healthcare professionals, commissioners, managers, service users and careers. the nice quality statement on postnatal care recommends that women who have transient psychological symptoms (baby blues) not resolved at 10–14 days after the birth should be assessed for mental health problems models in maternal and child health nursing: normalization process theory (npt): npt was the theoretical framework for the design, liaison psychiatric nursing: models and roles in maternal and child health nursing original research paper akoijam mamata devi phd scholar, shri jjt university, jhunjhunu, rajasthan professor, faculty of nursing, sgt university, gurugram nursing keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 54 x gjra global journal for research analysis implementation and evaluation of the move model (improving maternal and child health care for vulnerable mothers project), as it aims to support sustainability in health care behaviors, work practices and systems. npt is based on sociological theory that extends individual explanation of behavior to predicts facilitators and barriers to normalization of new clinical practice. the theory conceptualizes types of work required for implementation, embedding and integration of complex interventions. figure 1 normalisation process theory (npt) as a 'trial killer'. context: a l l imp or t a n t f o r deve lop ment , eva lu a t ion a nd implementation. the role of liaison psychiatry nurses in maternal health: liaison psychiatry services may have a role to play in remedying these deciencies in some areas, by setting up dedicated specialist teams and supporting the development of integrated perinatal mental health services based on a stepped care model of provision. the roles of the team would include: assessment; provision of psychological and other interventions particularly for complex cases; coordination and supervision of other services including iapt for the treatment of mild/ moderate problems; and consultation, supervision and training for non-mental health professionals, especially midwives and health visitors. particular emphasis should be placed on the early identication of problems, by promoting the screening of clients at their rst point of contact with routine services. a specialist service on these lines is provided in one of our sites, hull. it takes referrals both from the obstetric department in the hospital and from midwifery and other services in the community. referrals from midwives follow screening using questions recommended in nice guidance (“during the last month, have you often been bothered by feeling down, depressed or hopeless?” and “during the last month, have you often been bothered by having little interest or pleasure in doing things?”). all potential cases identied by the screening are then assessed by the specialist mental health team, with follow-up treatment including psychological interventions as appropriate. the service in hull was developed in response to a local need and represents one possible model for the improvement of perinatal mental health care. another survey of perinatal mental health support, carried out in the east midlands, sought the views of relevant professionals including midwives, health visitors, gps and obstetricians (rothera & oates, 2008). this identied a number of shortcomings, including: lack of knowledge and skills among non-specialist healthcare practitioners to detect and manage perinatal mental health problems; difculties in accessing psychiatric services; inadequate availability of systematic care pathways, protocols and guidelines; poor liaison between maternity, psychiatric and primary care services; and unclear roles and responsibilities. what is paediatric consultation-liaison? the paediatric liaison team remit is to offer assessment and treatment of psychiatric disorders related to physical illness, neuropsychiatric disorders, complex pain disorders and selfharm. pediatr ic consul tat ionl iaison (cl) comprises al l consultations, liaison, diagnostic, therapeutic, support and research activities carried out by psychiatrists and other mental health professionals in pediatric wards. the biopsychosocial approach holds a higher importance among paediatric age group due to multiple reasons: (a) they are at various level of physical, cognitive and emotional development; (b) family plays a very important role both in their health and illness; and (c) their understanding about illnesses, coping mechanism and the extent of disability vary from adult population pediatric cl as the process in which the child psychiatrist evaluates the patient, forms an opinion, and makes recommendations to the referring pediatricians (burket). there is at least four components play a major role in the illness and care of pediatric population: (a) the child, (b) the illness, (c) the family, and (d) the environment. need for pediatric liaison the risk of psychiatric disorder in children with physical illnesses is approximately double compared to the healthy children the psychological problems may be seen in 20-35% of the attendees at the pediatric clinics. these may range from psychological issues like difculty in adjustment to a life situation to a diagnosable psychiatric disorder. the rates of somatisation among those with psychological problems may vary between 75-90%. in a survey of paediatric clinics of 14 countries by who9, the worldwide prevalence of medically unexplained symptoms was found to be 19.7%. stress and anxiety is the most common underlying problem in medically unexplained symptoms, however parents often fail to identify them and seek multiple consultations. in a study by perera et al in a paediatric setting, 51% of all the patients with medically unexplained symptoms had identiable stressor and anxiety, but only 4% parents were able to identify the stressor. in another prevalence survey12 of the representative sample attending paediatric out-patient, 20% of the children were found to have emotional and behavioural problems and out of them, only a quarter received child mental health services. indian studies in india, there is lack of studies on paediatric c-l services and its utilization. various studies have reported paediatric referral rates to range from 7.5-8.6%. further awasthi et al reported that among all the paediatric referrals, 30% had no psychiatric illness, whereas in another 30% some psychological problem was present but no specic psychiatric diagnosis was made. among those with psychiatric diagnosis, 'hysteria'(17.5%) was the most common diagnosis. role of pediatric in liaison psychiatry nursing: consideration for the developmental perspective: paediatric age-group is a special group from developmental perspective – both physically and emotionally. they cannot be considered as mini-adults. their response to stress and coping mechanism are based on their perception of illness and the level of their cognitive and emotional development which are different from adults. thus, assessment and management needs consideration of the developmental stage of the child. similarly, care has to be taken on how to explain about a medical procedure to a child depending on his/ her developmental stage e.g. role play is more suitable, instead of a detailed explanation, for intravenous therapy in case of very young children. involvement of parents: parents are the main caregivers, chief interlocutors and volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 55gjra global journal for research analysis decision makers on behalf of minor children and, therefore, they play a signicant role in inuencing the attitude of child towards illness and treatment. sometimes, they may also be the cause of the illness manifestations in the child e.g. psychosomatic symptoms in a child with frequent family conicts. assess the impact on child's siblings: the illness of a child not only affects the child but also his siblings. often parents devote more time and resources on the care of the care of ill child, especially in chronic medical and psychosomatic illnesses. this results in frequent and long separations from other children, disturbance of daily routine; which in turn affects all the other components of the “network” by increasing distress in the child, parents and even increasing sibling rivalry. role of hospital environment – the hospital is often a new environment for the sick child which deprives the child of familiar environment, siblings, friends and at the same time, exposes him/her to several new and potentially frightful experiences e.g injections. the nature of reaction of a child often depends on the age, the length of separation from home and prior experience with hospitalization, the child's temperament, reaction of the parents, and mainly on the information and preparation given to the child. separation from parents, especially mother, often results in depression, withdrawn behaviour and increasing vulnerability to physical illness which rene spitz described as 'anaclitic depression' or 'hospitalism'. at times, the hospitalization may offer positive experience by creating new and different relationships. the nature of reaction can be largely inuenced by adequate information and preparation of the patient during admission. composition of pediatric c-l team: the essential components of the team should include a psychiatrist with training or sufcient experience in child psychiatric issues, child psychologist, child and family psychotherapist and preferably a social worker and a child mental health nurse. the actual composition can vary depending upon the resource available and the number of referrals. relationship with the paediatric team: as the child health service is a small community, the team should keep a close partnership and work in tandem with the paediatric team. thus, the aim should be to not only provide clinical service, but also form a partnership between groups of colleagues. this will eventually inuence the practice of paediatrics as well as of child and adolescent mental health. it also helps in removing stigma and prejudice against psychiatry, as the paediatric team gets sensitized to psychosocial issues and its management. understanding the perceived need of the paediatric team and providing effective, readily available service is important. child protection for abuse/neglect: separate meetings with broader involvement of service providers like social workers and local authorities need to be involvement in ensuring the best possible psychological and physical care of actual or suspected child abuse. this is more important when the perpetrator of the abuse is a family member of the child. models of paediatric consultation 1. emergency response model – to met the urgent demands like in emergency room and icus 2. anticipatory model – for pre-assessment and pretreatment like prior to a major procedure, breaking of a bad news, etc. this is mostly applicable in paediatric surgery units, cancer therapy etc. 3. case nding model – consists of an early identication and treatment of the children and families which would benet from psychological intervention. mostly applicable in general ward and out-patient settings. 4. education and training model – where the role of consultation psychiatrist is conned to giving opinion at joint clinical conferences, joint rounds and discussions. 5. continuity and collaborative care model – when there is continuous and concurrent paediatric and psychiatric treatment. true liaisoning occurs in this type of model. this is often found in chronic and long-standing illnesses like diabetes, cystic brosis, genetic disorders and paediatric oncology. all the above models, like in general c-l psychiatry models, mostly differ with regards to the level of independence of the liaisoning psychiatric team and responsibility of the patients. barriers to liaison between paediatrician and child psychiatrist: there can be several barriers to effective functioning of the pediatric c-l services. them delays in responding to a consultation or mismatch of the timings may deter a future referral. the approach to patient directive approach of paediatrician versus persuasive approach of child psychiatrist may at times create a conict amongst professionals. this difference in approach is in form of body versus mind, lifethreatening aspects versus quality of life, cure versus care, and so forth. there should be mutual understanding and respect about these issues, instead of having inappropriate expectations, hierarchy and status issues. close communication in the form of routine meetings and clinical conferences and understanding the way of work is the key to remove this barrier. attitude of the patient and families may pose an important barrier in paediatric liaison as family plays a much more prominent role in decision making in case of a child. the dichotomous view of mind and body, the fact that they brought their child for 'physical' problems, and the stigma attached to psychiatric illness often brings resistance and reluctance to the treatment offered. this may be resolved to a certain extent by prior 'conditioning' of the parents by the paediatrician, involving the liaison team early in treatment course instead of seeking a delayed consultation when the medical examinations fail to reveal any result. the liaison team should also hold combined sessions with the patient and caregivers to explain the nature and cause of illness. conclusion the risk of psychiatric disorder in children with physical illnesses is approximately double compared to the healthy children. several psychological, familial and social issues may need attention, especially in case of chronic illnesses. children are often at varying stages of cognitive and emotional development, which needs to be considered during assessment and management. family factors attain a greater signicance from an etiological and management perspective in case of children. consultation and liaison services geared towards pediatric population are likely to facilitate the early identication and management of mental morbidity in the younger population. references 1. national institute for health and clinical excellence (nice). antenatal and postnatal mental health: clinical management and service guidance cg192 london: nice, 2014. available from: https://www.nice.org.uk/ guidance cg192. 2. chatterje b, pattanaya rd, sagar r. consultation — liaison in paediatric population. journal of mental health and human behaviour. 2012;17(3):s6571. 3. nice (2007) antenatal and postnatal mental health: clinical management and service guidance. london: national institute for health and clinical excellence. 4. rothera, i. & oates, m. (2008) managing perinatal mental health disorders effectively: identifying the necessary components of service provision. psychiatric bulletin, 32, 131-133. 5. sharrock, j. & happell, b. (2002) the psychiatric consultation nurse: thriving in volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 56 x gjra global journal for research analysis a general hospital setting. international journal of mental health nursing, 11, 24-33. 6. harpham t, huttly s, silva mjd, abramsky t. maternal mental health and child nutritional status in four developing countries. j epidemiol community health 2005;59:1060–1064. 7. maternal mental health and child health and development in low and middle income countries : report of the meeting held in geneva, switzerland. 2008. 8. starting the conversation integrating mental health into maternal health care in india. indian j med res 145. 2017 march: 267-269. 9. mccauley k, elsom s, muircochran e. midwives and assessment of perinatal mental health. journal of psychiatric and mental health nursing, 2011:1-10. 10. henderson t. pediatric consultation-liaison psychiatry: a description of the consultation-liaison service offered by a tertiary level children’s hospital in cape town, south africa.2013. 11. whomaternal mental health.https://www.who.int/mental_health/maternalchild/maternal_mental_health/en/ 12. taft et al. maternal and child health nurse screening and care for mothers experiencing domestic violence (move): a cluster randomised trial. bmc med. 2015; 13: 150. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 57gjra global journal for research analysis 78.syed rubiya sultana online.cdr introduction laryngoscopy and intubation is needed for most patients undergoing surgical procedures under general anaesthesia. hypertension and tachycardia have been commonly associated with intubation under general anesthesia due to manipulation during laryngoscopy and stimulation of epiglottis. ivabradine is a cardiotonic agent which is highly selective inhibitor of “i ” channels, results in decrease in slope of f spontaneous depolarization leading to increase in time interval between successive action potentials in sa node thereby decreasing the heart rate. ivabradine reduces the heart rate without compromising hemodynamics, can be used in both hypertensive patients and normotensive patients. material and methods after obtaining the clearance from the institutional scientic and ethical commit tee study was undertaken at dr.jeyasekharan hospital and nursing home nagercoil, kanyakumari district, tamilnadu. the study period was 18 months from september 2017 to february 2018 . pre-anesthetic checkup was done including proper history, general and systemic examination for asa grading and also for inclusion in the study.90 patients aged above 15 years (asa i and ii) of either sex were selected and they were randomly allocated into two groups as per randomization method. group a – comprising 45 patients who received oral ivabradine. group b – comprising 45 patients, who received a placebo written and informed consent were obtained from the patient and standard protocols followed for anesthesia in both group patients. all patients were kept nil per oral for 6 hours prior to surgery time at operation theatre. premedication with inj. ondansetron 4mg iv+ inj. rabeprazole20 mg iv were given for all patients 1 hour prior to surgery in the preoperative room. a nurse not clinically involved in the study followed the randomization sequence using a computer generated random number chart with a block size of four and a 1:1 allocation ratio. the same nurse prepared sequentially numbered, opaque and sealed envelopes to implement the sequence,with either tab ivabradine 5mg or placebo and administered it to the patient with sips of water about 1 hour before intubation, after obtaining permission from the researcher without disclosing the name of the tablet. all patients and care providers, including anesthesiologists and study personnel were blinded during group allocation. all patients had intravenous infusion of iv uid ringer's lactate on ow prior to induction. patient was shifted into the operating room and connected to monitors after placing supine on the ot table.pulse rate (pr), respiratory rate (rr), non-invasive blood pressure (nibp), oxygen saturation (spo2) and electrocardiogram (ecg) monitoring was done using a standard calibrated monitor. the premedication, induction agent and muscle relaxant to facilitate intubation were standardized for both the groups. baseline hr,sbp,dbp and map were recorded and preoxygenation done for 3 min with a facemask.the patient induced by inj propofol 2mg/ kg and inj fentanyl 1 mcg/kg. intubation facilitated by using inj. vecuronium 0.1mg/kg i.v. attenuation of hemodynamic response to endotracheal intubation using oral ivabradine a prospective randomised controlled double blind study original research paper dr.syed rubiya sultana dnb anaesthesia registrar, dr. jeyasekharan hospital, nagercoil, tamilnadu, india-629003 anaesthesiology background:rapid and dramatic hemodynamic changes which adversely affect the patient may occur during laryngoscopy and intubation. the present study evaluates the effect of oral ivabradine on the hemodynamics during laryngoscopy and endotracheal intubation in patients undergoing surgical procedures under general anesthesia with ett. study design: a prospective, randomized, controlled, double-blind study. material and methods: 90 asa i and ii patients who underwent elective surgeries under general anaesthesia at dr jeyasekharan hospital and nursing home, were randomly divided into two groups of 45 each. group a received tab ivabradine 5 mg and group b received tab b complex.the hemodynamic parameters namely hr,sbp,dbp and map were monitored prior to the study drug as baseline and at the following time intervals ;after induction, after intubation, ,after 1,3,5,8 and 10 minutes after intubation. results: hr was signicantly lower in the ivabradine group compared to control group at all time interval after study drug. sbp,dbp&map were signicantly lower in the ivabradine group compared to control group after induction, after intubation, and 1,3,5,8 and 10 minutes after intubation. conclusions: ivabradine given before intubation prevents signicant rise in hr and sbp, dbp, map compared to placebo in patients during laryngoscopy and endotracheal intubation. abstract keywords : dr.renu devaprasath hod dept. anaesthesia, dr. jeyasekharan hospital, nagercoil, tamilnadu, india-629003 dr renjith i dnb anaesthesia registrar, dr. jeyasekharan hospital, nagercoil, tamilnadu, india-629003 dr. s. nishalperumal* anaesthesiologist,dr. jeyasekharanhospital,nagercoil, tamilnadu, india629003 *corresponding author 16 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra the lungs ventilated with 100% oxygen for 60 seconds. intubation done at around 60 minutes after ivabradine pretreatment in group-1 and 60 min after placebo in group -2 (correlating with peak action of the drug). intubation achieved with an appropriate size oral, cuffed, portex endotracheal tube by the aid of macintosh laryngoscope blade. hr,sbp, dbp and dbp were recorded post induction, post intubation and at predetermined intervals. balanced anesthesia was maintained with vecuronium bromide (0.02mg/kg) top-up doses; and intermittent positive pressure ventilation with nitrous oxide and oxygen in the ratio of 66%: 33% using circle absorber system connected to anesthesia work station. the surgeon was requested to defer putting the incision until 1,3,5,8 and 10 minutes recordings were completed .any post induction hypotension (map < 20%) was managed with uid bolus of ns 250 to 300 ml and ephedrine 6mg iv and with inj atropine 0.6 mg if heart rate was less than 20% of baseline heart rate. parameters recorded were heart rate, systolic bp, diastolic bp, mean arterial pressure. ten minutes after intubation, after taking the recordings of hemodynamic parameters, inhalational agent was introduced into the anesthetic technique. the study was discontinued once the sample size of 90 patients have been studied. the statistical analysis was done using spss (statistical package for social sciences) version 2020 statistical analysis software. signicance level is decided before starting study95% the parametric variables were collected and were analyzed by independent ttest.statistical analysis was performed using chi-square for non-parametric samples. p<0.05 was considered as statistically signicant.master chart was prepared using the available individual data from the patient proformas , following which the data was analyzed. results and discussion present study was undertaken to study the hemodynamic changes following intubation between patients who received oral ivabradine and those who did not. blood pressure and heart rate response to direct laryngoscopy and endotracheal intubation was studied in both the groups. table-1: hr changes in both groups placebo(n=45) ivabradine(n=45) t df p value mean sd mean sd heart rate baseline 84.22 11.419 77.13 8.05 3.404 79.069 0.001 hr-at induction 87.29 10.593 79.02 7.823 4.211 88 <0.001 hr-at intubation 91.36 10.671 76.71 7.765 7.444 88 <0.001 hr-1 min after intubation 89.51 10.211 74.76 7.595 7.778 88 <0.001 hr-3 min after intubation 88.24 10.107 73.42 7.359 7.953 88 <0.001 hr-5 min after intubation 86.67 9.902 71.96 7.483 7.951 88 <0.001 hr-8min after intubation 86.4 9.804 71.13 7.307 8.376 88 <0.001 hr-10 min after intubation 85.64 9.815 70.71 6.992 8.313 79.516 <0.001 table-2 : sbp changes in both groups placebo(n=45) ivabradine(n=45) t df p value mean sd mean sd sbp-baseline 114.42 7.275 116 6.671 -1.072 88 0.287 sbp-at induction 119.42 7.216 121.91 6.643 -1.702 88 0.092 sbp-at intubation 117.69 7.332 119.56 6.416 -1.285 88 0.202 sbp-1 min after intubation 115.56 7.573 117.04 6.684 -0.989 88 0.325 sbp -3min after intubation 113.42 7.347 114.73 6.545 -0.894 88 0.374 sbp-5 min after intubation 111.51 6.871 112.6 6.429 -0.776 88 0.44 sbp 8 min after intubation 109.84 6.829 111.18 6.114 -0.976 88 0.332 sbp-10 min after intubation 108.8 6.666 110.62 6.154 -1.347 88 0.181 table-3 :dbp changes in both group placebo(n=45) ivabradine(n=45) t df p value mean sd mean sd dbp-baseline 68.29 7.54 69.71 5.558 -1.019 88 0.311 dbp-pre induction 72.18 7.114 73.67 5.669 -1.098 88 0.275 dbp-at intubation 70.93 6.607 71.53 5.599 -0.465 88 0.643 dbp-1 min after intubation 69.18 6.576 69.71 5.763 -0.409 88 0.683 dbp-3 min after intubation 67.62 6.461 68.31 5.744 -0.535 88 0.594 dbp-5 min after intubation 66.33 6.36 67.04 5.657 -0.56 88 0.577 dbp8min after intubation 65.51 6.24 66.18 5.293 -0.547 88 0.586 dbp-10 min after intubation 64.4 6.103 65.62 5.577 -0.992 88 0.324 table-4 :map changes in both groups placebo(n=45) ivabradine(n=45) t df p value mean sd mean sd map-baseline 83.6756 6.52569 85.07 4.65037 -1.167 88 0.246 mappre induction 88.2422 6.23183 89.9133 4.8288 -1.422 88 0.159 map-at intubation 86.678 6.1195 87.538 4.8065 -0.741 88 0.46 map-1 min after intubation 84.7467 6.04414 85.446 4.91947 -0.602 88 0.549 map-3 min after intubation 82.9311 5.96356 83.766 5.4364 -0.694 88 0.489 map-5 min after intubation 81.58 5.77351 82.3111 4.92091 -0.647 88 0.52 map -8 min after intubation 80.45111 5.584256 81.17756 4.654674 -0.67 88 0.504 map-10 min after intubation 79.5222 5.53776 80.5538 4.72255 -0.951 88 0.344 x 17gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table-5 : distribution of age, weight, height and bmi there is no signicant difference in distribution of age, weight, height and bmi between two groups. figure-1: sex distribution in two groups no signicant difference in distribution of sex and asa between two groups. figure-2: asa distribution in two groups in this study hr was signicantly lower with a p value <0.001 in the ivabradine group compared to control group at all time interval after study drug. sbp, dbp&map were signicantly lower in the ivabradine group compared to control group after induction, after intubation, and 1,3,5,8 and 10 minutes after intubation. discussion rapid and dramatic hemodynamic changes adversely affect the patient. these changes may occur during the perioperative period. hypertension and tachycardia have been recognized as commonly associated with intubation under light anesthesia and is most evident during laryngoscopy and intubation. the effect is usually arising within 30 seconds after endotracheal intubation and lasting less than 10 minutes thereafter. hence controlling hemodynamic changes is an important aspect of anesthetic management to prevent complications. various strategies have been implemented for the attenuation of hemodynamic response to laryngoscopy and intubation with tracheal spray of lignocaine, increasing the depth by inhalational agents, various drugs like labetalol, nitroprusside, calcium channel blockers, etc but only few recent studies in southern part of india has been done with oral ivabradine. conclusions this study concluded that oral ivabradine has better heart rate control than placebo for attenuation of hemodynamics during laryngoscopy and endotracheal intubation in asa 1 and 2 patients without side effects. conicting interests author declares no conict of interest. funding no funding agency ethical approval obtained informed consentobtained acknowledgementsi would like to thank the patients for cooperating with us throughout the study period. i thank the department of anaesthesia for helping in conducting and publishing this study. references 1. c. g.r. singh d, kabra av. attenuation of hemodynamic response to laryngoscopy and endotracheal intubation using intra-oral ivabradine: a clinical study. j evol med dent sci. 2014 aug 27;3(39):9944–55 2. prevention of haemodynamic changes during laryngoscopy and endotracheal intubationa clinical study of oral ivabradine rajesh kunwer1 , mamta joshi2 , saurabh pathak issn (online): 2393-915x; (print): 2454-7379 | icv: 50.43 | volume 3 | issue 7 | july 2016 3. k.d. tripathy m.d. essentials of medical pharmacology 7th edition. chapter 39;559. chapter 29 ; page361366. 4. ibrahim a, atallah r. ivabradine versus propranolol given orally in microlaryngoscopic surgeries in attenuating stress response: a comparative prospective double blind randomized study. egyptian journal of anaesthesia. 2016;32(4):503-511. 5. a. j. shribman, g. smith and k. j. achola cardiovascular and catecholamine responses to laryngoscopy with and without tracheal intubation a. j. shribman, g. smith and k. j. achola br. j. anaesth. (1987), 59, 295-299. placebo(n=45) ivabradine(n =45) t df p value mean sd mean sd age 35.62 8.909 33.56 8.683 1.114 88 0.268 weight 61.5333 6.9922 57.67226.17956 2.776 88 0.007 height 157.56 4.099 152.91 8.19 3.402 64.736 0.001 bmi 24.751112.552683 24.717782.5853860.062 88 0.951 18 x gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra textintroduction: obesity had emerged important risk factors associated with various disease. prevalent of obesity is on the rise. in 2016, more than 1.9 billion adults aged 18 years and older were overweight. of these over 650 million adults were obese. in 2016, 39% of adults aged 18 years and over (39% of men and 40% of women) were overweight. overall, about 13% of the world's adult population (11% of men and 15% of women) were obese in 2016. the worldwide prevalence of obesity nearly tripled between 1975 and 2016. (1) elevated ldl (>190 mg/dl) and triglycerides are risk factors for coronary heart disease. in all individuals, emphasize must be given on heart-healthy lifestyle across the life course. a healthy lifestyle reduces atherosclerotic cardiovascular disease risk at all ages. in younger individuals, healthy lifestyle can reduce development of risk factors and is the foundation of atherosclerotic cardiovascular disease risk reduction. in young adults 20 to 39 years of age, an assessment of lifetime risk facilitates the clinician–patient risk discussion and emphasizes intensive lifestyle efforts. in all age groups, lifestyle therapy is the primary intervention for metabolic syndrome. (2,3) whole grain like wheat (tritium aestivum linn.) nds a place in the recommended dash diet and is an important component of human diet, particularly in developing countries. epidemiological studies reveal that consumption of whole grain and its products are protective against chronic diseases such as cardiovascular diseases, dyslipidemia, diabetes and cancer. wheat when harvested as young green shoots germinated over a period of 6-10 days is generally called 'wheat grass' and it is known as 'functional food' during which vitamins, minerals and phenolic compounds such as avonoids are synthesized in wheat sprouts reaching maximum antioxidant potential.(4) herbal products are highly acceptable and used 70 to 80% of the world population for their primary health care, especially in developing countries, due to their easy access, lesser side effects and low cost. it is also known to possess antioxidant as proven in several studies. (5,6) this property might protect the heart and preventing the most important cardiovascular complication. it may help in favourable lipid prole. this study will denitely help and add knowledge in scientic exploration of effect of wheat grass (tritium aestivum linn) on lipid prole by observing its effect on isoproterenol induced myocardial infarction in rats. subjects and methods: this was a longitudinal study done on thirty healthy albino rats weighing between 100-200gms. prior to the dietary manipulation, all rats were fed standard rat chow, containing 60% vegetable starch, 11% fat and 29% protein, water ad libitum and maintained on 12 hours light/dark cycle. simultaneously rats were acclimatized to the procedure of blood pressure measurement daily for one week. drugs & chemicals: the drugs selected for the study were obtained in pure powder form from the following sources. 1triticum aestivum powder –girmes wheat grass, pune 2carvediliol – alkem company, mumbai, maharastra, 400013 3isoproterenol (iso) – get well pharmaceuticals, new delhi myocardial infarction was induced in rats by intraperitoneal injection of isoproterenol hydrochloride at a dose of 20mg/100g body weight, dissolved in normal saline for 2 consecutive days. thirty albino rats were grouped into ve groups of six rats in each, and housed in separate cages group-wise, as follows. group 1 (control) : rats were administered normal saline 0.5ml orally for 15 day followed by normal saline 5ml s.c. on th th14 & 15 day, at an interval of 24 hr. group 2 (iso) : rats were administered normal saline 0.5 ml orally once daily for 15 days followed by iso 20mg/100g body weight th thsubcutaneously on the 14 & 15 day, at an interval of 24 hr. group 3 (tr low dose + iso) : rats were pretreated with triticum aestivum low dose 200mg/kg orally for a period of 15 days followed by subcutaneous injection of isoproterenol 20mg/100g body effect of wheat grass (tritium aestivum linn) on lipid profile in albino rats induced with myocardial infaraction. original research paper dr annapoorna sahoo tutor, pharmacology department, bhima-bhoi medical college and hospital, balangir, odisha x 51gjra global journal for research analysis pharmacology context: obesity had emerged important risk factors associated with various disease. prevalent of obesity is on the rise aims: to study the effect of wheat grass (tritium aestivum linn) on lipid prole by observing its effect on isoproterenol induced myocardial infarction in rats. settings and design: this was a longitudinal study done on thirty healthy albino rats methods and material: thirty albino rats were grouped into ve groups of six rats in each, and housed in separate cages groupwise. all groups except control received isoproterenol. in addition to isoproterenol, two groups were given wheat grass at different dosage and one group received carvediliol. serum lipid prole was assessed. statistical analysis used: anova test and post hoc dunnett test using spss version 16, unpaired t testresults: signicant reduction in hdl and increse in ldl, cholesterol and triglyceride was seen.. conclusions: triticum aestivum has a favourable effect on lipid prole. wheatgrass extract can be a good alternative or primary therapy in treating dyslipidemia. abstract keywords : tritium aestivum linn, dyslipidemia dr pravin dhone* professor and head, bhima-bhoi medical college and hospital, balangir, odisha *corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 52 x gjra global journal for research analysis th thweight on 14 & 15 day at an interval of 24 hr. group 4 (tr high dose + iso): rats were pretreated with triticum aestivum high dose 250mg/kg orally for a period of 15 days followed by subcutaneous injection of isoproterenol 20mg/100g body th thweight on 14 & 15 day at an interval of 24 hr. group 5 (carvedilol + iso): rats were pretreated with carvedilol 5mg/kg orally for a period of 15 days followed by subcutaneous injection of th thisoproterenol 20mg/100g body weight on 14 and 15 day at an interval of 24hr. biochemical studies : serum lipid prole (cholesterol, triglyceride, hdl, ldl) will also be estimated in all the groups. this was done by standard acceptable method. (7) statistical analysis--the comparison were done using anova test and post hoc dunnett test using spss version 16, unpaired t test and p<0.05 was considered as statistically signicant. results: effect of triticum aestivum linn. on various lipid prole is shown in in isoproterenol induced myocardial infarction in albino rats. as evident in the table, it is having comparable effect to that of carvedilol. wheat grass (wg) had signicantly increased the level of hdl and it has signicantly decreased the level of cholesterol, ldl and triglycerides. we also dose dependant result. (table 1) volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra group drug dose duration induction of mi 1 distilled water 0.5 ml for 15 days no treatment 2 distilled water 0.5 ml isoproterenol 20mg/100gbwt. sc inj on 14th& 15th day. 3 triticum aestivum extract 200mg/ kg parameters (mmhg) group1 control (distilled water) group2 control iso 20mg/100gbwt group3 wg200mg/kg +iso 20mg/100gbwt group4 wg250mg/kg +iso 20mg/100gbwt group5 carvedilol 5mg/kg+ iso 20mg/100gbwt cholesterol ± se 54.43 ±4.145 109.16*** ±4.88 90.49* ±5.52 67.73*** ±5.91 56.96 ±3.53 triglyceride ± se 132.32 ± 5.529 317.07*** ±13.5 247.405* ±7.45 178.638*** ±8.112 127.77 ±4.867 hdl ± se 27.135 ±1.87 33.14*** ±1.51 34.847* ±1.93 38.98*** ±2.14 41.03*** ±1.35 ldl ± se 66.97 ±0.59 39.9*** ±0.66 59.06* ±0.66 51.97*** ±0.6 44.99*** ±0.59 table 1: effect of triticum aestivum linn. on lipid prole. 4 triticum aestivum extract 250mg/ kg 5 carvedilol 5mg/kg discussion: this study was carried out to nd out effect of wheat grass (tritium aestivum linn) on lipid prole by observing its effect on isoproterenol induced myocardial infarction in rats. wheat grass (wg) had signicantly increased the level of hdl and it has signicantly decreased the level of cholesterol, ldl and triglycerides. we also dose dependant result. wheat grass refers to the young grass of wheat (triticum aestivum) germinated for a period of 6 to 10 days. it contains vitamin c and e, ß carotene, ferulic acid, vanilic acid and phenols, especially avonoids. wheat grass juice is found to have healing properties in various degenerative diseases and is known to benet blood cells, bones, glands, kidney and other parts of the body. (8,9) since little or no work has been done on cardio-protective effects of wheat grass, the present study was designed to analyse its role on isoproteronol induced myocardial insufciency. in the study , rst myocardial-infarction was induced with a �adrenergic agonist isoproterenol, which caused severe stress in the myocardium causing coagulative necrosis (i.e. infarct like) of heart muscle. pre-treatment of triticum aestivum linn.in both doses (ta linn + iso) showed a reduction in blood lipid prole levels with concomitantly increase in hdl cholesterol. lipid lowering effect of triticum aestivum linn.is due to the inhibition of cholesterol biosynthesis, increased fecal bile acid secretion and stimulation of receptor mediated catabolism of ldl cholesterol and increase in the uptake of ldl from blood by the liver. heart tissue injury induced by iso in rats was indicated by elevated level of the marker enzymes such as serum. (10,11,12) wheat grass by virtue of its avonoids and phenolics, effectively protected the heart and vessels from induced damage. hence wheat grass extract can become an effective therapeutic agent for treatment of dyslipidemia. to conclude, the present result suggests that triticum aestivum has a favourable effect on lipid prole. wheatgrass extract can be a good alternative or primary therapy in treating dyslipidemia. . references: 1. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight 2. https://www.heart.org/-/media/les/health-topics/cholesterol/chlstrmn gmntgd_181110.pdf 3. kannel wb. lipids, diabetes, and coronary heart disease: insights from the framingham study. american heart journal 1985;110(5):1100-7 4. pickering tg. pathology of exercise hypertension.herz .1987;12:11924.[pubmed :2953661] 5. kyrou i, chrousos gp, tsigos c. stress, visceral obesity, and metabolic complications. ann n y acad sci.2006;1083:77-110.[pubmed :17148735] 6. wofford mr, hall je. pathophysiology and treatmengt of obesity hypertension. curr pharma design . 7. brenda m davy, kevin p davy1comparison of assessment techniques: plasma lipid and lipoproteins related to the metabolic syndromelipids health dis. 2006; 5: 3. 8. padalia s, drabu s, raheja i, gupta a, dhamija m. multiple potential of wheatgrass juice (green blood): an overview. chron young scientist 2010; 1: 23-28. 9. sri jaya m, gayathri s. antioxidant activity of wheatgrass & impact of supplementing grass extract anaemics. biomed 2009; 4: 262-268. 10. koti bc, vishwanathswamy ah, wagawade j, thippeswamy ah. cardioprotective effect of lipistat against doxorubicin induced myocardial toxicity in albino rats. indian j exp biol. 2009;47:41–6. 11. otunola ga, oloyede ob, oladiji at, afolayan aa. effects of diet-induced hypercholesterolemia on the lipid prole and some enzyme activities in female wistar rats. afr j biochem res 2010; 4:149-154. 12. rukkumani r, aruna k, varma ps, menon vp. ferulic acid, a natural phenolic antioxidant modulates altered lipid proles during alcohol and thermally oxidized sunower oil induced toxicity. j nutraceut function med food. 2005; 4: 119 -132. 06.t s ambujam.cdr introduction general anaesthesia with neuromuscular paralysis is a common anaesthetic technique. neuromuscular blocking drugs interrupt transmission of nerve impulses at neuromuscular junction (nmj), aid endotracheal intubation and prevent patient movement to facilitate surgery. nondepolarizing neuromuscular blocking agents [nmba] competitively inhibit acetylcholine; differ in the onset & duration and method of action, potency, adverse effects and cost. benzylisoquinolone compounds atracurium and cisatracurium are intermediate acting non-depolarizing [1] nmbs. monitoring of neuromuscular blockade helps to detect the depth of neuromuscular blockade and adequacy of recovery of neuromuscular function following injection of [2,3] muscle relaxants. the response to train of four stimulation (tof) is the gold standard in monitoring the level of paralysis [4] following use of non-depolarizing muscle relaxant. the time between disappearance of the response and appearance of the rst twitch will be taken as the duration of intense paralysis. this study is designed to compare the difference in the duration of intense muscle paralysis following the initial paralyzing dose of the two agents in indian population. methodology after obtaining clearance from the scientic and ethical committees of the institution, the study was undertaken. inclusion criteria asa 1 & 2 physical status patients coming for elective surgery under general anesthesia with controlled ventilation ÿ age 18 -58 yrs. exclusion criteria: ÿ asa iii & iv ÿ patients coming for emergency surgeries ÿ patients not willing to participate in the study. ÿ pregnant patients it is a prospective, randomized, controlled, double blinded, interventional study comparing cisatracurium and atracurium. randomization was done using computer generated random numbers. all patients were given tab. alprazolam 0.25 mg night before surgery. all patients were pre-medicated with inj. ondensetron 4mg iv, inj. pantoprazole 40 mg iv half an hour prior to surgery. the pulse rate, nibp, ecg, spo noted. the peripheral nerve stimulator (pns) was 2 used for neuromuscular monitoring. patients were preoxygenated with 100% oxygen for 3 min.all patients were induced with propofol (2mg/kg) iv, followed by fentanyl (2mcg/kg) iv. a tof stimulus was delivered after induction to note baseline response and then the calculated dose of cisatracurium or atracurium was given. ÿ group a: cisatracurium 0.1mg /kg body weight iv ÿ group b: atracurium 0.5mg/kg body weight iv. a tof stimulus was delivered every 30 seconds, laryngoscopy and intubation was performed as soon as the response to tof stimulus had disappeared. thereafter a tof stimulus was delivered every 5 mins till 20 mins after intubation. subsequently a tof stimulus was delivered every 2mins until the appearance of rst single twitch. the time between disappearance of the response and appearance of the rst twitch was taken as the duration of intense paralysis. results table 1: duration of intense paralysis (mins) duration of intense paralysis following induction of neuromuscular blockade using cisatracurium vs atracurium as assessed by train of four stimulation: a prospective randomised comparative double blind study original research paper dr renu devaprasath dr. jeyasekharan medical trust, nagercoil, tamilnadu, india-629003 x 15gjra global journal for research analysis anaesthesiology background: this study was undertaken to determine the duration of intense muscle paralysis after the initial paralyzing dose of cisatracurium and atracurium which are intermediate acting nondepolarizing neuromuscular blocking agents. methods: after obtaining informed consent, 84 asa 1 and 2 patients, 18 to 58 years scheduled for elective surgery under general anaesthesia with paralysis were included in the study. patients were randomized to receive either atracurium 0.5 mg /kg or cisatracurium 0.1 mg /kg to facilitate tracheal intubation. premedication and induction were similar for all patients .the duration of intense paralysis was assessed by delivery of supramaximal train of four (tof) stimuli on the adductor pollicis using a peripheral nerve stimulator.the time between disappearance of the response and reappearance of the rst twitch in tof was taken as the duration of intense paralysis. results: there was a statistically signicant difference in the duration of intense paralysis between the two drugs. the duration of intense paralysis of cisatracurium was longer than atracurium with no statistical difference in onset of action. conclusion: although both atracurium and cisatracurium are intermediate acting non-depolarizing drugs cisatracurium provides longer duration of intense paralysis than atracurium. abstract keywords : atracurium, cisatracurium, train of four volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr alex francisco nicholas* dr. jeyasekharan medical trust, nagercoil, tamilnadu, india-629003 *corresponding author dr jeyanthan t dr. jeyasekharan medical trust, nagercoil, tamilnadu, india-629003 dr t.s. ambujam dr. jeyasekharan medical trust, nagercoil, tamilnadu, india-629003 dr syed rubiya sultana dr. jeyasekharan medical trust, nagercoil, tamilnadu, india-629003 atracurium cis-atracurium student's t-test duration of intense paralysis (mins) mean sd mean sd t p value 28.48 3.58 48.93 3.47 -26.610 <0.001 16 x gjra global journal for research analysis graph 1: duration of intense paralysis there was a signicant difference between the two groups in terms of duration of intense paralysis (mins). table 2: time to onset of intense paralysis (mins) graph 2: onset of intense paralysis there was no signicant difference between the two groups in terms of time to onset of intense paralysis (mins). discussion two non-depolarising muscle relaxants of intermediate duration of action , atracurium and cisatracurim were compared in this study in terms of duration of intense paralysis and onset of action. hemodynamic parameters including systolic blood pressure, diastolic blood pressure and heart rate were monitored. maximum duration of action of atracurium is suggested to be 25-30 minutes and cisatracurium to be 30-35 minutes with their equipotent doses. in this study mean duration of intense paralysis in cisatracurium group was 48.93 minutes with a dose of 0.1mg/kg which was more and statistically signicant (p < 0.001) as compared to 28.48 mins minutes in atracurium group with dose of 0.5mg/kg. [5] similar results were observed by el –kasaby et al. bluestein and colleagues in their study observed that increasing the dose of cisatracurium (from 0.1 to 0.15 and 0.2 mg/kg) increases the mean time of clinically effective duration (45 to [47]55 and 61 min, respectively). c.e. smith, compared duration of action of cisatracurium 0.1mg/kg and atracurium 0.5mg/kg [6] and found no statistical signicance. in our study mean onset of action in cisatracurium group was 3.25 minutes and atracurium group was 3.20 minutes which was not statistically signicant. el –kasaby et al in his study while comparing 3 groups of cisatracurium in different doses(2×ed95, 4×ed95, 6×ed95 dose) with 1 group of atracurium (2×ed95 dose). they observed that with the higher doses of cisatracurium (4×ed95 and 6×ed95) onset of [5]action was signicantly faster than with atracurium. in this study we found that, both groups had no signicant difference in terms of change of pulse rate, no signicant difference in terms of change of systolic bp, as evident by the results of 2-way repeated measures anova. there was a signicant difference between the two groups in terms of change of diastolic bp, as evident by the results of 2-way repeated measures anova. there was fall of diastolic bp in the patients treated with cis-atracurium. el –kasaby et al in his study reported that hemodynamic stability for both heart rate and mean arterial blood pressure were more evident even [5]with higher doses of cisatracurium. in this study we found that, two patients in atracurium group had skin rashes and bronchospasm. similarly a. m. elkasaby, in his study while comparing atracurium with different doses of cisatracurium observed similar results where 2 case who received atracurium had signs of histamine [5]release. also basta sj et al reported that atracurium releases histamine when doses of 0.5 mg/kg (two times ed95) [7]or more are injected rapidly. conclusion this study concluded that there was a statistically signicant difference in the duration of intense paralysis between the two groups .cisatracurium had a longer duration of intense paralysis compared to atracurium. there was no statistically signicance difference in the onset of intense paralysis between the two groups. conicts of interestsauthor declares no conict of interest. funding no funding agency ethical approval obtained informed consentobtained acknowledgements i would like to thank the patients for cooperating with us throughout the study period. i thank the department of anaesthesia for helping in conducting and publishing this study. references th 1. miller rd. neuromuscular monitoring. in:miller's anaesthesia. vol.1. 7 edition. viby-mogensen j; elsevier, 2010; 1515-1529. 2. murphy g, brull s. residual neuromuscular block. anesthesia & analgesia. 2010;111(1):120-128. 3. naguip m: pharmacology of muscle relaxant and their antagonist neuromuscular physiology and pharmacology. in: miller rd, anaesthesia; 7th edition. churchil livingston: philadelphia, 2006.481-572. 4. murphy g, szokol j, marymont j, greenberg s, avram m, vender j. residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. anesthesia & analgesia. 2008; 107(1):130-137. 5. atef h, helmy a, el-nasr m, el-kasaby a. cisatracurium in different doses versus atracurium during general anesthesia for abdominal surgery. saudi journal of anaesthesia. 2010;4(3):152. 6. smith c, van miert m, parker c, hunter j. a comparison of the infusion pharmacokinetics and pharmacodynamics of cisatracurium, the 1rcis 1�r cis isomer of atracurium, with atracurium besylate in healthy patients. anaesthesia. 1997;52(9):833-841. 7. basta s, ali h, savarese j, sunder n, gionfriddo m, cloutier g et al. clinical pharmacology of atracurium volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra atracurium cisatracurium student's ttest time to onset of intense paralysis (mins) mean sd mean sd t p value 3.20 0.27 3.25 0.25 -0.831 0.408 introduction leprosy is a chronic infectious disease caused by bacterial specie 'mycobacterium leprae' usually effecting nerve, skin, eyes and nasal mucosa. it is an age old disease, described in the literature of ancient civilizations. [1] despite a signicant reduction in the prevalence of leprosy in india, the social stigma still exists which provides a major setback for eradication of leprosy. leprosy has long been seen as the epitome of stigmatization and has become a metaphor for degradation in colloquial english. [2] stigma can be dened as an attribute that is deeply discrediting, and the stigmatized individual is one who is not accepted and is not accorded the respect and regards of his peers; one who is disqualied from full social acceptance. [3] stigma has a pervading affect on a patient's life, affecting marriage, employment, interpersonal relationships, leisure activities and attendance at social and religious functions. in a culture where a person is valued by the ability to support their dependents, unemployment because of leprosy can be an enduring effect not only economically but psychosocially too. [4] the stigma related to leprosy is often even more destructive than the health condition itself leading to shame, anxiety and a lack of self condence which can even result in suicide. [3] patients may nd it difcult to value themselves and have a positive selfimage. the self-loathing associated with leprosy can be permanent and persisting even after the disease is cured. [5] leprosy will never be eradicated if patients continue to delay initial presentation for fear of being shunned by society. aimto determine the deeper reasons for stigma through focus group discussion (fgd) amongst leprosy patients. material and methods the study was undertaken at dr. bandorwala leprosy hospital, kondhwa, pune. the hospital provides preventive, curative, referral and rehabilitative services to leprosy patients under a single roof. study design: cross-sectional, nonrandom with a qualitative approach study period: may 2017 study subjects: leprosy patients of age 18 or more years attending bandor wala leprosy hospital methodology the study was approved by institutional ethics committee (ecr-518).written permission from the concerned authority was obtained before the start of the study. the purpose of the study was explained to the respondents, after which written informed consent was obtained. focus group discussion (fgd) was conducted amongst 20 leprosy patients to understand the reasons for development of stigma in leprosy. the session of fgd was conducted at bandorwala's leprosy hospital in a separate room. different domains i.e. concealment of the disease, social participation, self-esteem and discrimination were considered as themes for fgd to investigate the deeper reasons for stigma. frequency of the answers for different domains was considered as evidence for the formulation of conclusion. results focus group discussion (fgd) was conducted among 20 leprosy patients to explore reasons leading to stigma amongst leprosy patients. demographic prole revealed the mean age of the leprosy cases to be 57.85 years ± 14.88 s.d. out of 20 patients attending fgd session, 13 were males and 7 were females. a large proportion of leprosy cases i.e. 58% were illiterate. around half (49%) of the leprosy cases were married and the remaining were widow/ widower (19%), divorced/ separated (18%) and unmarried (14%). the most frequent reasons for the stigma described by the leprosy patients were:1) concealment of the disease:majority of the cases (19 out of 20) believed that they had concealed leprosy from the society. all of the cases described that they were asked by their family members not to reveal the disease as the family members feared that it would be difcult for them to get married if the society comes to know about the leprosy patient in the family. one of the patient's grandmother asked the patient not to reveal the disease as it might stop people from visiting their house for the fear of getting infected by leprosy. as described by a 60 year old male patient “every leprosy patient tries to hide the disease from the society as a fear of possible discrimination by the society but it is difcult to hide the disease when the deformities develop. i even tried to hide the deformities initially by narrating to the people that the deformity of my nger is due to the result of an injury i received while ddling with a bicycle chain”. qualitative approach to explore stigma amongst leprosy patients original research paper dr. omair aziz wani demonstrator department of community medicine govt. medical college srinagar x 5gjra global journal for research analysis community medicine introduction:leprosy is a chronic infectious disease caused by bacterial specie 'mycobacterium leprae' usually effecting nerve, skin, eyes and nasal mucosa. despite a signicant reduction in the prevalence of leprosy in india, the social stigma still exists which provides a major setback for eradication of leprosy. aim: to determine the deeper reasons for stigma through focus group discussion (fgd) amongst leprosy patients. material and method:the study was undertaken at dr. bandorwala leprosy hospital, kondhwa, pune. focus group discussion (fgd) was conducted amongst 20 leprosy patients to explore the deeper reasons for stigma. results: negative societal behavior and a perception of being talked about negatively and looked down upon by the society causes reduction in self pride and self-esteem of the leprosy patients. fear of possible discrimination especially after the development of disabilities plays an important role in concealment of the disease of leprosy, leading to stigma. abstract keywords : stigma, leprosy, focus group discussion volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 6 x gjra global journal for research analysis in fear of stigmatization by the society which already exists, the cases try to conceal the disease. 2) social participation:leprosy may prevent a person from participating in the social events like marriage ceremonies, fairs and pooja or prayers held in the community. fear of getting discriminated by the society was mainly perceived after the development of deformities and was described as a major reason causing hindrance in social participation. one of the patient, a 58 year old male recalls that “after the development of ulcer on my leg, i stopped attending the social gatherings as i felt the bad odour coming out from ulcer may distract the people”. restriction from social participation can also arise from the negative attitude of society towards leprosy patients during social gatherings. majority of the patients (17 out of 20) were asked to stay in a separate room when they attended a social gathering as the people feared of getting infected from leprosy. a 35 year old patient revealed that while performing ablution for congregational prayers, the priest of the religious place noticed deformity on his arm. the patient heard the priest saying that he must not be allowed to offer prayers in congregation as it may result in others getting infected with leprosy. 3) self-esteem:self-esteem can be severely dented by leprosy. majority of the patients regard negative societal behavior as being a reason for low self-esteem. one of the patients, a 25 year old female describes social isolation as being the cause for loss of self-esteem and had experienced more alienation from the illiterate people as compared to the literate people. similar feeling was narrated by a 40 year old male patient who describes that mostly the illiterate people tend to stay away from him as compared to the literates. a perception that the people discuss negative things related to leprosy on noticing a leprosy person and avoid contact with a leprosy person, was regarded by three patients as the cause for the loss of self-esteem. 4) discrimination:feeling of getting discriminated can be one of the reasons for development of stigma amongst leprosy patients. a sense of inferiority creeps in the minds of leprosy patients as described by one of the patients that “my son, a graduate by education, may not get an appropriate match for marriage because of me as the people look down upon the family of leprosy patients, so we usually marry in leprosy family”. stigma can also arise from the misconception and negative attitude of family members toward the leprosy patients. one of the patients recalls that her mother did not talk to her on knowing that she has been diagnosed with leprosy. her mother regarded leprosy as a punishment of sins from god and asked the patient to perform sacrice of goat as a repent for her sins. another patient a 60 year old male in his words said “people run away from me because they feel i am suffering from a disease which is like tuberculosis and fear that i may transmit the disease by coughing”. the discrimination could also be real in nature. majority (18 out of 20) patients experienced of being avoided and discrim inated by the society at one time or the other. ten patients revealed that they were served tea in a separate glass or were asked to get a glass of their own while visiting a tea stall. one of the patient recalls that “the manager of a hotel did not serve me tea because of the disease even on showing him the certicate of getting cured from leprosy. the manager although knowing that i am cured and cannot transmit the disease asked me to stay away from the hotel because the manager thought that he might loose the customers on seeing a leprosy patient drinking tea besides them”. a 40 year old female narrated that while catching an auto rickshaw for leprosy hospital, the driver of the auto rickshaw on hearing the name of leprosy hospital immediately looks for deformity in the patient, and if deformity is present the rickshaw driver refuses to carry the patient to the hospital probably for the fear of getting infected the discrimination by the leprosy patients was even faced in the hospitals. couple of patients revealed that while visiting other hospitals for treatment for the ailments other than leprosy, the health professionals of the hospitals did not treat them fairly on knowing that the patients suffer from leprosy. the patients were asked to get treatment of other ailments from the leprosy hospital. conclusions majority of the leprosy patients faced discrimination from the society and family members which indicates the misconcept ions about leprosy in the community. discrimination towards leprosy acts as an important factor in development of stigma as it leads to the sense of being inferior amongst leprosy patients. inuence of family members seems to have a big impact on the leprosy patients in concealing the disease of leprosy. references: 1. w.h.o. list of tropical neglected diseases. available from www. who.int/ lep/en/. accessed on 05/06/ 2016. 2. harris k. pride and prejudice-identity and stigma in leprosy work. lepr rev 2011; 82(2): 135-46. available from https://www.ncbi.nlm.nih.gov/ pubmed/21888138. accessed on 15/06/2017. 3. arole s, premkumar r, arole r, maury m, saunderson p. social stigma; a comparative qualitative study of integrated and vertical care approaches to leprosy. lepr rev 2002; 73: 186-96. available from https://www.lepra.org.uk/ platforms/lepra/les/lr/june 02/ 0010.pdf. accessed on 15/08/17. 4. adhikari b, kaehler n, raut s, marahatta sb, ggyanwali k, chapman rs. risk factors of stigma related to leprosy-a systematic review. journal of manmohan institute of health sciences 2014; 1(2): 3–11. available from http://www.nepjol.info/index.php/jmmihs/article/viewfile/9902/8077. accessed on 20/09/17. 5. rafferty j. curing the stigma of leprosy. leprosy review 2005; 76(2): 119–26. available from https://www.lepra.org. uk/platforms/lepra/les/lr/ june05/150523.pdf. accessed on 5/05/17 volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction ÿ there are many drugs which have been used as adjuvants to local anesthetic agents to prolong the duration of peripheral nerve blocks. dexmedetomidine is [1]a new α2 agonist approved by fda in 1999 .low plasma concentration results in analgesia, [2]sympatholysis and mild sedation without any respiratory depression. perineural dexmedetomidine causes augmentation of local anesthetic effect without [3]causing nerve damage . ÿ hyaluronidase has temporary reversible depolymerizing [4]action on polysaccharide hyaluronic acid which is a important component of intercellular matrix. it improves the dispersal of solution and is used for [5][6]retrobulbar block to reduce the latency of anesthesia, attenuate an increase in intraocular pressure and to improve the spread of local anesthetic in orbit. ÿ considering these facts we carried out this study to evaluate the effect of addition of dexmedetomidine and hyaluronidase to local anes thet ic mix ture in supraclavicular brachial plexus block on the sensory and motor block characteristics with duration of perioperative analgesia .the study also observes the effects of dexmedetomidine and hyaluronidase on pulse rate,blood pressure,respiratory rate,spo2,ramsay sedation score ,side effects and complications . aims and objectives: ÿ primary objectives: 1) to evaluate the effect of addition of dexmedetomidine and hyaluronidase to local anesthetic mixture on the pattern of sensory and motor block: onset of sensory and motor block, peak effect , duration of blockade and on duration of perioperative analgesia. 2) to evaluate and compare the hemodynamic parameters and sedation score in the two groups respectively. secondary ojectives: 1) to study the side effects and complications related to dexmedetomidine and hyaluronidase if any. material and methods the present prospective randomized study was conducted in department of anesthesia; gmc bhopal and associated hamidia hospital in patients posted for upper limb orthopedic surgeries under supraclavicular brachial plexus block. after approval by institutional ethical committee and written informed consent; 40 patients of asa grade 1 and 2 posted for a comparative evaluation of dexemedetomidine and hyaluronidase used as adjuvants to local anaesthetics for supraclavicular brachial plexus block original research paper uditi parmar senior resident department of anaesthesiology, gandhi medical college, bhopal, madhya pradesh, india anaesthesiology background: dexmedetomidine is a new alpha 2 agonist approved by fda in 1999.low plasma concentration results in analgesia ,sympatholysis and mild sedation without any respiratory depression. perineural dexmedetomidine causes augmentation of local anesthetic effect without causing nerve damage. hyaluronidase has temporary reversible depolymerising action on polysaccharide hyaluronic acid which is a important component of intercellular matri aim: primary objectives: 1) to evaluate the effect of addition of dexmedetomidine and hyaluronidase to local anesthetic mixture on the pattern of sensory and motor block: onset of sensory and motor block, peak effect , duration of blockade and on duration of perioperative analgesia. 2) to evaluate and compare the hemodynamic parameters and sedation score in the two groups respectively. secondary ojectives: 1)to study the side effects and complications related to dexmedetomidine and hyaluronidase if any. material and method: it was a randomized, prospective, double blinded, comparative hospital based study at department of anaesthesiology, gandhi medical college, bhopal. 40 asa grade i-ii patients, age ranging from 20-40 years of either sex, scheduled for upper limb orthopaedic surgeries were randomly allocated into two groups of 20 patients each: ÿ group d-inj bupivacaine(0.5%)1mg/kg+inj lignocaine(2%)3mg/kg+inj dexem (50micrograms)diluted upto 20ml. ÿ group h-inj bupivacaine(0.5%)1mg/kg+inj lignocaine(2%)3mg/kg+inj hyaluronic acid 3000iu diluted upto 20ml. results: there was signicant decrease in time to each the sensory and motor block in group d as compared to group h with prolonged duration of sensory and motor block and reduction in post operative analgesic requirement in group d as compared to group h(p< 0.05) which shows that dexmedetomidine (50mcg) was effective as adjuvant to local anesthetics in early onset and prolonged duration of sensory and motor block. the duration of analgesia was signicantly higher in the patients belonging to the group d. likewise, the average number of rescue analgesic doses received by group h patients were more compared to patients in group d. conclusion: from our study we conclude that dexmedetomidine 50 mcg is signicantly superior to hyaluronidase 3000iu as adjuvant to local anesthetics for supraclavicular brachial plexus block.in patients undergoing upper limb orthopaedic surgeries. abstract keywords : dexmedetomidine, hyaluronidase , supraclavicular brachial block. rajni thakur* associate professor(designated) , department of anaesthesiology, gandhi medical college, bhopal, madhya pradesh, india *corresponding author volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 72 x gjra global journal for research analysis upper limb orthopedic surgeries; age ranging from 20-40 years were taken. patients were randomnly divided into 2 groups of 20 patients each. the randomization was done on the basis of chit and envelop method. ÿ group d-inj bupivacaine(0.5%)1mg/kg+inj lignocaine (2%)3mg/kg+inj dexem (50micrograms) diluted upto 20ml. ÿ group h-inj bupivacaine(0.5%)1mg/kg+inj lignocaine (2%)3mg/kg+inj hyaluronic acid 3000iu diluted upto 20ml. ÿ patient exclusion criteria: 1) patient refusal 2) known hypersensitivity to local anaesthetics 3) known case of major bleeding disorders 4) patient on anticoagulant therapy. 5) local infection, pre existing neurological disorders and nerve palsy. ÿ in the operation theatre, intravenous line, pulse oximeter, electrocardiography and a non invasive blood pressure monitor was attached. baseline parameters hr, sbp, dbp, map, spo2 and ecg were noted. ÿ patients were premedicated with inj. ondansetron 0.08mg/kg and after thorough explanation of the procedure, maintaining strict asepsis supraclavicular brachial plexus block was performed using nerve stimulator technique. ÿ after completion of supraclavicular brachial plexus block; hr, sbp, dbp, map, spo2 were again noted and sedation was assessed using ramsay sedation score at 2min, 5min and 10 minutes thereafter for every 10 minutes for 1 hour and then every 20 minutes thereafter till end of surgery. ÿ sensory block was assesed along the different nerve territories as: ÿ median nerve:along thenar eminence ÿ radial nerve:lateral side of dorsum of hand ÿ ulnar nerve:little finger ÿ musculocutaneous nerve:lateral border of forearm over site of radial artery. ÿ sensory block assessment was done using 3 point scale:0)normal sensation 1)loss of sensation to pinprick(analgesia) 2)loss of sensation to touch(anesthesia) assessment of motor block was done as follows: ÿ radial nerve:thumb abduction,extension at elbow and wrist. ÿ median nerve:thumb opposition ÿ ulnar nerve:thumb adduction ÿ musculocutaneous nerve:flexion at elbow. effect of sensory and motor block and post operative analgesia were assessed every 30 minutes for rst 2 hours ,every 60 minutes for next 4 hours and then at 9, 12,18 and 24 hours.pain was assessed using 10 point visual analogue score.rescue analgrsia was given in the form of inj diclofenac sodium 1.5mg/kg im when vas score was noted as >4 ÿ complication due to procedures like hematoma, pneumothorax, inadverent arterial puncture, post block neuropathy, hypotension, bradycardia, respiratory depression, dry mouth , hypersensitivity or local anesthetic toxicity were looked for. ÿ hypotension is defined as fall in sbp more than 20% from pre operative value. ÿ bradycardia is defined as fall in pulse rate of more than 20% from pre operative value. ÿ respiratory depression is defined as fall in spo2 less than 90% or respiratory rate less than 10/min statistical analysis the data was compiled and subjected to stastical analysis. results are tabulated and analyzed using spss software. student t test is used for continuous variables and chi square test for discrete variables is applied. results are expressed as mean±sd p value<0.05 will be considered signicant and p value<0.01 will be considered highly signicant. observation and results demographic parameters the group under study were comparable with regards to age, gender and asa status. sample size was taken on the basis of power of study and data was analyzed using t test and chie square test. 2)comparison of sensory and motor block characteristics between the two groups. 3)evaluation of postoperative analgesia volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra no of patients age(years) mean+sd gender (m:f) asa status 1/2 group d 20 32+11 12:8 12/8 group h 20 32+10.4 14:6 14/6 onset of sensory block(mi nutes) peak effect (minut es) duration of sensory block(min utes) onset of motor block(mi nutes) peak effect(mi nutes) duration of motor block(mi nutes) group d 1.9+0.8 4.8+1.8 622+166.4 2.9+0.9 6.2+2.1 432+130.3 group h 4.2+1.2 10+2.8 260.4+60.4 5.6+1.2 9.8+3.2 180+46.4 p value 0.038 0.046 0.042 0.032 0.045 0.037 duration of analgesia( minutes) time for 1st rescue analgesia(m inutes postoperativ ely) number of doses of analgesia required 24 hours postoperatively 0 1 2 3 group d 536+33.46 580 6patients 4 10 0 group h 380+84.60 420 2patients 8 8 2 p value 0.0001 0.046 0.042 0.0018 0.004 0.0001 x 73gjra global journal for research analysis perioperative hemodynamic parameters in the two groups respectively: the hemodynamic parameters including heart rate, systolic blood pressure and diastolic blood pressure were comparable in both the groups in preoperative, intraoperative and in postoperative period and there was no signicant difference in hemodynamic parameters in the two groups respectively with p value being insignicant(p>0.05) comparison of sedation scales between two groups: the ramsay sedation score was comparable in both the groups throughout the intraoperative period(p value>0.05) . discussion dexmedetomidine, the pharmacologically active d-isomer of medetomidine is a highly specic and selective �2 [1][2]adrenoceptor agonist with �2:�1 binding selectivity ratio of 1620:1 as compared to 220:1 for clonidine, thus decreasing the unwanted side effects of �1 receptors. presynaptic activation of �2 adrenoceptor in central nervous system (cns) inhibits the release of norepinephrine, terminating the propagation of pain signals and their postsynaptic activation inhibits sympathetic activity, thereby decreasing hr and bp. because of its effects on spinal α2 receptors, it prolongs analgesia when used with local anesthetics. yoshitomi et al., demonstrated that dexmedetomidine as well as clonidine enhanced the local anesthetic action of lignocaine via [7]peripheral α-2a adrenoceptors. masuki ., suggested that dexmedetomidine induces et al vasoconstriction via 2 adrenoceptors in the human forearm α [8] possibly also causing vasoconstriction around the site of injection, delaying the absorption of local anesthetic and hence prolonging its effect. esmaoglu ., reported et al prolongation of axillary brachial plexus block when dexmedetomidine was added to levobupivacaine[9]. hyaluronidase degrades hyaluronic acid, promoting the ow [4]of drugs through tissue . it has been available as an additive to local anesthetic solutions since 1948. its most common anesthesia application is in ophthalmic cases. hyaluronidase depolymerises hyaluronic acid, which is a major component of the extracellular matrix[5]. through this mechanism of action, hyaluronidase is known to accelerate the onset and improve the quality of anaesthesia for retrobulbar, peribulbar and subcutaneous inltration blocks by increasing the spread and dispersion of local anaesthetics [10-11]. this point may be particularly relevant for supraclavicular brachial plexus block, since incomplete blocks are generally attributed to limited spread of local anesthetic uid due to connective tissue barriers within the brachial plexus sheath in the present study, the addition of dexmedetomidine (50mcg) to local anesthetic mixture signicantly shortened the time to achieve complete sensory block and surgical anaesthesia,as compared to addition of 3000iu of hyaluronidase to local anesthetic mixture for supraclavicular brachial plexus block. therefore reducing the anaesthetic time before the start of the operation. the duration of perioperative analgesia was more in group d as compared to group h. the use of hyaluronidase reduced the duration of the sensory block. the duration of motor block analgesia were also reduced and it was statistically signicant. there was signicant difference in the total administered dose of postoperative analgesic medication in the two groups respectively. the patients in group h had more analgesic requirements as compared to group d and the difference was statistically highly signicant. a previous study reported the effect of the addition of hyaluronidase to bupivacaine 0.5% for axillary brachial plexus blocks [12]. in that study, 3000 iu hyaluronidase mixed with bupivacaine signicantly reduced the duration of the sensory and motor block, and had no effect on the number of patients experiencing a complete sensory block after 30 min. these results were similar to those obtained in the present study, as success rates for surgical anaesthesia were similar between the two experimental groups tested, while the duration of sensory anaesthesia was signicantly shorter in the hyaluronidase group and the duration of motor block showed a shorter trend. however, the former study performed pinprick tests only twice, at 15 and 30 min after the block placement, so the exact time of complete sensory block was not measured. furthermore, the block was conducted via the landmark-guided technique without the use of a nerve stimulator or ultrasound guidance. in the present study we have used dexmedetomidine(50mcg )in dose that causes earlier onset and prolonged duration of sensory and motor block with better postoperative analgesia with out any side effects . hemodynamic parameters were comparable in both the groups with p value being insignicant(p>0.05).none of the patients in the two groups showed hypotension, bradycardia or respiratory depression. we have also compared the ramsay sedation scale in the groups and it was also comparable in both the groups with p value being insignicant. none of the patients were deeply sedated in the two groups . reports of adverse effects associated with hylauronidase are rare, with most reported adverse effects involving allergic reactions to hyaluronidase no adverse effects were [13]. associated with the use of hyaluronidase in the present study. conclusion dexmedetomidine in comparison to hyaluronidase when added in supraclavicular brachial plexus block leads to : volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra ramsay sedation score group d group h 1 0 0 2 12 11 3 8 9 4 0 0 5 0 0 6 0 0 74 x gjra global journal for research analysis early onset and prolonged duration of sensory and motor block, prolonged duration of analgesia and decreased need for post operative analgesics with adequate intraoperative sedation with stable perioperative hemodynamics. thus dexmedetomidine can be used as a safe and effective adjuvant to local anesthetics in supraclavicular brachial plexus block to provide excellent peri-operative analgesia with minimal side effects. funding, financial disclosure, compensation: none conicts of interest: none references 1. virtanen r, savola jm, saano v, nyman l. characterisation of selectivity, specicity and potency of medetomidine as an alpha 2-adrenoceptor agonist. eur j pharmacol 1988;150:9-14 2. shehabi y, ruettimann u, adamson h, innes r, ickeringill m. dexmedetomidine infusion for more than 24 hours in critically ill patients: sedative and cardiovascular effects. intensive care med 2004;30:2188-96. 3. yazbek-karam vg, aouad ma. perioperative uses of dexmedetomidine. middle east j anesthesiol 2006;18:1043-58. 4. nathan n, benrhaiem m, lot h, et al. the role of hyaluronidase on lidocaine and bupivacaine pharmacokinetics after peribulbar blockade. anesthesia and analgesia 1996; 82: 1060–4. 5. lewis-smith pa. adjunctive use of hyaluronidase in local anaesthesia. british journal of plastic surgery 1986; 39: 554–8. 6. dunn al, heavner je, racz g, day m. hyaluronidase: a review of approved formulations, indications and off-label use in chronic pain management. expert opinion on biological therapy 2010; 10: 127–31. 7. yoshitomi, tatsushi dds*; kohjitani, atsushi dds, phd†; maeda, shigeru dds, phd*; higuchi, hitoshi dds, phd*; shimada, masahiko dds, phd‡; miyawaki, takuya dds, phd dexmedetomidine enhances the local anesthetic action of lignocaine via an �2a adrenoreceptor. july 2008 volume 107 issue 1 p 96-101 8. masuki s, dinenno fa, joyner mj, eisenarch jh. selective alpha2-adrenergic properties of dexmedetomidine over clonidine in the human forearm. j appl physiol. 2005;99:587–92. 9. aliye esmaoglu;fusun yegenoglu;aynur akin;cemil turk et al dexmedetomidine added to levobupicaine prolongs axillary plexus block. anesthesia & analgesia. 111(6):1548–1551, december 2010. 10. moore dc (1950) an evaluation of hyaluronidase in local and nerve block analgesia: a review of 519 cases. anesthesiology 11: 470-484. 11. eckenhoff je, kirby ck (1951) the use of hyaluronidase in regional nerve blocks. anesthesiology 12: 27-32. 12. keeler jf, simpson kh, ellis fr, kay sp. effect of addition of hyaluronidase to bupivacaine during axillary brachial plexus block. br j anaesth 1992; 68:68–71. 13. kim tw, lee jh, yoon kb, yoon dm. allergic reactions to hyaluronidase in pain management − a report of three cases. korean j anesthesiol 2011; 60:57–59. volume-8, issue-9, september-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 75gjra global journal for research analysis introduction central venous catheters (cvcs) are an integral part of patient care in the intensive care unit (icu). cvcs are often used as a portal for the delivery of medications, parenteral nutrition, collection of blood samples and monitoring hemodynamic variables in cr i t ical ly i l l pat ients . however,complications associated with cvcs occur in nearly 15% of patients, mainly infectious complications (5-26%), mechanical complications (5-19%) and thrombotic complications (2-26%)[ 1]. these result in prolongation of icu and hospital stay, increased hospital costs, morbidity and mortality[2]. despite the advent of ultrasound-guided vascular cannulation, which has reduced the incidence of insertion complications drastically, many hospitals in india and other developing countries still rely on the landmark based technique for cannulation, which has a reported success rate of 7599%[3]. use of cvc puts patients at risk for local and systemic infectious complications, including local site infection, catheter related blood stream infections(crbsi), septic thrombophlebitis, endocarditis, and other metastatic infections (e.g., lung abscess, brain abscess, osteomyelitis, and endophthalmitis). crbsi constitute one of the major nosocomial device associated infections[4]. for the surveillance of device associated infections, the data needs to be expressed as the number of device associated infections per 1000 device days as per the recommendations from the center for disease control and prevention, usa[5]. however, there has been very little data reported from adult indian icus on the rates of complications associated with cvc insertion and use, especially of infectious complications. the magnitude of the potential for cvcs to cause morbidity and mortality resulting from infectious complications has been estimated in several studies. according to the national nosocomial infection surveillance system of the cdc the rate of catheter-related bloodstream infection in icus range from 1.8 to 5.2 per 1000 catheter-days[6]. the cost of cvcassociated bsi is substantial, both in terms of morbidity and in terms of nancial resources expended. to improve patient outcome and reduce health-care costs, strategies should be implemented to reduce the incidence of these infections. this effort should be multidisciplinary, involving health-care professionals who insert and maintain intravascular catheters, health-care managers who allocate resources, and patients who are capable of assisting in the care of their catheters,regular surveillance needs to be undertaken for the formulation of appropriate infection control practices. absence of in-house data leads to difculties in planning of local strategies to tackle the menace of catheter related complications esp crbsi. materials & methods study place the study was conducted in department of anaesthesiology of armed forces medical college, pune after approval from ethical committee and written consent taken from all patients before being included in the study. study population patients requiring cvcs admitted in adult surgical intensive care unit. 150 patients were included in study after meeting inclusion and exclusion criteria. study design it was prospective observational study. inclusion criteria all the patients who received a cvc (jugular/subclavian/ femoral) in the operation theatre either as a part of anaesthetic care or in the icu, were included in the study. exclusion criteria ÿ patients with obvious source of infection excluded (fever, pneumonia, urinary tract infection, cellulitis, septicemia) by history, clinical examination, blood culture, chest x-ray, urine examination, etc. and relevant investigations pertaining to the suspected infection. ÿ patients having infective endocarditis, retroviral disease and immunosuppressive drugs. ÿ cvc insertions performed on patients without verifying their coagulation prole (as in an emergency) or on patients with uncorrected coagulopathy were excluded from the study. to study the incidence of bloodstream infections related to central venous catheterisation in intensive care unit of a tertiary level hospital original research paper dr. abhishek shrivastava graded specialist, military hospital,fatehgarh,uttar pradesh,india anaesthesiology introduction: this study was designed to evaluate incidence of bloodstream infections related to central venous catheterisation in intensive care unit of a tertiary level hospital. material and methods: study placeintensive care unit of a tertiary level hospital study population-150 patients were included in study after meeting inclusion and exclusion criteria. all the patients who received a cvc (jugular/subclavian/femoral) in the operation theatre either as a part of anaesthetic care or in the icu, were included in the study. study designit was prospective observational study. result: this study revealed a total of 24.66% of cvc associated infections. this included exit site infections (5.33%), catheter tip infections (13.33%) and crbsi (6%). the rate of infections associated with central venous catheterization was 35.03 per 1000 catheter days. abstract keywords : volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. abhishek gupta* assistant professor, g r medical college,gwalior,madhya pradesh,india *corresponding author 48 x gjra global journal for research analysis methodology ÿ the study was conducted from may 2017 to jun 2018. approval and written permissions from the hospital ethics and research committee was obtained. all the patients who received a central venous catheter (jugular/ subclavian/femoral) in the operation theatre either as a part of anaesthetic care or in the icu were included in the study. appropriate consent also was taken either from the patients themselves or from the next of kin or a legal surrogate. ÿ cvc insertions performed on patients without verifying their coagulation prole (as in an emergency) or on patients with uncorrected coagulopathy were excluded from the study. ÿ baseline data on each patient, like primary diagnosis, presence of any comorbid illnesses, date of icu admission and apache ii score was recorded. for each cvc insertion, data was collected as per the proforma attached (annexure i). central venous cannulations were performed only when the platelet count was more than 50,000/cumm and the prothrombin time (international normalized ratio) was less than 1.5 s, as per the icu protocol. central venous catheterization ÿ hand disinfection using an antiseptic rub was preferred during catheter insertion. for the insertion of cvcs, full scrub (up to the elbows) with an antiseptic solution was used. the maximal sterile barrier precautions in the form of use of cap, mask, sterile gloves, full-sleeved sterile gown and large sterile drapes were used. to prepare clean skin, alcoholic chlorhexidine (2%) was used. all lines were placed percutaneously using the seldinger technique. the cvc was placed according to the indication of its insertion and was held in situ by using suture. sterile transparent dressing was used at the catheter site. ÿ all the cannulations were performed either by an icu consultant or anesthesiologist or by a 2nd or 3rd year resident (with a minimum prior experience of at least 20 cvc insertions, under the supervision of a consultant). the choice of the cvc insertion site (either ijv/scv/femoral) was left to the discretion of the performing doctor. ÿ hand hygiene procedures were strictly followed before and after injection, blood sampling, dressing or any contact with the cvc or insertion site. the dressings were changed every day, the site was inspected for purulence and erythema and palpated for tenderness and induration (local signs of cvc infection). ÿ the date,site and side of cannulation and the number of punctures required for successful cannulation as well as complications, if any, were noted for each insertion procedure. ÿ the details of type of placement(emergency/elective), technique of placement(landmark/ ultrasound guided), duration of placement (<72 h/>72 h), type of catheter (7 fr 01 lumen/7 fr 02 lumen/7 fr 03 lumen), infection at catheterinsertion site, signs of systemic infections were also noted. ÿ cvcs were removed when no longer required or when suspected to be infected. the total duration of cvc placement was also be recorded. the catheter tip was sent for microbiological analysis after removal. ÿ on suspicion of an insertion-site infection ( indicated by erythema/pus at the entry point), site swabs were sent for microbiological analysis. if catheter tip colonization/ infection or catheter-related blood stream infection (crbsi) was suspected, the cvc was removed and the distal 5 cm of the cvc was collected aseptically in a sterile test tube and transported immediately to the laboratory for culture. immediately subsequent to catheter removal, two sets of blood(10ml) were collected aseptically from two different peripheral sites ( right and left) for blood culture and sent for culture analysis. all cvc tips were cultured using the standard semi quantitative culture (sqc) method.. the type of micro-organism growth was also be recorded. ÿ catheter tip colonization was dened as growth of more than 15 colony forming units on culture of the distal segment of the cvc. negative semiquantitative culture technique a negative sqc result was dened as an sqc yielding less than 15 colony forming units (cfu) in the absence of positive blood culture. ÿ were dened as follows: catheter-associated infections ÿ erythema, tenderness, induration or exit site infectionpurulence within 2 cm of skin at the insertion site of catheter along with microbiological growth on culture of the purulent exudates. ÿ growth of more than 15 colony catheter tip infection forming units on culture of the distal segment of the cvc with clinical signs of infection but without associated bacteraemia. ((i.e. catheter tip colonization without associated bacteraemia) catheter related local infection (crli)it includes exit site infection and catheter tip infection. ÿ catheter-related bloodstream infections (crbsi/crbi)isolation of the same organism from the catheter tip culture (growth of more than 15 colony forming units) and from at least one of the two blood cultures, along with signs and symptoms of infection. (i.e. catheter tip colonization with associated bacteraemia) ÿ thus, patients with clinical signs of infection and in whom the cvc tip yielded a positive growth (but without associated bacteraemia) were considered as having catheter tip infections while patients with clinical evidence of infection along with positive growth of the same organism on blood culture as well as cvc tip were diagnosed to have crbsi. ÿ the rate of catheter associated infections was calculated as incidence i.e. percentage of patients who developed catheter associated infections out of total number of patients and incidence density (per thousand catheter days) i.e. number of patients who developed catheter associated infections per thousand catheter days. ÿ besides the data related to cvcs, the outcomes of all patients included in the study at the end of icu stay i.e. died or discharged, were also be recorded. statistical analysis after data collection, data entry was done in microsoft excel sheet. data analysis was done with the help of spss software version 20.0. quantitative data was presented with the help of mean and standard deviation. qualitative data was presented with the help of frequency, percentage. analysis or their signicance was done by using the p values obtained through chi square test. for statistical comparison, the difference was considered signicant when the p-value was found to be less than 0.05. results a total of 150 patients in the age group between 14 and 86 years of both genders with indwelling cvcs were included. of volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 49gjra global journal for research analysis 150 patients, 95 (63.33%) were males and 45 (36.66%) were females(table-1). the minimum age was 14 years and the maximum age was 86 years, with an overall mean age of 53.82 (±16.42) years(table-1). internal jugular route was used in 130 (86.66%) patients, subclavian route in 18 (12%) and femoral route in 2 (1.33%) patients(table-2). of the 130 patients who were having internal jugular venous catheters, 25 (19.23%) patients had catheter tip colonization and 8 (6.15%) patients had exit site infection. of the 25 patients who were having catheter tip colonization , 7 patients were of crbsi and 18 patients were of catheter tip infection. of the 18 patients who were having subclavian venous catheters, 4 (22.22%) patients had catheter tip colonization and out of these 4 patients, 2 patients were of crbsi and 2 patients were of catheter tip infection. of the 09 patients in which catheter duration was ≤3 days, 01 (11.11%) patient had catheter tip infection and 01 (11.11%) patient had exit site infection. of the 141 patients in which catheter placed for more than 3 days, 28 (19.85%) patients had catheter tip colonization and 7 (4.96%) patients had exit site infection. of the 28 patients who were having catheter tip colonization, 9 patients were of crbsi and 19 patients were of catheter tip infection. of the 12 patients in which catheter inserted as an emergency procedure, there was no colonization of catheter and 2 (16.66%) patients had exit site infection. of the 138 patients in which catheter inserted as an elective procedure, 29 (21.01%) patients had catheter tip colonization and 6 (4.35%) patients had exit site infection. of the 29 patients who were having catheter tip colonization, 9 patients were of crbsi and 20 patients were of catheter tip infection. of the 87 (58%) patients in which central venous catheterizations done in a single attempt, 11 (12.64%) patients had catheter tip colonization and 4 (4.59%) patients had exit site infection. of the 11 patients who were having catheter tip colonization, 3 patients were of crbsi and 8 patients were of catheter tip infection. of the 53 (35.33%) patients in which central venous catheterizations done in two attempts, 15 patients had catheter tip colonization and 4 (7.55%) patients had exit site infection. of the 15 patients who were having catheter tip colonization , 4 patients were of crbsi and 11 patients were of catheter tip infection. of the 10 (6.7%) patients in which central venous catheterizations done in three attempts, 03 showed catheter tip colonization and out of these 03 patients, 2 were of crbsi and 1 patient was of catheter tip infection. of 150 patients who were included in the study, 8 patients died and 142 patients dicscharged. volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table-3 variables associated with catheter associated blood stream infections table 1: univariate analysis camparing the demographic prole and insertion characteristics among different cannulation site variables studied total ijv scv femoral vein f score/chi square p value signicance total cvcs 150 130 18 2 84.76 0.00 signicant mean age (s.d.) 53.82(16.42) 54.07(16.32) 52 (17.47) 47.5(31.82) 0.27 0.767 not signicant gender (male/female) (95/55) (81/49) (13/5) (1/1) 0.67 0.413 not signicant apache ii score; mean (s.d.) 14.26(2.68) 14.28(2.76) 14.06(2.10) 15(1.41) 0.13 0.875 not signicant no. of punctures 1.49(0.62) 1.38(0.52) 2.28(0.75) 1.5(0.71) 21.13 0.00 signicant duration of central line 7.04(2.23) 6.85(2.04) 8.72(2.87) 4.5(0.71) 7.48 0.001 signicant table 2: prevalence of central catheter-related factors variables total percent chi square p value signicance site of catheterization subclavian vein 18 12.0 194.56 0.00 signicant femoral vein 2 1.3 internal jugular vein 130 86.7 type of procedure elective 138 92.0 105.84 0.00 signicant emergency 12 8.0 number of punctures 1 87 58.0 59.56 0.00 signicant 2 53 35.3 3 10 6.7 duration of central line less than or equal to 3 9 6.0 116.16 0.00 signicant greater than 3 141 94.0 side of insertion rt 139 92.7 109.23 0.00 signicant lt 11 7.3 usg/landmark landmark 127 84.7 72.11 0.00 signicant usg guided 23 15.3 type of cental line 7 fr 03 lumen 104 69.3 102.01 0.00 signicant 7 fr 02 lumen 43 28.7 7 fr 01 lumen 3 2.0 variables incidence of crbsi pvalue incidence of exit site infection pvalue incidence of catheter tip infection pvalue incidence of catheter related overall infection pvalue 50 x gjra global journal for research analysis disscussion central venous catheters are routinely used medical devices for treatment of chronically and critically ill patients. blood stream infections related to central venous catheterization are a cause of signicant morbidity and mortality. the cost of cvc-associated bsi is substantial, both in terms of morbidity and in terms of nancial resources expended. a total of 150 patients with 1056 catheter days were included in our study. the rate of infections associated with central venous catheterization was 35.03 per 1000 catheter days. in this study, out of 150 patients with cvcs, 37 were having catheter associated infections with incidence of 24.66%. incidence of exit site infections was 5.33% (7.57 per 1000 catheter days), catheter tip infections was 13.33% (18.93 per 1000 catheter days) and crbsi was 6% (8.52 per 1000 catheter days). in present study out of 150 patients catheter colonization rate of (29/150) 19.33% was seen. crbsi rate of (9/150) 6% or 8.52 per 1000 catheter days was observed (all 09 organisms were common among blood culture as well as cvc tip culture). the incidence of crli was 18.66% or 26.51 /1,000 catheter-days in our study. catheter colonization rate was 62.5% and crbsi rate was 12.5% or 10 per 1000 catheter days in a study done by rupam gahlot et al [7] catheter colonization rate was 57.6% and . crbsi rate was 9.26 per 1000 catheter days in a study conducted by chopdekar et al.[8] crbsi rate was 4.01 per 1000 catheter days in a study conducted by pawar et al.[9] crbsi rate was 20.06 per 1000 catheter days in a study conducted by almuneef et al. [10] the incidence of crbsi and crli were 2.79 and 4.43% or 6.05 per 1,000 catheter-days, respectively in a study conducted by leonardo lorente et al. [11] world over, the reported incidence of exit site infections vary from 6 to 15%, catheter tip infections from 4 to 15% and of crbsis from 1 to 13%.[11] according to the literature, rate of crbsi is 1% to 13%.[1,9] our results are more or less similar with the study conducted by chopdekar et al.[8] ,rupam gahlot et al. [7] limitation the population in the present study sample includes only surgical icu patients and number of emergency catheter insertion was small. more prospective studies of sufcient size and to address all potential risk factors will enhance our understanding of the pathogenesis of cvc-related bsi and guide to develop more effective strategies for their prevention. conclusion our study revealed a total of 24.66% of cvc associated infections. this included exit site infections (5.33% or 7.57 per 1000 catheter days), catheter tip infections (13.33% or 18.93 per 1000 catheter days) and crbsi (6% or 8.52 per 1000 catheter days). references 1. merrer j, de jonghe b, golliot f, lefrant jy, raffy b, barre e, et al. complications of femoral and subclavian venous catheterisation in critically ill patients. jama 2001;286:700-7. 2. ramritu p, halton k, cook d, whitby m, graves n. catheter-related bloodstream infections in intensive care units: a systematic review with metaanalysis. j adv nurs 2008;62:321. 3. randolph ag, cook dj, gonzales ca, pribble cg. ultrasound guidance for placement of central venous catheters: a metaanalysis of the literature. crit care med 1996;24:2053-8. 4. surveillance of device-associated infections at a teaching hospital in rural gujarat india *s singh, y pandya, r patel, m paliwal, a wilson, s trivedi. 5. national nosocomial infections surveillance(nnis) system report, data summary from january 1990-may 1999, issued june 1999. am j infect control 1999;27:520-32. 6. centers for disease control & prevention. (2015). bloodstream infection event (central line associated bloodstream infection and non-central line associated bloodstream infection). 7. rupam gahlot et al. int j infect control 2013, v9:i2 doi: 10.3396/ijic.v9i2.013.13 8. chopdekar k, chande c, chavan s, et al. central venous catheter-related blood stream infection rate in critical care units in a tertiary care, teaching hospital in mumbai. ijmm 2011; 29: 169-171. 9. pawar m, mehta y, kapoor p, sharma j, gupta a, trehan n. central venous catheter-related blood stream infections: incidence, risk factors, outcome, and associated pathogens. j cardiothorac vasc anesth 2004; 18: 304-308. 10. almuneef ma, memish za, balkhy hh, hijazi o, cunningham g, francis c. rate, risk factors and outcomes of catheterrelated bloodstream infection in a paediatric intensive care unit in saudi arabia. j hosp infect 2006; 62: 207–213. 11. lorente l, henry c, martin mm, jimenez a, mora ml.central venous catheterrelated infection in a prospective and observational study of 2595 catheters. crit care 2005;9(6):r6315. various comorbidities yes 5/78 0.83 5/78 0.54 8/78 0.25 18/78 0.64 no 4/72 3/72 12/72 19/72 hypertension with diabetes ii yes 4/23 0.01 2/23 0.44 2/23 0.48 8/23 0.22 no 5/127 6/127 18/127 29/127 site of insertion ijv 7/130 0.59 8/130 0.52 18/130 0.81 33/130 0.69 scv 2/18 0/18 2/18 4/18 fv 0/2 0/2 0/2 0/2 type of insertion elective 9/138 0.36 6/138 0.07 20/138 0.16 35/138 0.50 emergency 0/12 2/12 0/12 2/12 no. of puncture 01 3/87 0.10 4/87 0.56 8/87 0.14 15/87 0.04 02 4/53 4/53 11/53 19/53 03 2/10 0/10 1/10 3/10 technique landmark 7/127 0.55 7/127 0.82 18/127 0.48 32/127 0.72 usg guided 2/23 1/23 2/23 5/23 type of central line 7 fr 01 lumen 1/3 0.06 0/3 0.09 0/3 0.71 1/3 0.32 7 fr 02 lumen 4/43 5/43 5/43 14/43 7 fr 03 lumen 4/104 3/104 15/104 22/104 duration of catheter less than & equal to 3 days 0/9 0.43 1/9 0.43 1/9 0.84 2/9 0.86 > 3 days 9/141 7/141 19/141 35/141 volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 51gjra global journal for research analysis introduction every organization irrespective of its nature is made up of people. they continue to maintain their commitment towards the organization are essential in attaining organizational objectives. organizations which are able to acquire, develop, stimulate and retain outstanding employees are effective and efcient. human resource thus plays a vital role either in the success or failure of an organization. human resource has long been considered an important factor in economic development. the word “resource” refers to productive power of natural goods. human resource is therefore the productive power. unlike the material resources, the human resources are the participants as also the beneciaries of economic development process. a successful enterprise stands on sound management which gets effective results through the people. experts express that management is an art as well as science of getting things done through and with people of all factor of production. “labour” is the most important factor and utilization of other resources largely depends on the proper utilization of time and energy on the part of workers. labour, at all times, has been considered as a separate factor of production. any work whether manual or mental which is undertaken for a monetary consideration is called “labour” in economics. the involvement and importance of human element is being increasingly realized by those responsible for the management of industrial establishments. hence it arises the need for understanding human resource management. the most important organizational problem to-day is that of personnel administration. some of the most important topics of research in this area may be skills and abilities needed by management executives, selection and training of employees in business and effectiveness of personnel management programmes. rate of growth in human resources is determined by variables such as population structure, migration and labour force participation. quality of human resources on the other hand is inuenced by the status of variables like education and training, health and nutrition and equality of opportunity. one of the hall marks of modern management is the ability to plan. manpower planning means forecasting or predicting the number of people whom the organization will have to raise or promote in a given period. broadly dened, manpower planning represents a systems approach to personnel management in which the emphasis is on inter-relationship among various personnel, personnel policies and programmes. this contrasts with the more traditional piecemeal approach concerned with selection, training, promotion and the various related but compartmentalized functions. 'it is the sum of total of inherent abilities, acquired knowledge and skills represented by the talents and aptitudes of an organization's work force as well as the values, and aptitudes of the employed person's. of all the m's in the management (i.e., materials, machines, methods, money and motive power) the most important 'm' is the men or human resources. it is the most valuable asset of any organization. manpower planning and human resource planning, though used as synonyms, yet they are different in purport and meaning. in the past, the phrase manpower planning was widely used, but now the emphasis is on human resource planning which is more broad based. human resource planning is the process by which a management determines how the current organization should move from its current manpower position to its desired manpower position. through planning, the management strives to have the right number and the right kind of people at the right place at the right time, to do things which result in both the organization and the individual receiving the maximum long range benets. challenges faced by banking industry in today's competitive business environment, quality and productivity are the two important factors for the survival and growth of any organization. satised employees can facilitate these two factors and thereby help the organization to compete in the market and to withstand the vagaries of market turbulence. the protability and success has become a question mark now-a-days. only a dedicated, qualied, efcient human resource can bring success to the organization in this age of high technology. training and development of human resource to match ever changing industry demands requires hr to develop new and innovative ideas that suit individual as well as the bank's criteria. employee motivation and satisfaction is another area of concern for the hr today. in order to reduce the attrition rate, hr needs to realize that monetary needs are not the only motivational drivers for an individual but a sense of belongingness must be imbibed in employees. with the increase in number of job options available nowadays, the hr function of an organization must take care that they hire those people who believe in long-term commitment to the organization. the hr then must take up the challenge of retaining them by developing retention techniques like holiday plans fun-at-work etc. he also faces the challenge of creating a balanced organization that originates from mergers and acquisitions. with the rising mnc's, hr needs to focus on issues such as cross-cultural or expatriates training, so that problems that can arise because of differences in international professional values can be minimised. the. key notion of success in the highly competitive current bank employees' perception on hrm original research paper dr. a. venkatachalam principal gtn arts college dindigul. x 37gjra global journal for research analysis commerce keywords : p. banupriya* ph.d., research scholar pg & research centre department of commerce gtn arts college, dindigul.*corresponding author volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 38 x gjra global journal for research analysis banking industry is not just winning customers but in training them. new customers will try bank offerings based on the perceived quality, and that result in satisfaction, the perceived value of bank will increase and thereby prompting repeat visit for further nancial requirements. this key concept of quality satisfactionloyalty relationship in retail banking market was put to test through an empirical approach 1 in this study and this view is exactly endorsed by the results of this study. conclusion the effective hr management of staff within the organization is important to the organization's efciency and effectiveness. boyne argued that public service progress depends on good management, including a reection on leadership skills and human resource management (hrm) practices. he handled and maintained the reection on rules and company constitution limits the improvement of recent public organization. human resource management system structures of the total activities relating in ensuring the effective and efcient utilize of the employees in the company to meet the company's goals and objectives. the development of efcient management of employees means cultivating effective working environments and contribution to the company's gain. therefore, the current study examined the hrm practices and job satisfaction of the employees, and perceived organizational performance of private banking sectors employees. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 16.bluetree 03.cdr the number of patients with type 2 diabetes is rapidly increasing, and type 2 diabetes is one of the most common chronic diseases. diabetic kidney disease (dkd) is among the most important complications of diabetes and often leads to the need for renal replacement therapy, including dialysis and 1renal replacement . thus, patients with diabetes represent a signicant global health burden. the increasing incidence and prevalence of dkd places signicant health burdens on 2patients and costs on our already stressed healthcare system . the diabetes control and complications trial (dcct), performed in patients with type 1 diabetes, and the united kingdom prospective diabetes study (ukpds), in patients with type 2 diabetes, revealed that intensive glycemic control might inhibit the progression of dkd. thus, hyperglycemia could be a major factor in the progression of dkd. however, dkd develops despite good glycemic control. thus, novel therapeutic agents beyond those for glycemic control in 1patients with dkd are needed . there are about 200 million people in the world with dkd in different stages, and hypertension, arteriosclerosis and diabetes mellitus are responsible for over 50% of end-stage renal disease. about 40% of patients with (diagnosed or not) diabetes mellitus has an advanced stage of kidney disease, often because of serious deciencies in the management of the disease itself. in patients with diabetes mellitus, kidney disease occurs and often develops insidiously; the main renal dysfunctions are due to the thickening of the glomerular basement membranes, the formation of microaneurysms and the development of 3mesangial nodules . the onset of a clinically documented diabetic nephropathy is generally preceded by the 4appearance of proteinuria greater than 500 mg/day . conventional therapies used in patients with type 2 diabetes mell i tus include medications such as metformin, sulphonylureas, thiazolidinediones, meglitinides, and insulin. except for pioglitazone, which is a thiazolidinedione, all other drugs require dose adjustments and an immediate suspension in patients with a reduction in the glomerular ltration rate (egfr). in these cases, in fact, there is the risk of development of lactic acidosis (metformin) or hypoglycaemic 3episodes (sulfonylureas, meglitinides, and insulin) . some reports suggest that hyperglycemia may play a signicant role in the development of dkd; thus, appropriate glycemic control seems to protect against dkd. several large clinical trials such as dcct and ukpds have shown that intensive glycemic control in patients with type 1 or 2 diabetes could delay the development of dkd. in contrast, recent studies have indicated that intensive glycemic control reduces albuminuria and proteinuria but cannot improve renal outcomes. furthermore, hypoglycemia exacerbates both macroand microvascular complications, including dkd. 1thus, glycemic control is insufcient to prevent dkd . in recent years, there have been several new categories of medications approved for the treatment of diabetes, including new insulins, glucagon-like peptide-1 receptor agonists (glp1 ras), dipeptidyl peptidase-4 inhibitors (dpp-4i), an amylin analog, and sodium-glucose cotransporter-2 inhibitors (sglt-2i). two classes of oral medications, dpp-4i and sglt2i, are potentially considered as options for add-on therapy to metformin for the management of diabetic kidney. dpp-4i acts via inhibiting the dpp-4 enzyme thus prolonging glucagonlike peptide-1 and glucose-dependent insulinotropic polypeptide activity. sodium-glucose linked cotransporters (sglt) is expressed in the proximal tubule and are of two isoforms: sglt1 and sglt2. in particular, sglt2 is a high-capacity, low-afnity glucose transporter that is expressed in the s1 and s2 segments of the proximal tubule. sglt2 is an efcient glucose transporter of the atp-dependent system that reabsorbs glucose.3 interestingly, sglt2 expression in the proximal tubule is increased in patients with type 2 diabetes, resulting in increases in glucose uptake exacerbating hyperglycemia.4 sglt2 inhibition can block glucose and sodium reabsorption at the proximal tubule. therefore, the administration of sglt2 inhibitors can excrete 80–100 g/day glucose in the urine, translating to 240–400 kcal/day. they have been proven to decrease glycated hemoglobin (hba1c) by 0.7–1.0% without severe hypoglycemia and to reduce body weight by 3–4 kg. empagliozin is a potent and selective sglt2 inhibitor. the empagliozin and progression of kidney disease in type 2 diabetes (empa-reg renal outcome) trial and the canagliozin cardiovascular assessment study program clearly showed the protective effects of sglt2 inhibitors on renal outcomes in patients with type 2 diabetes, including decreases in albuminuria and progression of nephropathy, doubling of serum creatinine levels, and initiation of renal 1replacement therapy . the potential mechanism of the benecial effects of sglt2 inhibitors may be through decre asing hyperltration. by reducing proximal reabsorption of sodium, distal sodium delivery is increased, activating tubular glomerular feedback leading to afferent arteriolar vasoconstriction and a reduction in hyperltration. this is a 2class effect and is reversible after stopping the drug . renal function should be regularly monitored in patients taking sglt2 inhibitors. inhibitors of dpp-4 reduce blood glucose in patients with type 2 diabetes by preventing degradation of incretin peptides such as glp-1, stimulating insulin release and inhibiting glucagon combination of empagliflozin and linagliptin: novel agents for managing diabetic kidney original research paper samir kanta datta sp more, suri, birbhum,731101 medicine keywords : volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra samir kumar mishra* d/81,hig, baramunda hb colony, bhubaneswar 751003 *corresponding author sandeep jain doctors house near pankaj house chindwara-480001 sandeep desai advance diabetes care 202-203, dreamland arcade opp jade blue, tithal road valsad -396001 sandeep tiwari raj nursing home pehowa city .136128 44 x gjra global journal for research analysis secretion. briey, glucagon-like peptide 1 (glp-1) produced by the l cells in the gut stimulates the secretion of insulin from the pancreatic beta cells in response to a carbohydrate-rich meal, slows gastric emptying inducing satiety, and reduces the endogenous production of glucagon during fasting states, therefore improving postprandial as well as fasting glycemia. the half-life of glp-1 is extremely short as it is cleaved by the dipeptidyl peptidase 4 (dpp-4). the activity of dpp-4 is increased in obese individuals and those with diabetes, therefore reducing the availability of glp-1. treatment with dpp-4 inhibitors improves glycemic control by restoring the 5physiologic levels of glp-1 . as dpp-4 inhibition leads to a glucose-dependent release of insulin, it is associated with a low risk of hypoglycemia. linagliptin is a potent and selective 6dpp-4 inhibitor . pooled data from 13 phases 2 or 3 trials of the dpp-4, linagliptin in type 2 diabetics showed intervention reduced the risk of kidney disease events by 16% compared to placebo. empagliozin and linagliptin have complementary mecha nisms of action to maintain glucose homeostasis in patients with type 2 diabetes. empagliozin lowers glucose through the urine by blocking glucose reabsorption in the kidney. the previous study showed that sglt2i treatment would increase endogenous glucose production. similarly, in addition to lowering fpg and post-challenge plasma glucose (ppg), empagliozin would also induce a compensatory increase in endogenous glucose production. glucagon increase would switch back after 4weeks of treatment. linagliptin, a dpp-4i, probably has the potential of inhibiting the increase in endogenous glucose production and then improve the glucose-lowering activity of empagliozin. in addition, this combination has been proved benecial to improve ß cell functions and insulin sensitivity. the american diabetes association recommends a glycemic target of glycosylated hemoglobin (hba1c) < 7%. the clinical trial combined empagliozin with linagliptin showed that the number of patients reaching hba1c< 7% exceeded 50%. in addition to both empagliozin and linagliptin being highly effective in achieving glucose homeostasis, there are other reasons for considering the combination. cherney et al. found that empagliozin could recede renal hyperltration, which 7represents intra-glomerular pressure . empagliozin consistently contributed to the weight loss during combining with linagliptin. the pharmacologic actions of empagliozin reducing sbp contain weight loss, osmotic diuresis, reduced arterial stiffness, and direct vascular effects, while linagliptin glanced off blood pressure. in consequence, combining empagliozin with linagliptin has a signicant advantage in exerting hypoglycemic actions and benecial effects on the 8kidney, body weight, and sbp . the potential mechanism of the benecial effects of sglt2i is believed to be through decreasing hyperltration. if true, then these sglt2i drugs may also be effective in nondiabetic kidney disease, a hypothesis that is being tested in the study to evaluate the effect of dapagliozin on renal outcomes and cardiovascular mortality in patients with ckd (dapa ckd) in which half the patients are diabetic and half are nondiabetic. the primary outcome is a composite of ≥50% sustained decline in egfr, esrd, or cv or kidney death. conclusion slowing progression of kidney disease is a critical goal for diabetic kidney patients. thus, the management of renal function in diabetic patients is critical. various big trials have established that intensive glycemic control might inhibit the progression of dkd. thus, hyperglycemia could be a major factor in the progression of dkd. however, dkd develops despite good glycemic control. thus, novel therapeutic agents beyond those for glycemic control in patients with dkd are the need of the hour. a combination of empagliozin and linagliptin is one such new therapeutic approach for the management of dkd. empagliozin is a potent and selective sglt2i while, linagliptin is a potent and selective dpp-4i. given the complementary mechanisms of action of empagliozin and linagliptin, the combination is expected to slow the progression of dkd. few trials have shown their potential as a renoprotective combination in diabetic patients. however, larger clinical trials need to be undertaken to establish their efcacy in slowing the progression of dkd. references 1. mima a. renal protection by sodium-glucose cotransporter 2 inhibitors and its underlying mechanisms in diabetic kidney disease. j diabetes complications. 2018;32(7):720-725. doi:10.1016/j.jdiacomp.2018.04.011 2. drawz p, hostetter th, rosenberg me. slowing progression of chronic kidney disease. elsevier inc.; 2020. doi:10.1016/b978-0-12-815876-0.00057-7 3. di lullo l, mangano m, ronco c, et al. the treatment of type 2 diabetes mellitus in patients with chronic kidney disease: what to expect from new oral hypoglycemic agents. diabetes metab syndr clin res rev. 2017;11:s295s305. doi:10.1016/j.dsx.2017.03.005 4. fowler mj. microvascular and macrovascular complications of diabetes. 2008;26(2):77-82. 5. carbone s, dixon dl, buckley lf, abbate a. glucose-lowering therapies for cardiovascular risk reduction in type 2 diabetes mellitus: state-of-the-art review. mayo clin proc. 2018;93(11):1629-1647. doi:10.1016/j. mayocp. 2018 .07.018 6. milligan s. combination therapy for the improvement of long-term macrovascular and microvascular outcomes in type 2 diabetes: rationale and evidence for early initiation. j diabetes complications. 2016;30(6):11771185. doi:10.1016/j.jdiacomp.2016.03.010 7. cherney dz, perkins ba, soleymanlou n et al. renal hemodynamic effectof sodium-glucose cotransporter 2 inhibition in patients with type 1 diabetesmellitus. circulation. 2013;129:587–97. 8. tan x, hu j. traitement combiné par empaglifozine et linagliptine chez les patients atteints de diabète de type 2. ann endocrinol (paris). 2016;77(5):557562. doi:10.1016/j.ando.2015.11.003 volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 45gjra global journal for research analysis introduction [1.2]the anb angle by riedel, 1952 and the wits appraisal by [3]jacobson, 1975 have been considered as the most commoncephalometric tools for assessing antero-posterior jaw discrepancies. the rst and commonly used method in orthodontic literature is the anb angle. the relative forward or backward positioning of nasion by virtue of an excessively long or short anterior cranial base (line sn) or a relative posterior or anterior positioning of both jaws within the skeletal craniofacial complex will directly inuence the anb reading. the clockwise or counterclockwise rotation of the jaws relative to the cranial reference planes also affects the [ � , 5 ]anb angle reading . accurate identication and reproduction, of the occlusal plane is not always easy. any change in the angulation of the functional occlusal plane, caused by either normal development of the dentition or orthodontic intervention; can profoundly inuence the wits 4appraisal .a measurement independent of cranial reference planes or dental occlusion would be a desirable adjunct in determining the apical base relationship. such a measurement was later developed and named, the beta 6angle by baik c y and ververidou . a line is extended form the center of condyle 'c' to b point and another linefrom point a to point b. then a perpendicular is drawn from cb line through point a. the angle formed at point a, between a-b line and the perpendicular constitutes the beta angle.malabar geographically occupies the northern part of kerala state,with the majori ty speaking malayalam language with dravidianethnicity. this study is being undertaken to estimate the reliability of beta angle values in differentiating a class iii skeletal base from a class i skeletal base aim and objectives 1. to assess the beta angle value of class iii group in malabar population 2. to assess the reliability of beta angle value in differentiating a class iiiskeletal relationships from a class i skeletal relationship in malabar population. materials and methods the present study was carried out in the department of orthodontics, govt. dental college, calicut. the number of samples obtained was 30 in class iii. all subjects selected were between the 11–25 years age group and had never undergone orthodontic treatment before taking the cephalogram and there was no history of permanent tooth extraction. cases with functional shift of mandible were also excluded from the study.the lateral cephalograms were taken using planmeca 2002 cc proline tm machine and standardised procedure. the cephalograms were traced on acetate matte tracing paper of 0.003-inch thickness with a sharp 3h drawing pencil on a view box using transilluminated light. angular and linear measurements were obtained nearest to 0.5mm and 0.5 degree by ruler, scale and protractor. cephalometric landmarks and measurements used in this study were s sella turcica. the geometric center of the pituitary fossa (sella turcica), determined by inspection. it is a constructed point in the midsagittal plane n – nasion. the intersection of the inter nasal and fronto-nasal sutures, in the midsagittal plane. it is the anterior most point of the fronto nasal suture in the median plane a point a, subspinale. the deepest midline point in the curved bony outline from the base of the alveolar process of the maxilla. i.e.the most posterior point between the anterior nasal spine and prosthion. in anthropology it is known as subspinale b point b, supramentale, sm. most anterior point of the mandibular base. the deepest (most posterior) midline point on the bony curvature of the anterior mandible, between infradentale and pogonion, in mid sagittal plane. in anthropology it is called assupramentale c – centre of condyle. located by tracing the head of the condyle and approximating its center. utilizing these landmarks, various linear and angular measurements were valued angular measurements sna the postero-inferior angle between the lines sn and na snb the postero-inferior angle between the lines sn and nb anb, the difference between the angles sna and snb. positive value when sna is greater than snb and vice versa beta angle the angle between the perpendicular from c-b line to point a and the a-b line. an anb value of <0 deg was the criterion for including the samples into class iii group. in each patient, the beta angle were measured and tabulated the reliability of beta angle in assessing class iii skeletal base original research paper dr. sreehari s* assistant professor, department of orthodontics, govt. dental college kozhikode. *corresponding author orthodontology this study aims to assess the efciency of beta angle, a cephlometric angle used for measuring sagittal skeletal base relationship to differentiate class iii skeletal base from class i skeletal base. 30 pretreatment cephalograms were grouped in to class i group and class iii group each based on angle anb, from 123 lateral cephalograms. the beta angle values obtained were analyzed. the angle beta is 80% sensitive and 87% specic in differentiating a class iii from a class i abstract keywords : beta angle, skeletal class iii dr. m. jayarama former professor & head, department of orthodontics, govt. dental college, kozhikode. dr. latheef vp associate professor, department of orthodontics, govt. dental college, thrissur. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 16 x gjra global journal for research analysis fig. 1. the beta angle results 0the mean value for beta angle in the class iii was 41.7 with a standard deviation of 3.7 table i table ii discussion anb angle is the most commonly used parameter among measurements used to assess the antero-posterior skeletal 2jaw relationships . the validity of these parameters has been investigated by many clinicians and researchers. 3,7jacobson observed that the anb angle does not provide an adequate assessment of jaw relationship, as the rotational growth of the jaws and the antero-posterior position of nasion 8inuence the anb angle. hussels and nanda noted two additional factors affecting the anb angle namely, the vertical lengths from nasion to point b and the vertical length from point a to point b. so the use of a new parameter in conjunction with other parameters for describing sagittal jaw relationship seems preferable. this study is carried out primarily to evaluate angle beta as an alternative or additional diagnostic parameter to angle anb in assessing antero-posterior skeletal relationship and to assess its reliability in differentiating a class iii skeletal base from a class i skeletal base. 30 cephalograms traced in both classes were included in the study. 0the mean beta value obtained class iii was 41.7 . 6 0thecorresponding value obtained in the baik study was 40 . the mean beta values obtained in the present study were slightly higher than that of original study conducted in white population. the difference in populations considered in the two studies might be the reason for getting different mean beta angle values. the standard deviations from the mean beta values for different groups were analyzed. so a beta 0angle value higher than 38 can be considered as class iii. receivers operating characteristic curves [roc] were used for examining the sensitivity and specicity of beta angle in differentiating the skeletal pattern in to class i and class iii groups. roc curves are useful in evaluating the performance of classication schemes in which there is one variable with two categories by which subjects are classied. it gives the measurements in sensitivity and specicity. sensitivity of a test is an indication of the capability of a test to accurately yield positive results when applied to patients known to have a disease. it measures the true positive [tp] value. specicity of a test is an indication of the capability of a test to yield negative results accurately, when applied to subjects known to be free of disease. it measures the true negative [tn] value. 0the result showed that beta value of 38 has 80% sensitivity and 87% specicity for considering it under the class i skeletal group when compared to class iii group. it implies that above 0the beta angle value 38 , chance for beta measurement to come under class i group is relatively less. that means, the 0 beta values above 38 can be considered as class iii. the values achieved in this study almost coincide with the mean beta value [33.80] ± 1 sd of the class i anb group. summary and conclusion the present study was undertaken to evaluate the reliability of beta angle in assessing sagittal class iii skeletal base relationship cephalometrically. from the ndings obtained in the present study,it can be concluded that 0 1. beta angle value greater than 38 can be considered as a class iii skeletal base 2. beta angle is a valuable parameter based on specicity and sensitivity in differentiating a class iii skeletal base from a class i skeletal base. 3. beta angle measurement can be recommended as additional or alternative parameter to angle anb. references 1. richard a. riedel. the relation of maxillary structures to cranium in malocclusion andin normal occlusion. angle orthod1952; 22:142-145. 2. richard a. riedel. an analysis of dentofacial relationships. 1957; am. j. orthod. 43:103-119. 3. jacobsen a. the wits appraisal of jaw disharmony. am j orthod1975; 67: 125138. 4. bishara s e, fahl j a, peterson l c. longitudinal changes in the anb angle and witsappraisal: clinical implications. am j orthod1983; 84:133-9. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra no age sex anb [deg] beta angle [deg] 1 24 m -1 40.5 2 22 m -2 35 3 16 f -2 42 4 14 f -3.5 41 5 17 m -5 44.5 6 18 m -5 41 7 15 m -3 45.5 8 15 f -0.5 39.5 9 14 f -2 41 10 21 f -1 38.5 11 18 m -1 42.5 12 18 m -2 45 13 16 m -2 40 14 13 f -1 36 15 13 m -1 39.5 16 17 m -1 38 17 16 m -1 37 18 20 m -1 42 19 13 f -4 42 20 13 m -5 47 21 20 f -2 43 22 14 f -5 48 23 15 m -0.5 42.5 24 20 f -4 42.5 25 13 f -4.5 50 26 13 m -4.5 47 27 13 f -3 41 28 21 f -1 34 29 13 f -4 44 30 12 m -3 41 anb n mean std deviation std error 95% condence interval for mean lower bund upper bound <0 30 41.683 3.74277 .68333 40.2858 43.0809 x 17gjra global journal for research analysis 5. charles m. taylor. changes in the relationship of nasion, point a and point b, and theeffect upon anb. am j orthod1969; 56: 143-163 6. chong yolbaik and maria ververidou. a new approach of assessing sagittaldiscrepancies: the beta angle. am j orthod 2004; 126:100-5. 7. jacobsen a. update on the wits appraisal. angle orthod1988; 58:205-19. 8. wolfram hussels and ram s nanda. analysis of factors affecting angle anb. am jorthod 1984; 85: 411-423. volume-8, issue-11, november-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 18 x gjra global journal for research analysis 22.dr suhas murali.cdr introduction : obscure gi bleed is a condition when there is denitive gastro-intestinal(gi) bleed, whose source remains elusive despite an initial negative upper-gi endoscopy and a 1colonoscopy . occult gi bleed can occur anywhere in the gi tract. but the diagnosis becomes extremely tricky when endoscopic reports are negative for gross bleeds. the newer diagnostic modalities like capsule endoscopy (ce ) thus perfectly t into this vacuum of diagnostic modalities. we report one such case diagnosed by capsule endoscopy. case report : a 52 year old otherwise healthy female patient presented to the casualty with complaints of generalized weakness & easy fatigability since 1 month. there was no history of any bleeding tendencies. routine investigations showed a severe anemia of 6.7g/dl hemoglobin. stool for occult blood was positive. this prompted us to focus on the gi tract for the source of the bleeder. she later underwent an upper giendoscopy which was normal. a colonoscopy also showed a normal study. then suspecting the source of the bleed to be rdbetween the duodenum 3 part and the ileo-caecal junction, the patient was subjected for a capsule endoscopy (ce) examination. this showed multiple bleeding spots in the jejunum which were actively bleeding. the patient was then posted for surgery, when she underwent a short segment resection anastomosis of the jejunum. figure -1 : the picture shows the capsule endoscopy sho wing active bleeding from the jejunum. on histopathological examination of the resected sample, it showed congested mucosa with lamina propria showing numerous ectatic blood vessels of varying sizes suggestive of vascular ectasias. results : post-operatively the patient showed remarkable improvement with no sequele and was discharged 10 days later from hospital. discussion : gastro-intestinal bleeds that occur as a result of bleeders in between the ligament of treitz and the ileo-caecal valve; in other words between that part of the gastro-intestinal tract not visualized by the routine upper-gi scopy and colonoscopy 2accounts for approximately 5% of gastro-intestinal bleeding . amongst the most common causes bleeding from this region includes angiectasias which accounts for 30-40% amongst 3these; specially in elderly . other important causes of occult gi bleeds from the small bowel includes nsaid induced enteropathy, ibd with ulcers or erosions, tumours, radiation enteropathy, dieulafoy's lesions & small bowel varices. the location of these lesions make it extremely tricky to diagnose. the capsule endoscope however lets us have a visualization of the entire small intestine. compared to intraoperative enteroscopy , capsule endo scopy had a sensitivity of 95% and specicity of 75% in a 4prospective of 47 patients in. comapred to ct angiography and standard angiography, capsule endoscopy detected more bleeding source lesions 5(72% with vce vs 24% with cta and 56% with angiography). benets of capsule endoscopy include its non-invasive nature, better patient compliance and safety. but drawbacks include inability as a therapeutic intervention, many false positive results and chances of erratic passage causing missed lesions. if signicant lesions like the one discovered in our patient is detected, the patient is referred for specic management of the cause. if the initial capsule endoscopy is negative one more attempt maybe done. if the second capsule endoscopy is also negative then the patient maybe managed conservatively. conclusion : the main objective of this case report was to highlight the role of capsule endoscopy in reaching and identifying occult bleeding points which were till recently inaccessible. even though capsule endoscopy lacks the therapeutic intervention needed, it can direct the physician on further course of management. hence we suggest that capsule endoscopy as the rst investi gation of choice for evaluation of small bowel in patients with occult gastro-intestinal bleeds. references : 1. thomas j.s, dennis m.j. sleisenger and fordtran’s gastrointestinal and liver diseases 9th,19:285 2. katz lb. the role of surgery in occult gastrointestinal bleeding. semin gastrointest dis 1999;10:78-81. 3. foutch pg. angiodysplasia of the gastrointestinal tract. am j gastroenterol 1993;88:807-18. 4. hartmann d, schmidt h, bolz g, et al. a prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure gi bleeding. gastrointest endosc 2005; 61:826-32. 5. saperas e, dot j, videla s, et al. capsule endoscopy versus computed tomographic or standard angiography for the diagnosis of obscure gastrointestinal bleeding. am j gastroenterol 2007;102:731-7. a case report of vascular ectasias of gi tract presenting as occult gastro-intestinal bleed diagnosed on capsule endoscopy original research paper dr. santosh hajare professor, department of gastroenterology, j.n.medical college, kle university, belagavi x 7gjra global journal for research analysis gastroenterology keywords : volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. suhas. murali* resident in general medicine, j.n. medical college, kle university, belagavi *corresponding author introduction lagan:in ayurvedic texts acharya had described lagan under the heading of vartmagat vyadhi. ““améémüè müìpûléè xjéñsééå aéëçîljéuéiqéïpéuééååâeéè| xémülqòûè ìméîcnûséè müéåséméëqééhééå séaéhéxiéñxéè ||” xéñ. e. 3/27 a small zizipus (badar) like structure appears at the lid which is painless, hard, bulky & apaki and cystic in nature is called as lagan. in ashtang sangraha and madhavnidan saatyaki says that lagan is a granthi which is painless, hard structure at varta ma which is apaki and shleshmaudbhava. treatment:“zséåwqééåmélééwûséaéhééæ cé ìoéxé cé péå±é || aéëçíjé¶éç réè m×üíqém×üiééååeé³ééíqémüécé ||” xéñ. e. 8 /8 sushruta acharya describes lagan as on bhedya vyadhi. usually bhedan karma should be done when pakva avastha comes. but lagan is apaki so in lagan bhedan should be done if it dose not cure by medicine line of treatment. kanchanar guggul:-as a systemic medication müéçcélééuxré aéúwûïrééié iuécéç méçcémésééåîlqéiééqéç | lééaéuxré mühéérééš qéëucéxré méséçméséç || méjrééìoéípéiékééì§éhééç méséqééksïç mé×jémümé×jémü | uéâhéxréé¤éqéåmüš mé§émæüséé iuécééç méñléè || oçûƒûoûƒû xéqéékééré xéuééïhréåmü§é céñhéïréåié | rééuécéñhéïíqésç xéuéïç iééuééléåuéé§é aéñaaéñsséñè || xéçƒóûš xéuéïqéåmü§é ìméhqûm×üiuéé ìuékééuréåié | aéñìoûmüéqééìwémüéè m×üiuéé méëpééiéå pé¤éréå³éuè || aéséaéqçû eéréiréñaéëqéméícéqéoéñïséhéïï cé | aéëçíjéléç uéëhééìlé aéñsqééçš mñü¹éìlécépéaéçsuqéç || méësåwûéšéléñ méélééjéïç yuééjééå qéñçhqûïìiémüé péuéè| yuééjéè zéìsuxééuxré yuééjéè müéåwhééåpéréépéuéè| péæ. u.aéséaéçqûéíkémüéu. 33-38 kanchanar, guggul, trifala, trikatu, varun, dalchini, ilayachi, tejpatra. properties :dosha : kapha – vataghna. dushya:rasa, rakta, mans, meda lekhana, pachan, ksha pana. rogadhikar :shotha(oedema), arbud(tumor),granthi, vra na, galganda,gulma, gandamala, kushta, bhagandar, apachi, pakva vidradhi etc. materials and methods method of preparation:take ne powder of all above mentioned drugs except guggul. give heat to guggul exudates and water, till up to just liquefy them. then add above mentioned quantity of churna & thoroughly mixed. thereafter tablets were prepared, each weighing 250 mg and dried in shadow. each tablet : contains kanchanar guggul 250 mg approx. maatra :500 mg to 1000 mg anupan :koshna jala sevankal :-after meal, two times a day. colour :brown colour, biconvex tablets. rasa (taste) :tikta gandha (odour) : nirgandha inclusion criteria:total 30 patient were taken for this study 1) s exmale & female. 2) patient which is ready to accept our treatment 3) post operative patients of “lagan” (chalazion) were randomly selected irrespective of age, sex, cast and religion, economical and educational status. exclusion criteria:1) patient suffering from other systemic diseases i.e. hype to study the efficacy of kanchanar guggul in post operative management of lagan. original research paper dr. nikhil dilip chaudhari m.s.(shalakya-tantra netrarog) associate professoe in dept. of shalakya -tantra . r.b. ayurvedic medical college & hospital, agra,uttar pradesh. x 33gjra global journal for research analysis ayurveda in this present era the human life style, habits and environment is dramatically changed. these changes give rise to various eye diseases requiring special attention. the fast food, junk food habits environmental pollution, dust, working habits like heavy computer work, driving vehicles, and also watching t.v. continuously, use of cosmetics and the negligence regarding refractive errors in young generations is more, all that things are hazardous for ophthalmic health given rise to disease like “lagan” (chalazion). “lagan” is one of the diseases described by sushruta acharya under the heading of vartmagata vyadhis. lagan is the “kolpramano” swelling in eyelid, which is itchy, painless, hard, tense or cystic in nature. chalazion is rare and recurrence is common. the treatment in modern science consists of local antibiotic and hot compression with light massage if the chalazion does not disappear with the appropriate treatment. the treatment consists of incision and curettage. the recurrence of chalazion is common. therefore, i thought of treating post operative “lagan” (chalazion) with ayurvedic medicine. while going through texts. i found references of kanchanar guggul as a rogadhikar on granthi roga also kanchanar guggul as a shothahara, lekhya, vedanahara & vranaropaka, hence. i have decided to see whether post operative management of chalazion with kanchanar guggul will be effective or not. abstract keywords : lagan, kanchanar guggul. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 34 x gjra global journal for research analysis rtension, h.i.v. asthama, diabetes, etc. 2) patient suffering acute or chronic eye diseases i.e. glau coma , etc. 3) patient below 14 yrs & above 60 yrs. of age will not be sele cted. 4) known case of allergic to kanchanar guggul. result:ÿ 18 males and 12female patient were taken for study. so it can be said that, though lagan (chalazion) is a common in both sex. it is pre dominant in male. it might be possible that due to the cosmoses consciousness the male patients. ÿ it is clear that lagan (chalazion) is more common in the age group of 14 to 25 years.(11 patients) ÿ lagan is more in student age group may be due to work on computer, plying in dust, motorcycle driving, study, more use of cosmetics. ÿ it is clear that lagan is more common in married people (i.e.17 patients) than unmarried people (i.e.13patients) because of lagan is more common in young age groups. ÿ the symptoms of pain, lid oedema, conjection, discharge are recovers in 7day. discussion patients came with complaint of painless nodular swelling of the eyelid, which is rm, tens, and non-tender and no any signs of inammation. spontaneous resolution of chalazion is rare and recurrence is common. the treatment in modern science consists of local antibiotic and hot fomentation with light message if the chalazion does not disappear with the appropriate treatment. the treatment consists of incision and curettage with the recurrence of chalazion is common. therefore, i thought to treat post-operative “lagan” (chalazion) with ayurvedic medicine. while going through texts. kanchanar guggul as a rogadhikar on granthi roga also kanchanar guggul as a shothahara, lekhya, vedanahara & vranaropaka, hence. i have decided to see whether post operative management of chalazion with kanchanar guggul will be effective or not. the study entitled “to study the efcacy of kanchanar guggul in post operative management of lagan.” patients were diagnosing based on sign and symptoms, which is mentioned in ayurvedic and modern text. the patients suffering from lagan were randomly selected irrespective of age, sex, cast and religion, economical and educational status. 30 patients are selected randomly and patients were treated with kanchanar guggul vati 250mg 2 tab. twice daily for 7 days along with koshna jala. rd th thfollow up on 3 , 5 & 7 days was done. the subjective gradation of symptoms was done. all the clinical observation was recorded in tabular form. and statistical analysis was done by applying student's t test. from the above observation, we can discuss the study as:according to sex: it was found that lagan (chalazion) is a common in both sex. it is pre dominant in male. it might be possible that due to the cosmoses consciousness the male patients according to occupation:lagan (chalazion) is more common in the age group of 14 to 25. lagan is more in student age group may be due to work on computer, plying in dust, motorcycle driving, study, more use of cosmetics. according to marital status:lagan is more common in married people than unmarried because of lagan is more common in young age groups. according to economic status:lagan is more in middle class as compare to lower class may it can be possible because of middle class population is more in the our hospital area. according to diet:on the observation of it is clear that lagan is more in people taking mixed diet than vegetarian people. pain on considering the symptoms of pain .it was found that, in trail grup symptom of pain is found in 30 patient. after treatment the symptoms of pain reduced totally in 30 patients. lid oedema on considering the symptoms of lid oedema.it was found that, in trail grup symptom of lid oedema is found in 30 patient. after treatment the symptoms of lid oedema reduced totally in30 patients. congestion on considering the symptoms of congection .it was found that, in trail grup symptom of congection is found in 28 patient. after treatment the symptoms of congection reduced totally in25 patient and 3 patient had mild form of congection. discharge on considering the symptoms of discharge. it was found that, in trail grup symptom of discharge is found in 30 patient. after treatment the symptoms of discharge reduced totally in25 patient and 5 patient had mild form of discharge. from statistical analysis it can be conclude that this treatments is effective. hence, from the above results it may be abstracted that trial group (kanchanar guggul) provided better overall relief in the patients of postoperative of lagan. samprapti-bhanga:according to sushruta acharya, lagan is kapha pradhan and shastrasadhya vyadhi. in lagan kapha vitiates mansa, rakta, meda, and sira. this vitiated kapha dosha produce aruj, apaki, kathin itchy “kolpramano” granthi like swelling (shotha) at vartma mandala. as a lagan is a bhedya and lekhya vyadhi. therefore incision and curettage was doing but after proper curetting, there was some brous tissue was remaining. kanchanar guggul given orally after incision and curettage. kanchanar guggul having kaphavata nashak and it acts on rasa, rakta, mans, meda dhatu dushti. on the basis of its lekhana property, kanchanar guggul acts on remaining tissue it prevents recurrence of disease and it also helps the operative wound healing due to its vranaropana property and its prevents or decreases of post operative infection due to antiseptic activity. volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra it is a vranaropaka so it helps in post operative rapid wound healing and as a shothahara it reduce a surgical edema (shoth) and also helps to reduce post operative pain due to his vedanahara property. basically kanchanar guggul is kapha vatahara, medohara it helps to resolve meda and siragata drushti that is why there is a less chance of recurrence. conclusion after evaluating the observation from trial group and taking in to consideration of the statistical analysis of this study. we come to the conclusion that :ÿ the clinical features of post-operative lagan are closely related to chalazion. ÿ kanchanar guggul is proved to be cost effective, safe and better drug. ÿ effect of kanchanar guggul in reduction of clinical symptoms is well appreciated within 7days. ÿ it is also observed that this line of treatment did not produce any type of side effect ÿ so the systemic drug kanchanar guggul is better option in post-operative lagan. references 1. charak smhita : agnivesh eited by bramhanand tripathi 4th ed”n chaukhambha sanskrit series varansi – 1996 2. dravya guna vigyana : acharya priyavat sharma, published by chaukhambh academy,varanasi. 3. essential of ophthalmology : samir basak. 2nd ed”n 1999, published by international 60; lenin saranee. calcutta700013 4. madhav-nidan : madhavkar with madhukosha and vidyotini comm.. edited by yadunandan upadhyaya, chaukhambha sanskrit pratisthan, varanasi.20” ed”n 1992. 5. shshrut samhita : sushrut, idited by kaviraj ambikadatta shastri, 14th ed”n 2001 chaukhambha sanskrit sanstha,varanasi.-221001 6. bhaishajya ratnawali : ambika datta shastri, 7th ed”n chaukhambha. 7. ashtang sangraha : english translation by prof. k .r. shrikant murthy. chaukhambha orientaliya. varanasi 2nd ed”n . 2000. x 35gjra global journal for research analysis volume-9, issue-2, february-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra introduction tb still represent a threat challenge to humanity .india has the highest burden of tb in the world account for nearly 1/5 of global burden of disease.in india extrapulmonary tb comprises 20% of all tb cases.lymph node involment is the most common extrapulmonary manifestation. method and material the study was conducated at jlnmc bhagalpur .sample size was 100 and duration of study was 4 month from1-9-2018 to 3112-2018. hundred cases were detected as granulomatous inammation in giemsa staining of aspirates from fnac. granulomatous lesions were grouped into 3 categories . a working diagnosis was arrived at by analysis of history, clinical examination and fnac and afb stainig. result granulomatos lesion100 afb positive cases70(44 cases m.tb positive and 26 cases m.tb negative). afb negative cases30 cytological smear of tuberculous lymphadenitis were grouped into 3 categories. epitheloid granuloma with necrosis60% only necrosis no granuloma30% epitheloid granuloma without necrosis10% zn stained smear were used for screening and grading of af bacteria. 1+ smear with occasional bacilli 2+smear with single scattered afb 3+smear with large no of bacilli arranged in bundle. gender wise distribution granulomatous lesion female60% , male40% agewise distribution of granulomatous lesion 1-10yrs3% 11-20yrs11% 21-30yrs44% 31-40yrs31% 41-50yrs8% 51-60yrs2% 61-70yrs-0 71-80yrs1% distribution of lesion according to site of fnac cervical lymph node60% supraclavicular lymph node-20% axillary lymph node -10% inguinal lymph node5% preauricular lymph node-3% skin and subcutaneous lesion-2% discussion fnac is a simple and economic procedure for diagnosis of tb compared with core needle biopsy /excision biopsy and also during the follow up of patients with antitb t/tment .accurate and timely diagnosis together with effective tb t/t ment is the mainstay of tb care.a conrm diagnosis of tb can only be given an isolation of mtb and dna sequence of bacteria in aspiraton .fnac is a very useful and reliable test in case of extrapulmonary tb. granulomatous inammation is common presentation of tb .second most most common infectious cause of granulomatous inammation is fungus.similar study was done by departmet of pathology .in the present study we tried to correlate b/w granulomatous lesion and acid fast positive tubercuous cases.blind fnac can approach safely in the supercial lesion.in our studys most of the cases from lymph node .cervical lymph node was the most common site followed by supraclavicular lymph node.similar study was performed by majeed muhamma mudassar et al. in our studies male gender more affected then female.similar study was done by bezabih et al. in my study granulomatus lesion are divided into 3 category . epitheloid granuloma without necrosis study of correlation between granulomtous lesion on fnac and afb positive tb cases original research paper dr rina kumari tutor/ senior resident department of pathology, j l n medical college bhagalpur pathology tuberculosis is the commonest infectious disease in the developing world. many diagnostic tests are devised for its detection including direct smear examination. this study was designed to corelation b/w afb positive and patients diagnosed to have granulomatous inammation on fine needle aspiration cytology using special stains. materials and methods: a descriptive cross-sectional survey was done on 100 cases of granulomatous inammation consistent with tuberculosis diagnosed on ne needle aspiration cytology at the department of pathology, jlnmc, bhagalpur.after reporting granulomatous inammation on giemsa staining of aspirates from fnac, unstained slides were subjected to special stains, like zn. cases positive for afb on zn stain were noted down along with their frequency and percentages. results: forty-four cases (62.85%) of afb positive smears were reported as tb while 26(37.14%) cases were afb positive were m.tuberculosis negative . cervical lymph nodes were the most commonly involved site (60%) and males(60%) were affected more (40%) than females. most cases of afb-positive smears were associated with epitheloid granuloma wth caseation necrosis (60%)followed by only caseous necrosis(30%)andepitheloid granuloma(10%). conclusion: special stains should be done on all granulomatous inammation cases seen on fnac for conrmation of tb . abstract keywords : fnac, granulomtous,afb positive tb volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr dhanesh kumar* tutor department of pathology j l n medical college bhagalpur *corresponding author dr r .k. mishra professor department of pathology j l n medical college bhagalpur 16 x gjra global journal for research analysis epitheloid granuloma with necrosis necrosis without epitheoid granuloma similar study was done by afrose ruquiy et al, bharti arati et al.on the basis of appearance, blood mixed aspirate were noted more commonly in 80% cases followed by purulent or pus material in 10% cases and caseous or cheesy material in 10% of cases whereas ,hemiataha et al observed blood mixed aspirates in 87.3% andpurulent or cheesy material 12.7% cases.our studied most common age group affected 21-40 yrs(75%) followed by 11-20yrs >41-50yrs >1-10 yrs >51-60 yrs(2%). conclusion fnac is a a sensitive ,simple, soft minimally invasive procedure to diagnosed tuberculous lymphadenitis .study of both fnac and zn staining for afb improve the diagnostic yield .if fnac is supplemented with special stain like zn staining gms and pas. it may help to differentiate b/w many infective causes of granulomatous inammation. figures epitheloid granuloma necrosis without epitheloid granuloma acid fast positive m.tuberculosis bacteria epitheloid granuloma with necrosis references 1. kumar a. lymph node tuberculosis. in: sharma sk, mohan a, editors. tuberculosis. 2nd ed. new delhi: jaypee brothers medical publishers; 2009. pp. 397–409. [google schola]. 2. ahmad ss, akhtar s, akhtar k, naseem s, mansoor t, khalil s. incidence of tuberculosis from study of ne needle aspiration cytology in lymphadenopathy and acid fast staining. indian j community med. 2005;30:63–5. [google scholar]. 3. ergete w, bekele a. acid fast bacilli in aspiration smears from tuberculous patients. ethiop j health dev. 2000;14:99–104. [google scholar]. 4. metre ms, jayaram g. acid-fast bacilli in aspiration smears from tuberculous lymph nodes. an analysis of 255 cases. acta cytol 1987;31:17-9. 5. rajwanshi a, bhambhani s, das dk. fine needle aspiration cytology in diagnosis of tuberculosis. diagn cytopathol 1987;3:13-6. 6. arora vk, chopra kk. extra pulmonary tuberculosis. indian j tuberc. 2007;54:165–7. [pubmed] [google scholar]. 7. das dk, pant jn, chachra kl, murthy ns, satyanarayan l, thankamma tc, et al. tuberculous lymphadenitis: correlation of cellular components and necrosis in lymph-node aspirate with a.f.b. positivity and bacillary count. indian j pathol microbiol. 1990;33:1–10. [pubmed] [google scholar]. 8. rajwanshi a, bhambhani s, das dk. fine-needle aspiration cytology diagnosis of tuberculosis. diagnostic cytopathology. 1987;3(1):13–16. [pubmed] [google scholar]. 9. koo v, lioe tf, spence raj. fine needle aspiration cytology (fnac) in the diagnosis of granulomatous lymphadenitis. ulster medical journal. 2006;75(1):59–64. [pmc free article] [pubmed] [google scholar]. 10. ezabih m, mariam dw, selassie sg. fine needle aspiration cytology of suspected tuberculous lymphadenitis. cytopathology. 2002;13(5):284–290. [pubmed] [google scholar]. 11. sarwar a, aftab s, mustafa m, moatasim a, siddique s, sani a. spectrum of morphological changes in tuberculous lymphadenitis. internation journal of pathology. 2004;2(2):85–89. [google scholar]. 12. 0llner jj, toossi z. tuberculosis. in: kelley wn, ed.te x t -book of internal medicine. 2nd ed. philadelphia, pa: lippincott;1992:1426-1434 . volume-9, issue-1, january-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra x 17gjra global journal for research analysis introduction supraclavicular brachial plexus block is a common regional anaesthetic technique used to provide anaesthesia and analgesia for upper limb surgery. dexmedetomidine, is highly selective and specic α2 adrenergic agonis t , having analgesic , sedat ive, [2]antihypertensive and anaesthetic-sparing effects produces manageable hypotension and bradycardia but lacks respiratory depression. it has been extensively studied as an adjuvant to local anaesthetic agents. dose range 0.5–2 µg/kg [3]has been used in various studies. hyaluronidase depolymerises hyaluronic acid, a major component of extracellular matrix. it accelerates onset and improves quality of anaesthesia for subcutaneous inltration blocks by increasing spread and dispersion of local [4-6]anaesthetics. material and methods after the institutional ethics committee's approval and written informed consent, this prospective randomized study was conducted on sixty patients of asa grade i and ii of either sex, aged 20-40 yrs scheduled for upper limb orthopaedic surgeries. patients known to be sensitive or allergic to study medication, history of cardiac, respiratory, hepatic, renal disorders, clotting disorders and pregnant women were excluded. details of procedure were fully explained to patient during preoperative visit. patients were randomly divided into two groups of thirty patients each. patients in group d (n = 30) received 10 ml of bupivacaine 0.5% with 1 ml (100 µg) dexmedetomidine and group h (n = 30) received 10 ml of bupivacaine 0.5% with 1 ml (150 iu) hyaluronidase. all patients were fasted for 6–8 hours before surgery. inside operating room, iv access secured with wide bore cannula in non-operative arm and infusion of lactated ringer started. patients were premedicated with inj. ondansetron 4 mg, ranitidine 50 mg via drip and midazolam 2 mg intravenously. supplemental oxygen provided via nasal prongs @ 4 l/min. baseline heart rate (hr), non-invasive blood pressure (nibp) and spo were recorded prior to block. 2 under all aseptic precautions, the supraclavicular brachial plexus block was performed in the supine position. sensory and motor blocks were evaluated every 2 min within rst 30 min following completion of drug administration. vital parameters (pulse, blood pressure, respiratory rate and spo ) 2 were recorded every 5 min for rst 30 min and thereafter every 10 min till the end of surgery. sensory block was assessed by pinprick test and graded as grade 0-no sensation felt grade 1-dull sensation felt grade 2-sharp pain felt. motor block was assessed using modied bromage scale as, 3-extension of elbow against gravity 2-exion of wrist against gravity 1-nger movement 0-no movement. onset of sensory block was dened as time from injection of local anaesthetic till no response to pinprick test and onset of motor block was dened as time between injection and motor paralysis. duration of sensory block was considered as time interval from complete sensory block till rst postoperative pain, and duration motor block was dened as time interval between complete paralysis and complete recovery of motor function. postoperative pain levels were assessed by visual analogue scale (vas) from 0 (no pain) to 10 (severe pain). time between end of local anaesthetic administered and rst comparative evaluation of dexmedetomidine and hyaluronidase as adjuvant to 0.5% bupivacaine plain in landmark guided supraclavicular brachial plexus block for upper limb surgeries original research paper dr. deepak khare senior resident, department of anaesthesiology, gandhi medical college, bhopal (m.p.) anaesthesiology background and aims:various additives are mixed with local anaesthetic agents to increase the quality of block in regional anaesthesia. we compared dexmedetomidine and hyaluronidase as an adjunct to bupivacaine (0.5%) in supraclavicular brachial plexus block with respect to the onset and duration of sensory and motor block and duration of analgesia. material and methods:sixty american society of anaesthesiologists grades i and ii patients scheduled for various orthopaedic surgeries of the upper limb under supraclavicular brachial plexus block were divided into two equal groups in a randomized, double-blind manner. patients were assigned randomly to one of the two groups. in group d (n = 30), 10 ml of 0.5% bupivacaine plus 1 ml (100 μg) dexmedetomidine and in group h (n = 30), 10 ml of 0.5% bupivacaine plus 1 ml (150 iu) hyaluronidase were given. the onset and duration of sensory and motor block, duration of analgesia, and quality of anaesthesia were studied in both the groups. results:there was statistically signicant difference in the onset of sensory and motor block in both the groups. the durations of sensory and motor blocks were 502.66 ± 43.78 and 557.67 ± 38.83 min respectively, in group h, whereas they were 535.9 ± 43.78 and 558.40 ± 38.83 min, respectively, in group d. the duration of analgesia was 525.33 ± 42.99 min, signicantly less in group h compared to 610.20 ± 42.89 min in group d (p < 0.001). the quality of anaesthesia was signicantly better in dexmedetomidine group compared to hyaluronidase group (p < 0.001). conclusion:the addition of dexmedetomidine prolongs the durations of sensory and motor block and duration of analgesia and improves the quality of anaesthesia as compared with hyaluronidasee when injected with bupivacaine in supraclavicular brachial plexus block. abstract keywords : dexmedetomidine, hyaluronidase, supraclavicular brachial plexus block volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. yashwant dhawale* associate professor, department of anaesthesiology, gandhi medical college, bhopal (m.p.) * corresponding author 4 x gjra global journal for research analysis analgesic request was recorded as duration of analgesia. adverse events comprised hypotension (mean arterial pressure <20% from baseline), bradycardia (hr <50 bpm), hypoxemia (spo <90%), nausea and vomiting. at the end of 2 surgery, the quality of anaesthesia was assessed according to [7]a numeric scale 4excellent: no complaint from patient 3good: minor complaint with no need for supplemental analgesia 2moderate: complaint which required supplemental analgesics 1unsuccessful: patient was given general anaesthesia. data were analyzed by student's t-test and chi-square test. p value < 0.05 was considered statistically signicant. results the demographic data were comparable in each group [ ]. although sensory and motor block onset times were table 1 shorter in group d than in group h, the difference was statistically signicant [ ].table 2 table 1: sensory and motor block durations were signicantly prolonged in group d compared to group h (p < 0.001). the duration of analgesia was signicantly longer in group d than in group h (p < 0.001) [table 2]. table 2: baseline hemodynamic parameters were comparable in both groups [figures 1 and 2]. although there was signicant fall in mean pulse rate and blood pressure in dexmedetomidine group, no treatment was required. hr and arterial pressure were comparable during the study period in both groups. the quality of anaesthesia was found signicantly better in patients who received dexmedetomidine (p < 0.05). figure 1: comparison of pulse rate. figure 2: comparison of blood pressures. sbp: systolic blood pressure dbp: diastolic blood pressure none of the patients experienced hypotension, bradycardia, or hypoxemia that required treatment. drowsiness, nausea and vomiting were not seen in any patients. discussion we compared addition of dexmedetomidine (100 µg) and hyaluronidase (150 iu) as an adjuvant to bupivacaine in supraclavicular brachial plexus block. the onset time for both sensory and motor blocks using dexmedetomidine in b u p i v a c a i n e w a s f a s t e r t h a n h y a l u r o n i d a s e . dexmedetomidine provided longer duration of motor & sensory blocks, prolonged duration of analgesia and better quality of anaesthesia. it was reported in various studies that the addition of α-2 adrenoreceptor agonists to local anaesthetic agents in peripheral nerve blocks improved quality of anaesthesia and .[8,9,10,11]prolonged duration of analgesia [12]yoshitomi et al found that addition of dexmedetomidine to lignocaine enhances local analgesic effect. two different [13]sciatic nerve rat models, brummett et al found that dexmedetomidine added to bupivacaine signicantly prolonged the duration of analgesia. the mechanism by which α-2 adrenoreceptor agonist produces analgesia and sedation is l ikely to be [14]multifactorial. peripherally they produce analgesia by [15]reducing release of nor epinephrine and causing α-2 receptor-independent inhibitory effect on nerve action [16]potentials. centrally, α-2 adrenoreceptor agonists produce analgesia and sedation by inhibition of substance p release in the nociceptive pathway at the level of the dorsal root neuron [17]and by activation of α-2 adrenoreceptors in locus coeruleus. α-2 adrenoreceptors are coupled via a pertusis toxin-sensitive g protein to potassium ion channel and results in an increase [18]potassium ion channel conductance. furthermore, the block was conducted via the landmarkguided technique without the use of a nerve stimulator or ultrasound guidance, which may have led to the relatively lower block success rate for radial nerve compared with that in our study. reports of adverse effects associated with hyaluronidase are [19]rare. no adverse effects were seen with hyaluronidase in present study. conclusion our study demonstrated that addition of dexmedetomidine to bupivacaine in supraclavicular brachial plexus block prolonged the duration of analgesia and improved quality of anaesthesia as compared to hyaluronidase with hemodynamic stability and lack of side effects, thus making dexmedetomidine an attractive choice for adjuvant to bupivacaine in supraclavicular brachial plexus block. acknowledgment we thank the department of orthopaedics, gandhi medical college, bhopal for their cooperation. financial support and sponsorship nil. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra variables group d group h age(years) 37.83±11.28 38.03±11.25 weight(kg) 57.93±7.36 56.47±7.80 sex ratio(m:f) 22:8 20:10 type of surgery ·lower end humerus 6 5 ·radius/ulna/both 10 11 ·hand 4 4 variables group d group h onset of sensory block(min) 9.17 ± 1.262 13.8 ± 4.621 onset of motor block(min) 12.63 ± 2.189 15.6 ± 6.300 duration of sensory block(min) 535.90 ± 43.78 502.66 ± 43.78 duration of motor block(min) 558.40 ± 38.83 557.67 ± 38.83 duration of analgesia(min) 610.20 ± 42.89 525.33 ± 42.99 x 5gjra global journal for research analysis conflicts of interest there are no conicts of interest. references: 1. abdallah fw, brull r. facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: a systematic review and metaanalysis. br j anaesth 2013;110:915-25. 2. bajwa sj, kulshrestha a. dexmedetomidine: an adjuvant making large inroads into clinical practice. ann med health sci res 2013;3:475-83. 3. kettner sc. dexmedetomidine as adjuvant for peripheral nerve blocks. br j anaesth 2013;111:123. 4. nathan n, benrhaiem m, lot h, et al. the role of hyaluronidase on lidocaine and bupivacaine pharmacokinetics after peribulbar blockade. anesthesia and analgesia 1996; 82: 1060–4. 5. lewis-smith pa. adjunctive use of hyaluronidase in local anaesthesia. british journal of plastic surgery 1986; 39: 554–8. 6. dunn al, heavner je, racz g, day m. hyaluronidase: a review of approved formulations, indications and off-label use in chronic pain management. expert opinion on biological therapy 2010; 10: 127–31. 7. memis d, turan a, karamanlioglu b, pamukçu z, kurt i. adding dexmedetomidine to lidocaine for intravenous regional anesthesia. anesth analg. 2004;98:835–40. 8. gabriel js, gordin v. alpha 2 agonists in regional anesthesia and analgesia. curr opin anaesthesiol. 2001;14:751–3. 9. bhatnagar s, mishra s, madhurima s, gurjar m, mondal as. clonidine as an analgesic adjuvant to continuous paravertebral bupivacaine for postthoracotomy pain. anaesth intensive care. 2006;34:586–91. 10. el-hennawy am, abd-elwahab am, abd-elmaksoud am, el-ozairy hs, boulis sr. addition of clonidine or dexmedetomidine to bupivacaine prolongs caudal analgesia in children. br j anaesth. 2009;103:268–74. 11. marhofer d, kettner sc, marhofer p, pils s, weber m, zeitlinger m. dexmedetomidine as an adjuvant to ropivacaine prolongs peripheral nerve block: a volunteer study. br j anaesth. 2013;110:438–42. 12. yoshitomi t, kohjitani a, maeda s, higuchi h, shimada m, miyawaki t. dexmedetomidine enhances the local anesthetic action of lidocaine via an alpha-2a adrenoceptor. anesth analg. 2008;107:96–101. 13. brummett cm, amodeo fs, janda am, padda ak, lydic r. perineural dexmedetomidine provides an increased duration of analgesia to a thermal stimulus when compared with a systemic control in a rat sciatic nerve block. reg anesth pain med. 2010;35:427–31. 14. esmaoglu a, yegenoglu f, akin a, turk cy. dexmedetomidine added to levobupivacaine prolongs axillary brachial plexus block. anesth analg 2010;111:1548-51. 15. sato j, perl er. adrenergic excitation of cutaneous pain receptors induced by peripheral nerve injury. science 1991;251:1608-10. 16. gaumann dm, brunet pc, jirounek p. clonidine enhances the effects of lidocaine on cber action potential. anesth analg 1992;74:719-25. 17. guo tz, jiang jy, buttermann ae, maze m. dexmedetomidine injection into the locus ceruleus produces antinociception. anesthesiology 1996;84:873-81. 18. kamibayashi t, maze m. clinical uses of alpha2 -adrenergic agonists. anesthesiology 2000;93:1345-9. 19. kim tw, lee jh, yoon kb, yoon dm. allergic reactions to hyaluronidase in pain management – a report of three cases. korean journal of anesthesiology 2011; 60: 57 –9. volume-8, issue-10, october-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 6 x gjra global journal for research analysis 07.dr rajeev kumar ranjan.cdr introduction stroke has been conventionally dened as a neurological decit of focal nature persisting for more than 24 hours due to stoppage of cerebral blood supply. this dening timeline boundary is also useful in distinguishing transient ischemic attack (tia) which is not of more than 24 hours duration but can mimic stroke clinically. (1) the problem of stroke is ram pant worldwide but in resource limited settings particularly in third world and developing countries like india it's a major problem as it not only causes morbidity but due to lack of dedicated care also produces mortality and complications compounding the problem.(2,3) advances in care in the course of recent years have extraordinarily improved the result for stroke patients with a decrease in mortality and more patients at last accomplishing autonomy. among a few potential changes, three components are to a great extent liable for this improvement. first was the development of devoted stroke units that offer both intense and rehabilitative consideration for the different and variable needs of stroke patients. second was the presentation of intravenous thrombolysis, which addressed the principal compelling treatment for intense ischemic stroke. and lastly third which is by no means is the least, is general awareness in the public about the gravity of the situation. (4,5) various governments are more proactive now as they are now with dedicated programmes to increase the awareness , generate the evidence about the prevalence , and improved surveillance like uk's act fast campaign programme , and in india npcdcs (6,7) . despite the advances even in developed countries and in india many patients don't fully recover from stroke and remain crippled for many years resulting in huge economic losses. this scenario has been well generalized as the rule of one third which says one third dies after stroke , one third remains long term disabled while rest of the third recover fully to have their dependency removed .( 8,9) most of strokes are ischemic (around 80%) and the greater part of these identify with issues with blood vessel blood stream to the cerebrum; ischemic stroke auxiliary to venous inadequacy is substantially less normal. hemorrhagic stroke represents the rest 20% . (10, 11) with modern changes and new innovations in technology now a days imaging is an integral part for any case of stroke coming to the emergency of any multi or superspeciality facility. (12, 13) an early imaging in stroke patients not only helps in excluding hemorrhages in the intracranial area, marking out the ischemia, and ruling out any mimickers. it also helps in better visualization of the intracranial and extracranial vasculature and helps in understanding the status of cerebral perfusion. the imaging also marks out clearly the infarct core and the penumbra which aids in further management of the stroke patients . (13,14) computed tomography (ct) scanning is the gold standard when it comes to choosing for the imaging modality in patients coming in emergency department with stroke presenting as some neurologic decit or other associated features. ct scans owing to certain advantages over other modalities have been the mainstay as they are more reliable in showing the difference between cerebral hemorrhage and infarction as well as its relative availability. (12, 13) owing to these advantages and ease of availability or vice versa ct has remarkably changed the way patients with computed tomography (ct) scan evaluation of stroke patients in radiodiagnosis department of rims, ranchi original research paper dr. rajeev kumar ranjan associate professor, department of radiodiagnosis, rims, ranchi, jharkhand x 17gjra global journal for research analysis radiodiagnosis introduction: advances in care in the course of recent years have extraordinarily improved the result for stroke patients with a decrease in mortality and more patients at last accomplishing autonomy. computerized tomographic (ct) scanning is the gold standard when it comes to choosing for the imaging modality in patients coming in emergency department with stroke presenting with some neurologic decit or other associated features. methodology: a cross sectional study of the available ct records for patients coming with stroke in rims ranchi was evaluated from feb 2018-aug 2018 after seeking appropriate clearance. data thus collected were analyzed using spss version 16 using standard statistical methods like mean, standard deviation, chi square test of signicance etc. p values of <.05 were considered to be of statistical signicance. results: a total 275 patients were included in the evaluation . in this study we found that the average age for male particiapnts were 55.75 ±7.99 while females were having a mean age 53.07 ± 11.85 . 25% of the patients with stroke were not diagnosed as hypertension cases while most patients recorded a gcs in mild category (44% ), while more stroke incidents were infarct in nature ( 51%) followed by hemorrahgic incidenes (21%) . cerebrovascular accidents were right side (51%) on location while mixed location ndings were (21% ). conclusion: our investigation shows that ischemic stroke is comoner than hemorrhagic in patients and greater part happened in the older patients. computer tomography (ct ) is an exceptionally valuable instrument in making the analysis of stroke just as separating hemorrrhage from ischemia which is useful in treatment of stroke patients. abstract keywords : volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. paras nath ram* associate professor, department of radiodiagnosis, rims, ranchi, jharkhand *corresponding author dr. suresh kumar toppo professor & head, department of radiodiagnosis, rims, ranchi dr. pulak abhishek senior resident, department of radiodiagnosis, rims,ranchi 18 x gjra global journal for research analysis stroke are now managed with reduced mortality and morbidity owing to prompt diagnosis, better guided interventions and follow up . this study is done with an aim to understand the incidence of stroke in patients coming in the department of radio diagnosis for ct scan. the study intends to nd out the nature of stroke, its occurrence in various age groups, different genders and various types of hemorrhages or infarcts coming up in the hospital . data regarding these are almost non existent for jharkhand , in ranchi and neighboring districts . this study will give an insight and will aid further research in this area . materials & methods a cross sectional study was undertaken after clearance from the appropriate authorities. the study consists of data collected from 275 patients undergoing ct scan in the department of radiodiagnosis rims, ranchi who presented with clinical features of stroke. study was done from feb 2018 to aug 2018. questionaire to collect the data was designed in the radio diagnosis department of rims, ranchi. patients with history of head injury were excluded from the study. ct scan of patients were done on siemens somatom sensation 16 slices ct scan machine. records of patients undergoing ct scan for stroke as primary diagnosis was reviewed in the department. we looked for age, gender, and address, and above poverty line/below poverty line, htn diagnosed or not, stroke features, gcs and ct ndings. incomplete entries (if any) and follow up cases, were excluded from our record review. statistical analysis was done after having the data on ms ofce , microsoft excel sheets on spss version 16.0 . measures of central tendency , mean standard deviation and percentages were used to describe the results . while tests of association like chi square were used to determine the relationship between various ndings. p value of <.05 was considered to be statistically signicant. results a total 275 records were included in the evaluation . in our record analysis we found that the average age for male particiapnts were 55.75 with a standard deviation of 7.99 while females were having a mean age 53.07 with a standard deviation of 11.85. we had as per the records 136 males while 139 females . none of the males were less than 18 years while females were in the age group of 12-70 . we futher had a breakdown of various religion , ses , locality and employment status of the records of ct avaialble in the department (table 1, 2) . study showed that most of the patients seen were hindu(58.2%) followed by sarna ( 16.4%) and sikh(14.5%). (table 1) . we had more bpl patients but apl patients too were present for ct scanning of their episodes of stroke or neurological decit which was close to 40% ( table 2) . the majority of pateints wth stroke were in the age group of 45-65 (72%) while for males and females the break up was 76.5% and 67.6% respectively . age category and sex were associated with statitical signicance . (table 2) . we also evaluated the ct scan records for various features like location of the injury , type of cerebrovascular compromise , whether hypertension was prediagnosed or not and glassgow coma scale scores at the time of admission mentioned . gcs was graded in three categories mild degree of confusion with scores of 13-15 , while moderate for scores of 9-12 and severe for scores of 3-8 . we found that 25% of the patients with stroke were not diagnosed as htn cases while most patients recorded a gcs in mild category 44% , while more stroke incidents were infarct in nature ( 51%) followed by hemorrahgic incidenes (21%) . most of the cerebrovascular incidents were right side (51%) on location while mixed location ndings were 21% . (table 3) volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra table 1 : socieconomic distribution of records review according to religion and gender gender male =136, females 139 religion total hindu muslim sikh sarna total age categorization 12-30 n 2 3 1 1 7 % 28.6% 42.9% 14.3% 14.3% 100.0% 30-45 n 23 0 6 2 31 % 74.2% 0% 19.4% 6.5% 100.0% 45-65 n 114 19 29 36 198 % 57.6% 9.6% 14.6% 18.2% 100.0% 65-70 n 21 8 4 6 39 % 53.8% 20.5% 10.3% 15.4% 100.0% total n 160 30 40 45 275 % 58.2% 10.9% 14.5% 16.4% 100.0% p value<.05 figure 1: left hemispheric intracerebral hemorrhage in one of the patients figure 2: right mca territory infarct in one of the patients table 2 : gender wise distribution of ses, residence and employment status of records gender ses residence employment total apl bpl urban rural employed non employed male age categorization 30-45 n 7 5 1 11 12 0 12 % 58.3% 41.7% 8.3% 91.7% 100.0% 0.0% 100.0% 45-65 n 45 59 47 57 55 49 104 % 43.3% 56.7% 45.2% 54.8% 52.9% 47.1% 100.0% 65-70 n 3 17 2 18 8 12 20 x 19gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra % 15.0% 85.0% 10.0% 90.0% 40.0% 60.0% 100.0% total n 55 81 50 86 75 61 136 % 40.4% 59.6% 36.8% 63.2% 55.1% 44.9% 100.0% female age categorization 12-30 n 3 4 2 5 1 6 7 % 42.9% 57.1% 28.6% 71.4% 14.3% 85.7% 100.0% 30-45 n 3 16 8 11 6 13 19 % 15.8% 84.2% 42.1% 57.9% 31.6% 68.4% 100.0% 45-65 n 40 54 40 54 10 84 94 % 42.6% 57.4% 42.6% 57.4% 10.6% 89.4% 100.0% 65-70 n 5 14 12 7 5 14 19 % 26.3% 73.7% 63.2% 36.8% 26.3% 73.7% 100.0% total n 51 88 62 77 22 117 139 % 36.7% 63.3% 44.6% 55.4% 15.8% 84.2% 100.0% discussion as the population increases along with a life style which is conducive to developing the ncds the number of stroke patients will increase thus mandating rapid evaluation of such patients . as of now non contrast ct is the primary imaging modality being employed routinely for all stroke cases . ct is all the more normally used owing to its across the board accessibility, reasonableness for the unwell and therapeutically temperamental pat ient and precis ion in barr ing contraindications to intravenous thrombolysis. what's more, when evaluated by competent people, non-contrast ct gives complimentary data on the nearness of early infarct and, now and again, gives a particular proportion of blood vessel rupture when a hyperdense course is recognized. (15,16) in our study we saw majority of patients were in the age group of 45-60 (72%) . this nding is in accordance to other studies conducted in similar settings . (12,13,17) we found an association of males and their employment status to be of staisitcal signicance which is similar to ndings from other studies as well (11,12) . the location of the cerebrovascular accident in form of infarcts were almost similar to other studies across different study settings ( 8,9,12) the relationship of hypertension and its consequences as stroke is well known but as the rule of halves suggest for htn in our study too we saw almost 25% of stroke patients not being diagnosed with hypertension . this ndings has been well illustrated in other studies as well ( 8,10,12,13) conclusion as its record based review with small smaple size more research needs to be done for tangible evidence to suggest and address various aspects of the stroke incident in patients. in our study infarcts were more common occurrence as has been the trend world wide. timely ct is an integral component in management of stroke patients so that they can recover and morbidity can be lowered. references 1. mathers cd, bernand c, iburg km, inoue m, ma fat d, shibuya k, et al. global burden of disease: data sources, methods and results. world health organization; 2004. 2. collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. stroke unit trialists’ collaboration. bmj 1997; 314: 1151–9. 3. mair g, wardlaw jm. imaging of acute stroke prior to treatment: current practice and evolving techniques. br j radiol. 2014;87(1040):20140216. doi:10.1259/bjr.20140216 4. wardlaw jm, murray v, berge e, del zoppo g, sandercock p, lindley rl, cohen grecombinant tissue plasminogen activator for acute ischaemic stroke: an updated systematic review and meta-analysis.lancet. 2012 jun 23; 379(9834):2364-72. 5. the international stroke trial (ist): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. international stroke trial collaborative group. lancet 1997; 349: 1569–81. 6. dombrowski su, mackintosh je, sniehotta ff, et al. the impact of the uk 'act fast' stroke awareness campaign: content analysis of patients, witness and primary care clinicians' perceptions. bmc public health. 2013;13:915. published 2013 oct 2. doi:10.1186/1471-2458-13-915 7. dghs, mohfw. national programme on prevention and control of diabetes, cardiovascular diseases and stroke. new delhi: mohfw;2008. 8. saka o, mcguire a, wolfe c. cost of stroke in the united kingdom. age ageing. 2009;38(1):27–32. doi:10.1093/ageing/afn281 9. national institute for health and care excellence (nice). stroke quality standard (qs2). 2010. available from: http://www.nice.org.uk/guidance/qs2 10. adams hp, del zoppo g, alberts mj, et al. guidelines for the early management of adults with ischemic stroke. circulation. 2007;115(20):e478e534. 11. srinivasan a, goyal m, azri fa, lum c. state-of-the-art imaging of acute stroke. radiographics. 2006;26(suppl_1):s75-s95. 12. eze c, okaro a, ohagwu c. pattern of computed tomography ndings in cerebrovascular accident patients in south eastern nigeria–a retrospective study of 480 patients. eur j sci res. 2009;34:104-109. 13. mullins me. modern emergent stroke imaging: pearls, protocols, and pitfalls. radiologic clinics. 2006;44(1):41-62. 14. watila m, ibrahim a, balarabe s, et al. risk factor prole among black stroke patients in northeastern nigeria. journal of neuroscience and behavioral health. 2012;4(5):50-58. 15. cortijo e, garcía-bermejo p, calleja ai, et al. intravenous thrombolysis in ischemic stroke with unknown onset using ct perfusion. acta neurol scand. 2014;129(3):178–183. doi:10.1111/ane.12160 16. kane i, whiteley wn, sandercock pa, wardlaw jm. availability of ct and mr for assessing patients with acute stroke. cerebrovasc dis. 2008;2 5(4):3 75–3 77. doi:10.1159/000120688 17. sudlow c, warlow c. comparable studies of the incidence of stroke and its pathological types: results from an international collaboration. stroke. 1997;28(3):491-499. table 3 : description of the ct ndings and its relationship with htn diagnosis occurrence location glasgow coma scale total ischaemic hemorrhagic mixed right left bilateral mild (13-15) moderate (9-12) severe (3-8) htn diagnosed y n 111 51 45 121 56 30 102 60 45 207(75%) % 53.6 24.6 21.7 58.5 27.1 14.5 49.3 29.0 21.7 100.0 n n 31 24 13 33 10 25 21 37 10 68(25%) % 45.6 35.3 19.1 48.5 14.7 36.8 30.9 54.4 14.7 100.0 total n 142 75 58 154 66 55 123 97 55 275(100%) % % 51.6 27.3 21.1 56.0 24.0 20.0 44.7 35.3 20.0 100.0 p value >.05 p value <.005 p value <.005 86.dr suraj singh bhadoria online.cdr introduction the word hijras refers to the khawaja sarah, those people who live in a community made for some purpose towards human welfare, good wishes and their bright future. they are basically a transgender, a person who does not satised with their birth assigned sex. they are born in between men and [2].women. neither a complete men and complete women therefore, every hijras are undergoes into castration or [4].penectomy as per their third gender variance every hijras considered as transgender but every transgender is not becoming an hijras. hijras have strong background in our sculpture of hindu mythology. now these people are considered as a third gender people according the supreme court decision on 2014. these community of people belongs to the lgbtq, which shows an multiple dimensions and variations in gender. here, l stand for lesbian relates to those females who interested in another female and married him. g stand for the gay, relates to those male people who interested in another male for married him. b stands for the bisexual, those people who born as either male and female and interested in both the sex, gender. so, there are two categories of bisexual, male bisexual and female bisexual. male bisexual having interest in both the female as well as male person. whereas female bisexual having interest in both the male and female individual. t stands for the transgender person who neither be complete male and female. they are people who does not satises with their birth assigned sex. they are considered as two main variety, such as male transgender and female transgender. male transgender is those who born as a female but having male soul, spiritual power in their body as soon as possible converted into male body transition. whereas female transgender is those persons who born as a male body but having a female spiritual soul, spirit and converted as soon as female transition. so, these are the two main categorisation of transgender which plays an important role in this group of community. at the end q stands for queer which means a people who cross dressed in aspect of their gender variance. a male wear female cloth and make their hair style as female long hair. similarly, a female wears a male like cloths and dress up a male like short cut hairs. according to this there are different gender variance seen in our community with number of people with some unique features and characters on him. in our hindu mythological background this hijras considered as an reunion of two energy, powers in a single materialism. they exist in everywhere as some devine and a unique creature of god as an avtar. in vedic these genders of people called as tritiya prakriti. a third gender of people. there are various characters in ramayan and mahabharat which plays an important role as kinner, hijras in their life span giving to some purpose towards humanity. there are some special dimensions of these group of community. transgender (hijras) reects that female soul trapped in a male body, which dened as transgender wom an. so, this reecting as a transitional zone of a two-gender variance. but on other hand there is no gender of any soul. but still we have this signicant value of transgender as a gender variance. life is considered as union of mind, body and spirit. similarly, in dimensions of transgender this mind is not matched with their anatomical structure of body, which already dene as materialism. the intellectual property of this mind like will, emotions, desire is always opposite to the body. suppose if there is a person who born as a male but their intellectual property, mind is more towards feminine characters. so, they are not satised with their gender hence they undergo into the transition of female asper their intellectual property (mind) called as (mtf) similarly in case of a person born as female but their intellectual property, mind is more towards the masculine character, so they do not satisfy with their gender and undergoes into the transition into male body called as (ftm). when these group of people join a community towards a various aspect of hijras life in mythological background original research paper dr. suraj singh bhadoria post graduate scholar, department. of homeopathic pharmacy, bharati vidyapeeth (deemed to be university) homeopathic medical college and post graduate research centre, pune, maharashtra, india. x 41gjra global journal for research analysis homeopathic in this study we are going to show the various phases, life style and aspect of hijras with the correlation in our hindu mythological background. hijras are generally considered as a devine, sub demi gods, they have some spiritual power, blessing towards the human welfare, good wishes, luck etc, these powers given by god to him. they are known as a god child, made for some purpose and aim towards the community of living entity. the people of this community also maintain a equilibrium between human entity and nature. there is various cultural aspect of these kind of people regarding to the rituals and workship in our community. god made everyone as a unique character to act their role in this universe. similarly, these community of people also made for some has some unique characters, features in respect to their god creature. hindu mythology gives a unique signicant value of hijras in human welfare. but there is some social stigma, rejections, discrimination which affects the social, economic, health status of these community of people in our india. abstract keywords : hijras, lgbt, gender variance, prostitutes. avtar, masculinity, feminity. avtar, vedic culture, ardhnari, reunion, masculinity, feminity. fertility. transformation, nirvana. aravan, transformation, sacrices. hijras, niravana, guruchela. masculinity, feminity, union. hiv, marginalization, disrespectful. constitutional rights, citizenship, discrimination. volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. arun bhargav jadhav* head of institute, bharati vidyapeeth (deemed to be university) homeo pathic medical college and post graduate research centre, pune, maharashtra, india. *corresponding author 42 x gjra global journal for research analysis human welfare and good wishes they are called as hijras. there are various synonyms of hijras such as in tamil nadu they are called as aravani, in andra pradesh they are called as shiv shakti, in maharashtra, karnataka, they are servant of goddess renuka devi and jogtas. the main signicant part of hijras community is clapping. this sound of clapping denes some signicant role in energy, they sound like a different. there is some special features and uniqueness in their life style habits. which reect some message towards philosophical background. in our society these people live and in search of himself. they join a group of community which similar as him. they come under the inuence of god. which denes as a creature of this universe. and complete their whole life style in serve of humanity, wellness. in our society there are some myth related to gender variance like they accepted only two gender people of male and female sex, on other hand they did not accepted this third gender people. because they consider him as an something abnormal to him. they did not understand and accepted this multiple dimensions, features of gender. so, there is rejection, discrimination, social violence, stigma towards these gender and community of people. because their life style, habits and characters are very different from others one. hence it affected their social, economic, educational status and health status. there are less resources, facilities towards these genders of people. they always treated like a different, therefore excluded from our society. the most important thing is many hijras are work like a prostitute, sex worker. they highly [1]involved in a sexual activity . these people are specially inviting and plays an important role in occasion of child birth and marriages for their good [3]luck and wishes . hijras belongs to all cast, religion and community. they [5]spread all over the areas . spirit of hijras basically hijras, kinner derived as reunion of two energy together in a single materialism. which makes some uniqueness in their special characters. there are two soul of masculinity and feminity. masculinity is derived from lord shiva and feminity is derived from goddesses shakti. therefore, hijras are considered as neither a complete male and female. they have special power of these two energies. every science is derived from two basic component such as philosophical background and scientic background. this philosophical relates to non-materialism and scientic relates to materialism. hence in aspect of philosophical background if two energy meet together one or one is always a one. in mathematical expression [1 + 1 = 1]. on other hand in materialism, non-philosophical background this one and, one unites together and form two. in mathematical expression it is [1 + 1 = 2]. therefore, hijras born as a reunion of these two sources of energy together in some purpose of human welfare. these spirits have some special features like they always work together, they never be separated out, their dependency is togetherness. the effect of these two energies are also to be different on body parts. such as the masculinity energy is dominating more towards the right sided of body whereas the feminity energy is dominating more towards on the left sided body part. so according to this there is equal division, uniformity of both these energies in a single whole body. these union of two different energies act on body. under the inuence of god as curses and manifest as an avtar (blessing) to him. these two energies are never overlap together. they always remain constant and uniform in a same direction. which does not affect from external, environmental stimuli. when we talk about the nature of these two energies, one is dominating and another one is recessive. background of hijras in hindu mythology a. hijras in ramayan there were many stories regarding to hijras in our mythol ogical background. in times of ramayan, ram was fought with demon ravenna and go to the sri lanka to bring hiss wife, sita. and again, back to the india. before this, his father commanded that ram leave to ayodhya and go to the forest for atlest 14 years. as a result, ram went, the whole individuals and citizen was followed him. because the citizen of ayodhya loved ram so much, they came behind ram. as ram were came to banks of river at edge of the forest, he returns to people and said, ladies and gents please wipe your tears and go away. there are some group of people who were not men or a woman so, they were stayed there because ram did not ask to them to go away. they remained stay and waiting for the ram around 14 years. when ram return from lanka and he was found that a group of people still waiting for him. so, he said to these people why you didn't return. these people told to ram that you said ladies and gents but not our community. so, we still waiting for you. hence, there is some tears rolling from the eyes of ram and they all were blessed by ram. they have power to bless good fortune and fertility. b. hijras in mahabharat there are many characters plays their role in the mahabharat. there was a vedic culture which allowing the transgender people to live accordingly to their gender. arjuna and brhinnala. there was a character of arjuna lives incognito for the one year as a part of the prince because he must pay for losing a game of dice and also rejecting the advances of one of celestial nymphs. therefore, arjuna decides to hide himself in the guise of eunuchs / transvestite, then he wears a bangles made of white conch, braiding his hairs like a woman, clothing himself like an female and serving the ladies of king court (rajagopalachari 1980). on other hand there was an important role, character in mahabharat named as sikhandi he was neither a men and woman. lies in between the men and woman and having a rightful place in the society. shikhandi was a powerful and strong character. there was an important character in mahabharat aravan a son of arjuna. he asked to lord krishna about their three boons. in her third boons he was asked to lord krishna to be married before his death. but there was a problem that no king married their daughter for aravan to knowing that next day he died. hence to full these third boons of aravan lord krishna himself took an avtar of mohini as a female spirit and become bride for aravan for one day, and married him to full their wishes. and next day when aravan sacriced his life and [6]mohini mourn aravan's death after his sacrices . origin of hijras'ardhnarishwar’ as we know hijras are neither a man and woman, they always volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra lie in between the gender of men and woman. according to our hindu mythology background this kind of people are considered as a ardhnari, half woman god. in ancient time there was a story that brahma a creature of this universe face some problems regarding the upcoming junration because on that time brahma created the junration of male dominating, a men but the junration does not go forward so due to this problem brahma go to the supreme of god lord shiva and said about these junration problem in this earth. hence, lord shiva shows their avtar of ardhnarishwar. in which half right sided part of body covers masculinity of lord shiva and half left sided part of the body covers by the feminity shakti. as a result, brahma recognise them and create a woman in this earth to continue the next junration in corresponded to men. from this concept it was found that hijras are the creature of lord shiva (masculinity) and shakti (feminity) with their union in a single material body, entity bahuchara matahijras in hijras community bahuchara mata, recognized as a form of the mother goddess. is a household deity that is worshipped, mostly, for her perceived ability to bring fertility to people, specically childless couples and newlyweds. women will also pray to her if they want specically male children. although the bahuchara mata is praised for her ability to bring good fortune in the form of the male children and fertility, she is also capable of bringing the horrible misfortunes to those one who deceive her on that time. there are some variations in mythological stories of this bahuchara mata. in these stories' thieves are trying to take away her virtue in the rape. in another story, she attempts to war off their advances by the cutting of their breast to maintain her virtue and purity. on other hand thieves succeed in raping her and she consequently transforms them into the eunuchs to speak her ability to bodily transformation. therefore, hijras castrate themselves in her name. this occasion is known as a nirvana, when a newly transgender women enter in the community of hijras. hence, this bahuchara mata is one of the goddesses of [9] hijras community . marriage of hijras life in southern india, there is a eighteen day festival from which one day marriage with the aravan. there was a hero in mahabharat named as aravan a son of arjun who sacrices his life. on other hand there is transformation of lord krishna as a female form of mohini to married with aravan before his death to full their last wishes. there is a festival devoted to the male to female transfo rm ation of transgender woman. in a town of koovagam, near che nnai in state of tamil nadu. in the month of chitirai (april may). at the koothandavar temple. around many transgender persons from all over the world. they all are going to participating in these festivals and become a mohini as a incarnation of lord krishna and married to aravan and on next day they going to state of mourning and widowhood. so, every transgender woman devoted to sacrices of aravan in mahabharat. hence in tamil nadu every transgender woman [7]said to be aravani. this is a major festival in our indian . how to became a hijras when a person born a male gender but not satised with their birth assigned sex due to their female soul so he rst lives their society and go to the search of himself. as a result, he goes to the rituals of gharana, he is basically castrated and this procedure is generally known as a niravana. the whole ritual is celebrated as a ceremony and after this male became a hijras/ chela of the guru. so, in hijras community this guru chela plays an important role in their whole life span. guru is a main leader of every chela. guru is there is no member of men in this community, only there is a sister, mother and daughter. guru plays an important role in chela as if her mother, father everything. after entering in this community, a person should understand and accept all the rituals, background study of the hijras life style. for participating in various ceremonies like child borth and marriages for performing their dance and clapping to give blessing and good wishes to that community. significance of clapping hijras has special features of clap, because as we know that hijras are those people who neither be a men and woman. they lie in between the men and woman or somewhat they have all and equal quality, combination of men and woman so this signies that when they clap there is union of these two different energies of masculinity as well as feminity togetherness. in during clapping when one hand meets to another hand so it denes that one energy meets to another energy in a single materialism. this plays an important role. in our street, colony, areas when these people came so rst, they clap. the sound of their clapping is loud and different. which shows something in their uniqueness. on other hand when hijras people give blessing and curses to any one individual so they also clap. which is somewhat a transformation of the energy from one state to another one for some purpose behind it. earning source of hijras in the community of hijras life the main source of their earning is badhai as perform their dance in special places, ceremony of child birth and marriages, to give their blessing and good fortune to the newly born baby and newly married couple for their upcoming life. this plays an important role in our hindu mythological background. on other hand theses hijras are also going to bagging in the street, public places, in trafc signals because there are no such resources, job opportunity, right to career as similar as non-transgender person have. so, they have a poor economic status. due to these hijras are also becoming a sex worker. to sale their body for earning. kind of hijras there are mainly four types of hijras. such as; 1. intersexual / hermaphroditethese are the person who born as both male and female genital organs. there are three main categories. such as; a. true hermaphroditethey are basically a person who born with the both testis and ovaries in a body. b. female hermaphroditethey are born as xx chromosome with internal female organ but their external genitalia like a male one. c. male hermaphroditethey are born as a male with xy chromosome having a internal male genitalia but external genitalia like an female one. 2. impotent personthese are the impotent who does not participate in any sexual activity and reproductive life due to their impotency. they are not able to give an birth of a child so they faces so social stigma. hence, welcome in the community of hijras life style. 3. transsexual personthey are such kind person who born as a male body with complete male genitals but they are not satised with their birth sex. so, they unsatised with their gender and want to change their body by some surgeries called as sex reassignment surgeries, where transition of male to female body. they are named as transgender woman. they became an hijras. x 43gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra there are two main categories, such as; a. castrated men hijrasthey are such men who remove their pennis and join the hijras community. b. noncastrated menthey are such men who did not remove their pennis but join the hijras community. 4. fake hijrasthey are such kind so person who dressed up like a female, clap in public places for the purpose of [7]bagging and earn money only life style of hijras these people are always live in a community, group, locality and they call everyone as she and dress up like a woman and do ever work in their house like a woman. they talk, walk, do everything like a woman. they usually live in a rent houses with four to ve members. they spend their money in purchasing of the makeup kit and jewellery because their main earning is badhai, participating in ceremony of child birth and marriages. so, they look like a beautiful lady with attractiveness in their personality. and the most important thing is they celebrates every ceremony like their happiness. so, they are very open and true hearted personality. there are lots of discrimination, rejections, stigma from our society towards this kind of people but still they live very happiest person in this world. this is a special feature of hijras life. they started every morning as a new one. they mostly travelled in the rickshaw. because when they travelled in buses so men touch him on any body parts, they pass comments on him and the most important thing is there is no compartment of transgender person. there is only two main compartments of men and woman. so, it shows some kind of rejection and exclusion to these people. health status hijras in hijras community the hiv human immune deciency virus infection and other sexually transmitted infection is very commonly seen. because hijras also involved in a sex worker, selling their body to earn money. there is no such precautions, [10]measurement in the health status of these group of people . social status hijras hijras faces many discriminations, marginalization, abuses in our india. discrimination regarding to their class, to their gender identity, all these things make stigmatized. they are rstly rejected from their family, social organizations and suffered form various form of social exclusion. they are mostly forced into the ritualized bagging because of no proper education system, no proper health care system, employment system giving to him. so, they are mostly excluded from our [11]society . health care systemhijras in our health care system these hijras does not treated like another patients. they addressed him in a very disrespectful manner. when the transgender is reluctant to show their ano rectal area. so, they are very subjected to abusive language by the physician examination or somewhat of the paramedical staff. they are generally admitted under the male ward of sexually transmitted infections to their castration [12]and cross dressing . legal position of hijras in, 2014, supreme courtjudgment (national legal services authority union of india) that afrms the constitutional rights towards the transgender people and their communities. thus, it gives a legal recognition of the transgender person as [13]subjective of citizenship and their rights . transgender protection bill (2016)in this bill the denition, description of transgender is partially, half male and female or combination of both the male and female. they are neither be a complete male and female. they are belonging to such who are not satised with the gender assignment at during the birth. there are two main categories of these genders. such as; transgender men and transgender woman. highlights of bill; 1. they must obtain a certicate as a identity proof and invoke right under the bill. there is a screening committee granted by district magistrate with some members. such as; a. medical ofcer. b. psychologist, psychiatrist. c. district welfare ofcer. d. transgender person. there is some offence to these kinds of people. if they beg, denied access to public place, physically, sexually abuses. so, 2 years imprisonment and ne. 2. there is right for education. 3. right for employment. 4. right for health care system. these rights made to prevent all the discrimination towards the transgender people. methodology the data is collected from the various research papers, research articles, various journals and combined it to form a generalised conclusion of given data. databases like google scholar were used for collecting the articles. result and discussion hijras are the part of our society with strong mythological background and considered under the third gender because they are neither men and woman. they lie in between the men and woman. female soul trapped in a male body called as male transgender. they leave social network and go to search of himself and join a community and live in respect to their own culture and religion for fullment of some good purpose in their life. as per this whole literature work, it was found that hijras has a strong mythological background. they have special features of god as a avtar or blessing on him and they plays an important role in our society as a luck and good fortunes. they are excepted under the third gender category as per vedic literature. but still there are some rejection and discrimination phases in hijras life. they excluded from our society and marginalized. there is lack of economic source, health care system, educational support, employment support which all decreases their social status. they are god own children. made for some good purpose, but we forced him into bagging, as a sexual worker, prostitution etc. hijras dances in every ceremony of child birth and marriages as their own celebration for giving blessing, good fortune to people in their upcoming life but still our society rejected these people. therefore, these people face so many social stigma from birth to death. acknowledgement authors are thankful to bharati vidhyapeeth (deemed to be university) homoeopathic medical college and research centre for providing necessary infrastructure and research facilities. authors would like to extent there for most byline to dr. anita sardar patil (pg co ordinator) for the unmatched support, for constant check on the progress of the project, dr. tejas prabhakar gosavi for his relentless guidance references 1. nanda, s. (1986). the hijras of india: cultural and individual dimensions of volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 44 x gjra global journal for research analysis an institutionalized third gender role. journal of homosexuality, 11(3-4), 35-54. 2. chakrapani, v., babu, p., & ebenezer, t. (2004). hijras in sex work face discrimination in the indian health-care system. research for sex work, 7, 1214. 3. nanda, s. (2015). hijras. the international encyclopedia of human sexuality, 501-581. 4. cohen, l. (1995). the pleasures of castration: the postoperative status of hijras, jankhas and academics. sexual nature, sexual culture, 276-304. 5. kodad, h. s., & kazi, s. a. understanding the psyche of the indian hijra: a woman’s soul in a man’s body. 6. bhardwaj, v., & chatterji, s. (2017). the plight of the third gender: quest for identity in the narratives me hijra me laxmi and the truth about me: a hijra life story (doctoral dissertation, lovely professional university). 7. punniyamoorthy, r. (2015). a study on growing up thirdgendered and social perception. 8. mithani, a., & burfat, f. m. (2003). hijra–the sex in between. j independ stud res, 1. 9. nanda s. the hijras of india: cultural and individual dimensions of an institutionalized third gender role. journal of homosexuality. 1986 jan 28;11(34):35-54. 10. sahastrabuddhe, s., gupta, a., stuart, e., godbole, s., ghate, m., sahay, s., ... & mehendale, s. m. (2012). sexually transmitted infections and risk behaviors among transgender persons (hijras) of pune, india. jaids journal of acquired immune deciency syndromes, 59(1), 72-78. 11. mal, s. (2015). let us to live: social exclusion of hijra community. asian journal of research in social sciences and humanities, 5(4), 108-117. 12. chettiar, a. (2015). problems faced by hijras (male to female transgenders) in mumbai with reference to their health and harassment by the police. international journal of social science and humanity, 5(9), 752. 13. dutta a. contradictory tendencies: the supreme court's nalsa judgment on transgender recognition and rights. j. indian l. & soc'y. 2014;5:225. x 45gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 29.dr. shweta m. dhage.cdr introduction salivary gland lesions comprise 2-6.5% of all head and neck 1 2 neoplasms in adults and 2% of overall tumors in human. the common clinical presentation is enlarged mass usually seen in major salivary glands like parotid, submandibular & sublingual glands whereas it is less common in minor salivary glands in lip, cheek, palate, oral cavity & lacrimal glands. such an enlarged mass or nodule is easily accessible for fnac. in 1847, the use of aspiration cytology for salivary lesions was reported for the rst time by kun and the procedure was reintroduced in 1930 by martin and ellis, while eneroth et al promoted the use of fnac in head and neck 3,4 region specically in salivary glands, in 1950 & 1960. fnac is being widely used for both major and minor salivary gland lesions and it can differentiate between neoplastic and non5 neoplastic lesions. although salivary gland lesions form a minority of cases , they present with marked diversity upon fnac in the form of simple cysts like mucocele or retention cyst, inammatory lesions like acute or chronic sialadenitis, benign neoplasms like pleomorphic adenoma, basal cell adenoma or warthin's tumor and malignant neoplasms like mucoepidermoid carcinoma, acinic cell carcinoma or 6adenoid cystic carcinoma. although cytomorphological features of most of the lesions are predictable, various confounding cytological factors make some fna smears 4 difcult to interprete. in developing countries like india, where malnutrition , poverty and lack of awareness are major issues, patients seek medical facilities very late and so chances of 7,8malignancy are high as compared to developed countries. fnac is preferred over biopsies for salivary lesions as it is easily accessible, chances of spillage, recurrence and capsular inltration are minimal. also cell blocks can be prepared in the same setting. also ancillary techniques can be 6performed thereafteron cell blocks. the present study was undertaken to study age, sex, site wise distribution and the cytomorphological spectrum of salivary gland lesions in tertiary care center of estern vidarbh, maharashtra, india. material and methods the present study was carried out on patients presenting with palpable enlarged mass or nodule in the cytopathology section over a period of one year from january 2019 to december 2019 in tertiary care hospital. patients were referred from ent, medicine and surgery opd. a total of 65 cases were studied with detailed clinical history, clinical examination and an ultrasound or ct imaging if available and prior consent was taken from all the patients. fnac was performed by using 5 ml plastic disposable syringe and disposable 23 guage needles. three slides were made from aspirated material, two were xed with 85% isopropyl alcohol and stained with haematoxylene & eosin and papaniculou stains, while third slide was air dried and stained with may grunwald giemsa stain. special stains like pas, zeihl neelsen were also studied. fna results were obtained after correlation with clinical history and radiological ndings and then compared with the ndings of other studies in the literature. results a total of 65 cases of salivary gland lesions were obtained in the department of cyto-pathology over a period of 1 year between january 2019 and december 2019. all the 65 patients underwent a diagnostic fnac in cytopathology section. in the present study, age range of patients varied from 14 to 80 years. youngest patient (14 year old) was diagnosed with sialadenitis and oldest (80 year old) was diagnosed with pleomorphic adenoma on fnac. majority of patients (27.6%) were noted in the age group 41-50 years followed by the age group 21-30 years (16.9%) as shown in table 1. in the present study, males (35/65) showed predominance over females (30/65) with sex ratio 1.1:1. table 1: age and sex wise distribution of salivary gland lesions (n=65) cytomorphological spectrum of salivary gland lesions: a one year study original research paper dr. suwarna b patil associate professor, department of pathology, gmc akola, maharastra, india x 23gjra global journal for research analysis pathology fnac has a good sensitivity, specicity and accuracy in early diagnosis and management of salivary gland lesions. the present study was carried out on 65 patients presenting with palpable enlarged salivary mass or nodule in the cytopathology section over a period of one year from january 2019 to december 2019 with the aim of categorizing the lesions among females and males, studying age incidence & site. most common age group involved was 41-50 years and male showed predominance over females. parotid gland was the commonest gland involved. pleomorphic adenoma (38.4%), mucoepidermoid carcinoma (6.1%), sialadenitis (4.6%) were the most common benign, malignant and inammatory lesions respectively in the present study. fnac for palpable salivary gland lesions is a diagnostic and therapeutic asset. abstract keywords : salivary, fnac, pleomorphic adenoma, mucoepidermoid volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra dr. dilip s. sarate professor, department of pathology, gmc akola, maharastra, india dr. shweta m. dhage* assistant professor, department of pathology, gmc, akola, maharastra, india *corresponding author dr. pradeep s. umap professor and head, department of pathology, gmc, akola, maharastra, india dr. shahnawaz khan junior resident ii, department of pathology, gmc, akola, maharastra, india age group male female total % 11-20 05 00 05 7.6 21-30 06 05 11 16.9 31-40 03 06 09 13.8 41-50 11 07 18 27.6 24 x gjra global journal for research analysis table 2 : site wise distribution of salivary gland lesions (n=65) in the present study, the most common site for the lesions was parotid region (52.3%) predominantly on right side. it was followed by submandibular region (36.9%) majority on the right side. table 3: distribution of salivary gland lesions (n=65) in the present study, salivary gland lesions were differentiated into non-neoplastic and neoplastic (benign & malignant) lesions. neoplastic lesions (55.3%) were more than nonneoplastic lesions. among non-neoplastic lesions, majority cases were of sialadenitis (23.1%) followed by benign cystic lesions (16.9%). among neoplastic lesions, benign neoplasms (43.0%) were more common than malignant (12.3%). among benign tumors, pleomorphic adenoma (38.4%) was the commonest (figure 1a) followed by basal cell adenoma (1.5%) and warthin's tumor (1.5%) (figure 1b). while among malignant tumors, majority cases were of mucoepidermoid carcinoma (figure 1d) (6.1%) followed by acinic cell carcinoma (figure 1c) (3.0%) and carcinoma ex pleomorphic adenoma (1.5%) which was the case of recurrence after 6 years as shown in table 3. figure 1: photomicrographs of salivary gland lesions a) pleomorphic adenoma: chondromyxoid stroma, epithelial and mesenchymal components (200x, mgg stain) b) warthin's tumor: clusters of oncocytes with mature lymphocytes in the dirty background (200x, pap stain) c) acinic cell carcinoma: overlapping clusters of acinar cells with bland nuclei (100x, pap stain) d) mucoepidermoid carcinoma: sheets of intermediate squamous cells with intermingled mucin lled cells. (200x, h & e stain) discussion the present study was a retrospective study and a total of 65 cases were studied. fnac of salivary glands is being used very commonly as a preoperative diagnostic tool. it is well tolerated and readily accepted by patients as they get report within a short span. we studied a total of 65 cases of salivary gland lesions and above results were obtained. these results were compared with various studies in the literature. in the present study, the age range was 14-80 years with sex ratio 1.1:1. while 9study done by singh a et al observed age range 8-69 years with 4sex ratio 1:1.4 and fereshteh am et al noted age range 14-76 years which was comparable. majority of patients were noted in 8,9,10, the age group of 41-50 years (27.6%) while other studies 11noted the commonest age group of 21-40 years. in the present study, males (35/65) showed predominance over females (30/65) 10while in other studies like linen mw et al , khandekar mm et 1 4al and fereshteh am et al . in the present study, majority of cases presented with parotid volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 51-60 06 07 13 0.2 61-70 03 03 06 9.2 71-80 01 02 03 4.6 total 35 30 65 100 site right left bilateral total % parotid 20 14 34 52.3 submandibular 12 11 01 24 36.9 lip 04 6.1 sublingual 02 3.0 cheek 00 01 01 1.5 total 65 100 lesions number % non neoplastic 29 44.6 sialadenosis 03 4.6 sialadenitis 15 23.1 benign cystic lesions 11 16.9 neoplastic 36 55.3 benign 28 43.0 pleomorphic adenoma 25 38.4 basal cell adenoma 01 1.5 warthin tumor 01 1.5 oncocytoma 01 1.5 malignant 08 12.3 adenoid cystic carcinoma 01 1.5 acinic cell carcinoma 02 3.0 mucoepidermoid carcinoma 04 6.1 carcinoma ex pleomorphic adenoma 01 1.5 gland (55.3%) involvement followed by submandibular gland (36.9%) and minor salivary gland ( lip, cheek, palate). similar observations were made by studies conducted by singh a et al 9 13 14 1, gao n et al , ashraf a et al & khandekar mm et al . in the present study, neoplastic salivary gland lesions (55.3%) were more common than non-neoplastic lesions (44.6%). among neoplastic lesions, 77.7% (n=36) were benign neoplasms and 22.2% (n=36) were malignant neoplasms. these ndings were similar to the ndings in studies done by 9 singh a et al (78.3% benign vs 21.6% malignant) , hughes kv 15 16et al (80% benign vs 20% malignant), cajulis rs et al (75.9% benign vs 14.6% malignant). among benign neoplastic lesions, the present study observed pleomorphic adenoma as the commonest neoplasm which was similarly found in studies 1 9 done by khandekar mm et al , singh a et al and chatterjee 17mt et al . in the present study, among malignant lesions, majority of cases were mucoepidermoid carcinoma followed by acinic cell carcinoma and adenoid cystic carcinoma which was similar to the ndings of study done by khandekar mm et 7 17al1 while other studies like singh a et al , chatterjee mt et al , 18stewart cj et al . in this study, among non-neoplastic lesions, sialadenitis (23.1%) was the commonest lesion which was comparable to 9 19 singh a et al while goh yh et al showed 53.7%, which is very 14 high and ashraf a et al showed 12% in their studies. conclusion fnac is a safe, simple, reliable, cost-effective and well tolerated preoperative procedure with minimal morbidity carried out in the outpatient department yielding accurate diagnosis of inammatory, benign and malignant salivary gland lesions. among benign neoplasm, pleomorphic adenoma is the commonest lesion while among malignant neoplasms mucoepidermoid carcinoma forms the majority and the common non neoplastic lesions are sialadenitis. fnac can be used preoperatively to avoid unnecessary surgeries and the discomfort to open biopsy. so, this simple and time saving procedure is a boon for both clinicians and anxious patients as malignancy in suspicious cases gets ruled out within no time. fnac is preferred over biopsies for salivary lesions as it is easily accessible, chances of spillage, recurrence and capsular inltration are minimal. also cell blocks can be prepared in the same setting. also ancillary techniques can be performed thereafteron cell blocks. fnac for palpable salivary gland lesions is a diagnostic and therapeutic asset. references 1. khandekar mm, kavatkar an, patankar sa, bagwan ib, puranik sc, deshmukh sd. fnac of salivary gland lesions with histopathological correlation. indian j otolaryngol head neck surg. 2006; 58(3): 246-8. 2. lingen mw, kumar v. head and neck. in: robbins’ and cotran. pathological basis of disease, 9th edn. kumar v, abbas ak, aster jc. (eds). philadelphia: elsevier saunders; 2014: 742-747. 3. eneroth cm, frazen s, zajicek j. cytologic diagnosis of aspirate from 1000 salivary-gland tumours. acta otolaryngol. 1966; suppl 224: 168+. 4. fereshteh a, asmazila b, nurismah md, sharifah na. diagnostic challenges in ne needle aspiration cytology of salivary gland lesions. malaysian j pathol 2015; 37(1) : 11 – 18 5. singh nanda kd, mehta a, nanda j. fine-needle aspiration cytology: a reliable tool in the diagnosis of salivary gland lesions. j oral pathol med. 2012; 41(1): 106-12 6. klijanienko j. head and neck; salivary glands. in fine needle aspiration cytology, 4th edn. orell sr, sterrett gf, darrel w (eds). singapore: elsevier limited; 2005: 41-77. 7. marsden ath. distinctive features of tumours of salivary glands in malaya. br j cancer 1951;5:375. 8. davies jp. salivary gland tumours in uganda, cancer 1964;17:1310-22. 9. singh a, haritwal a, murali bm. correlation between cytology and histopathology of the salivary gland. australasian medical journal amj 2011; 4, 2, 66-71. 10. rosai j. major and minor salivary glands. in: ackerman’s surgical pathology. volume 1. 9th edn. rosai j. (eds). new york: cv mosby co; 2004: 639-669. 11. kumar pv, sobhani sa, monabati a, talei ar, shirazi b. cytologic ndings of a pleomorphic adenoma of the breast: a case report. acta cytol 2004; 48: 849852. 12. lingen mw, kumar v. head and neck. in: robbins’ and cotran. pathological basis of disease, 7th edn. kumar v, abbas ak, fausto n. (eds). philadelphia: elsevier saunders; 2005: 791-794. 13. gao n, li y, li lj, wen ym. clinical analysis of head and neck cancer cases in south west china 1953-2002. j int med res 2009; 37: 189-197. 14. ashraf a, shaikh as, kamal f, sarfraz r, bukhari mh. diagnostic reliability of fnac for salivary gland swellings: a comparative study. diagn cytopathol 2010; 38: 499-504. 15. hughes kv, olsen kd, mccaffrey tv. parapharyngeal space neoplasms. head neck 1995; 17: 124-130. 16. cajulis rs, gokaslan st, yu gh, frias-hidvegi d. fine needle aspiration biopsy of the salivary glands. a ve year experience with emphasis on diagnostic pitfalls. acta cytol 1997; 41: 1412-1420. 17. a pathological study of benign and malignant tumours of sallvary glands. chatterjee mt, panda pk. mjafi 2000; 56 : 282-286. 18. stewart cj, mackenzie k, mcgarry gw, mowat a. fine needle aspiration cytology of salivary gland: a review of 341 cases. diagn cytopathol 2000; 22: 139-146. 19. goh yh, sethi ds. submandibular gland excision: a ve year review. j laryngol otol 1998; 112: 269-273. x 25gjra global journal for research analysis volume-9, issue-3, march-2020 • print issn no. 2277 8160 • doi : 10.36106/gjra 1. introduction epilepsy is one of the most common neurological disorders in children. it was estimated that 6 of 1,000 children worldwide suffer from epilepsy, and it is estimated that it is twice as 1frequent in children as adults. epilepsy incidence is estimated to be more in developing countries than in industrialized countries. in developing countries, the incidence of childhood epilepsy from birth to 16 years is 2estimated at around 40 out of 100,000 children per year. vitamin d plays an important role in many different physiological functions. vitamin d has an important role during brain development, proliferation, differentiation, 3neurotrophic and neuroprotective. studies showed that vitamin d deciency is a risk factor for neurological diseases such as alzheimer's, parkinson's, multiple sclerosis, 4,5depression, schizophrenia, autism and epilepsy. management of epilepsy is by giving antiepileptic drugs. antiepileptic drugs (aeds) are usually given long term and use a combination of several drugs to control seizures, so we must pay attention to the side effects of each drug used. the use of aeds can cause vitamin d deciency, through the induction of cytochrome p450 that will increase the catabolism of vitamin 6,7,8d. in indonesia, there were less study about the effect of long term aeds administration on vitamin d. because of the limited data, this study aim to determine the association of antiepileptic drugs with vitamin d status in childhood epilepsy. 2. methods the design of this study was concecutive, cross sectional study. this study was conducted in outpatient pediatric neurology clinic haji adam malik hospital, medan, north sumatera. this study was held from february to april 2019. the study was approved by the research ethics committee of the university of sumatera utara faculty of medicine. inclusion criteria were dened as epileptic children, aged 0-18 years who had been used antiepileptic drugs. we excluded children with obesity, impaired liver function, renal failure and those who consumed vitamin d supplements. all cases who meet inclusion criteria underwent test for 25(oh)d level. blood specimen were taken from all the subjects after obtaining parental consents. abnormal vitamin d was dened as 25(oh)d level less than 30 ng/ml, whereas normal vitamin d level as ≥ 30 ng/ml. there are 4 types of drugs used as antiepileptic drugs, namely phenobarbital, valproic acid, carbamazepine and topiramate. antiepileptic drugs were categorized based on their enzyme inducing properties, polytherapy combination and monotherapy. type of antiepileptic drugs, number of aeds, duration of therapy and using of rst and second line aeds as monotherapy and polytherapy combination were analyzed. first line aeds dene as using phenobarbi tal , valproic acid or carbamazepine as therapy meanwhile topiramate as second line therapy. data were analyzed by using ibm spss statistics version 22.0. mean and standard deviation (sd) were estimated for various variables. categorical variables were presented as the association of antiepileptic drugs with vitamin d status in childhood epilepsy original research paper ratna suwita batubara department of child health, faculty of medicine, universitas sumatera utara, haji adam malik general hospital, medan, indonesia *corresponding author x 99gjra global journal for research analysis neurology background:epilepsy is a common neurological disorder of childhood requiring long term of antiepileptic drugs that has been associated with low 25-hydroxyvitamin d (25(oh)d) status and high prevalence of vitamin d deciency. however, studies on the effect of long term antiepileptic drugs use on vitamin d had inconsistent results. the aim of this study was to analyze the association of antiepileptic drugs (aed) with vitamin d status in childhood epilepsy. methods: a cross sectional study was conducted from february to april 2019 at children outpatient clinic haji adam malik hospital. one hundred and two epileptic children taking antiepileptic drug were enrolled consecutively. all cases who met inclusion criteria, underwent test for serum 25(oh)d that were categorized as normal (≥30 ng/ml) and abnormal (<30 ng/ml). antiepileptic drugs were categorized based on their enzyme inducing properties, polytherapy combination and monotherapy. results: from 102 patients, 77 children (75.5%) had abnormal vitamin d with average level of 25(oh)d was 24.37 ng/ml (sd 9.23). the mean of age was 9.26 years (sd 4.96), 57.8% were boy and 79.4% on monotherapy. association between enzyme inducing vs non-inducing properties, monotherapy vs polytherapy and duration of therapy with vitamin d status were non signicance with p value 0.277, 0.713 and 0.728 respectively. sodium valproate was the most common aed used in mono therapy (87.7%) and combination of sodium valproate-topiramate in polytherapy (42.9%). the differences of an abnormal vitamin d in those on aed as monotherapy were not signicant (p=0.713). similarly in polytherapy, there were non-signicant difference of vitamin d level in each combination of aed (p=1). conclusion: there was no signicant association of antiepileptic drugs with vitamin d status in childhood epilepsy. ththis study was presented as poster presentation at the 15 asian oceanian congress of child neurology, kuala lumpur, malaysia, september 2019 abstract keywords : epilepsy, antiepileptic drugs, vitamin d volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra johannes harlan saing department of child health, faculty of medicine, universitas sumatera utara, haji adam malik general hospital, medan, indonesia yazid dimyati department of child health, faculty of medicine, universitas sumatera utara, haji adam malik general hospital, medan, indonesia cynthea prima destariani department of child health, faculty of medicine, universitas sumatera utara, haji adam malik general hospital, medan, indonesia 100 x gjra global journal for research analysis chi-square or fischer's exact test for cells value <5 to evaluate the factors that associate with aeds using and the association with vitamin d status. a value of p<0.05 was considered as statistically signicant with 95% condence interval (ci). 3. result subject's characteristics a total of 102 epileptic children with epilepsy who were treated at the paediatric neurology outpatient clinic haji adam malik medan from february to april 2019 who had met the inclusion criteria. characteristics of research subjects are presented in table 1. the majority of research subjects were male (57.8%) with an average age of 9.26 years. epilepsy with generalized seizures is more common than focal seizures (77.5%) while the most common cause of seizures is idiopathic (54.9%). table 1. characteristics of the study subjects monotherapy is the most type of therapy (79.4%) with valproic acid as the most aed used as monotherapy (87.7%). the average serum vitamin d level was 24.37 ng / ml where most subjects had abnormal vitamin d levels (75.5%) consisting of insufciency in 43 subjects (42.2%) and deciency in 34 subjects (33.3%). only 25 subjects (24.5%) had normal vitamin d levels. the average duration of treatment with aed was 26.28 months. tabel 2. associations between vitamin d status and type of aed, number and duration of therapy a b chi square, fischer's exact tabel 2 shows that there was no signicant association between the type and duration of therapy and type of aeds with serum vitamin d levels in the study subjects with p values of 0.227, 0.713 and 0.728, respectively. table 3. association between vitamin d status and type of aed in monotherapy the analysis used to assess the relationship between aeds types of rst and second line monotherapy is the chi square test. types of aeds monotherapy are divided into two groups namely rst line (phenobarbital, valproic acid, and carbamazepine) and second line (topiramate). table 3 shows that there was no signicant difference in vitamin d between groups using rst-line aeds and groups using second-line aeds with p value >0.05. tabel 4. association between vitamin d status and type of aed combination in polytherapy the association of aeds combination in politherapy with vitamin d in table 4 was analyzed using the fischer exact test showing the value of p (1), so it can be concluded that there is no association between aeds combination with vitamin d. 4. discussion epilepsy is a long-term neurological disorder that is most often found in childhood. most epilepsy sufferers need longterm, even lifelong aeds, which has the potential to 9experience undesirable metabolic side effects. given that adequate vitamin d is important for various health functions, making the effect of aeds on vitamin d metabolism very 10 interesting. one cause of vitamin deciency d is a long-term use of anticonvulsants in epileptic children. the anticonvulsant effect on vitamin d levels has been studied for more than 40 years. the prevalence of vitamin d deciency in people with epilepsy varies depending on the denition of vitamin d deciency, anticonvulsant type, amount and 11duration of administration and place of study. in this study the prevalence of abnormal vitamin d levels (<30 ng/ml) was 75.5% with an average value of 24.37 ng/ml. assessment of abnormal vitamin d levels (<30 ng/ml /) based on the endocrine society and the national kidney foundation kidney disease outcomes quality initiative (kdoqi). this denition is more consistent with the classication used in adults based on the occurrence of bone health disorders and increased levels of parathyroid hormone at vitamin d levels 12,13up to 32 ng / ml. the same prevalence with the result of research conducted in germany, in epileptic children aged 5-12 years, that it was 10 more than 75%. however, it had a wide different when compared with the national prevalence of vitamin d deciency in healthy children. cross sectional study, a part of the south east asian nutrition survey (seanut) conducted in 48 districts in indonesia in healthy children aged 2 to 12.9 years reported that no children had vitamin d deciency. there were 45.1 % experienced insufciency and 49.3% with adequate status, while only 5.6% have enough vitamin d levels. the vitamin d classication used as follows, vitamin d volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra characteristics n (%) gender male 59 (57.8) mean age (sd), years 9.28 ± 4.96 type of epilepsy generalized focal etiology of epilepsy idiopatic symptomatic number of antiepileptic drug monotherapy polytherapy type of antiepileptic drug enzyme inducer non-enzyme inducer type of aed in monotherapy first line second line type of aed combination in politherapy first line + first line first line + second line status of 25(oh)d normal abnormal mean vitamin d level (sd), ng/ml duration of therapy < 2 years ≥ 2 years mean duration of aed (sd), months 79 (77.5) 23 (22.5) 56 (54.9) 46 (45.1) 81 (79.4) 21 (20.6) 18 (17.6) 84 (82.4) 77 (95.1) 44 (4.9) 10 (47.6) 11 (52.4) 25 (24.5) 77 (75.5) 24.33 ± 9.08 52 (51) 50 (49) 26.28 ± 23 vitamin d status pr (95% ci) p valueabnormal normal type of aed enzyme inducer non-enzyme inducer 16 61 2 23 0.3 (0.07-1.56) b0.23 number of aed monotherapy polytherapy duration of therapy < 2 years ≥ 2 years 60 17 38 39 21 4 14 11 1.5 (0.45-4.92) 1.3 (0.53-3.24) a0.71 a0.73 antiepileptic drug vitamin d status pr (95%ci) p valueabnormal normal first line second line 56 4 21 0 0.7 (0.63-0.83) 0.57 aed combination vitamin d status pr (95%ci) p valueabnormal normal first line + first line first line + second line 8 9 2 2 1.1 (0.13-0.94) 1 deciency if serum 25 (oh) d levels <25 nmol/l (<10 ng / ml), insufciency between 25-49 nmol/l (10-19.6 ng / ml), this is strong 50-74 nmol/l (20-29.6 ng / ml) and desirable status if ≥ 1475 nmol/l (30 ng/ml). study in sri lanka, india, korea, malaysia reports that the incidence of vitamin d deciency in epileptic children is 15,16,17,1853.7%, 45%, 9.1% and 22.5% . this may be due by the different denitions of vitamin d deciency used, the duration of aeds administration, the method, ethnicity of the research subject, and the place / environment of the study. in these 4 studies, the criteria for the research subjects were epilepsy patients who had consumed aeds for 1 year or more, whereas in this study the minimum time limit for aeds use was not determined. this can lead to a higher prevalence of abnormal vitamin d levels in this study. until now there has been no consensus on the denition of 19vitamin d status in children and adolescents. globally, levels of 25 (oh) d below 10 ng / ml are considered the lowest cut off for vitamin d status. endocrine society task force publishes a guideline that denes adequate vitamin d if serum 25 (oh) d levels >30 ng/ml, 20-30 ng / ml insufciency and deciency 20 <20 ng/ml. serum 25 (oh) d levels are recommended between 30-100 ng/ml to avoid health problems. level 25 (oh) d 40-60 ng/ml is considered the best. vitamin d poisoning 21occurs when serum 25 (oh) d levels> 150 ng/ml. sun exposure is the main source of vitamin d (> 90%) through 22synthesis in the skin facilitated by ultraviolet b. the amount of vitamin d synthesized by the skin depends on various factors such as individual age, geographical location, use of 12,23sunscreen, and skin pigmentation. children, especially infants, need less sun exposure than adults to produce adequate concentrations of vitamin d because of the ratio of body surface to volume and the ability to increase vitamin 24 production which is greater than that of adults. however, until now there has been no recommendation to determine the appropriate duration of sun exposure for a pediatric population, there are variations in vitamin d synthesis between individuals so it is difcult to determine 13recommendations. in this study the duration of sun exposure was not assessed. the average age of epilepsy sufferers (9.26 ± 4.96 years) which is a school age group causes their chance to play in the sun and physical activity outside the home has begun to decrease and more activity is done indoors. limited mobility and disability of epileptic children also play a major role in reducing the synthesis of vitamin d in children due to rarely 1,25being outside the house. antiepileptic drugs are used to prevent the recurrence of seizure. long last seizure can cause damage until the death of brain cells. the principle of epilepsy treatment is starting from monotherapy, because most of patients are successfully 26,27managed with the rst or second line monotherapy. although the use of rst-line aeds (valproic acid, phenobarbital, carbamazepine and phenytoin) is quite large compared to second-line aeds, but from statistical tests there is no signicant association. if it fails with monotherapy, another aed (polytherapy) can be added. it is estimated that 35% of epilepsy patients do not respond to monotherapy, and are candidates for the use of 28,29polytherapy. the administration of polytherapy with a lower dose aeds or is being selected as the management of refractory patients who have received a maximum dose of 27monotherapy aeds. in the polytherapy group used combination of 2 or more drugs. the group of epilepsy patients receiving polytherapy in this study was 20.6% and the combination of valproic acid and topiramate was the most widely used aed as polytherapy (42.9%). there were no signicant differences in levels of 25 (oh) d between the groups of patients taking monotherapy compared to the groups using polytherapy or between each aeds combination used as polytherapy. likewise with the results of research in korea by baek et al, ramya and nagarjunakond in india that there were no differences in vitamin d levels between patients 17,30,31receiving monotherapy and polytherapy. in contrast, research by nettekoven et al in germany, fong et al in malaysia stated that polytherapy is one of the risk factors for 10,48decreasing vitamin d levels in people with epilepsy. this difference may be caused by the existence of various complex interactions between various aeds to the metabolism of 30vitamin d. some studies report that the long use of aeds will affect the decrease in vitamin d levels in epilepsy sufferers. the exact duration of use of aeds which can cause vitamin d deciency 16is unclear. research by baek et al in korea states that 25 (oh) d levels were signicantly lower in patients who received 17aeds for more than 2 years. in this study, no signicant association was found between aeds use <2 years and aeds use ≥2 years on vitamin d levels of epilepsy sufferers. inactivation of vitamin d by aeds occurs mainly due to induction of liver enzymes and due to activation of pregnane x 32,33receptors (pxr), steroids and xenobiotic receptors (sxr). activation of vitamin d (d2 and d3) initially occurs in the liver where hydroxylation occurs to 25 (oh) d by cyp27a. antiepileptic drugs combine and activate sxr and subsequently join the retinoid x receptor (rxr), which then activates the 24-hydroxylase enzyme by interacting with the vitamin d element which is responsive to 24-ohase. this will 34,35increase the destruction of 25 (oh) d and 1,25 (oh) 2d. however, several studies reported no difference between enzyme-inducing and non-enzyme-inducing aeds on vitamin 36d. status. a systematic review was conducted by robien et al. did not nd sufcient evidence to explain that aeds affect 37serum vitamin d levels. this is consistent with the results of this study where there is no signicant relationship between enzyme-inducing aeds (phenobarbital and carbamazepine) and non-inducing enzyme aeds (valproic acid and topiramate). hypovitaminosis d can cause decreased intestinal calcium absorpt ion. thus, a low dietary calc ium intake, hypovitaminosis d induced by vitamin d will cause a detrimental effect on bone mineral metabolism. genetic factors can also inuence an individual's susceptibility to the 38,39effects of aeds on vitamin d and bone metabolism. feldkamp et al bbserved that a decrease in bone cell proliferation due to the direct effect of aeds on bone cells 40which plays a role in causing skeletal damage. furthermore, either aed is induced or non-enzyme induction also plays a role in bone mass loss because it inhibits intestinal calcium 41absorption and vitamin d activation. in this study, calcium and bone mineral density (bmd) tests were not carried out so we cannot see the effect of decreasing vitamin d levels on health bone. limitations of this study are the absence of data on vitamin d levels in healthy subjects and vitamin d levels before the use of aed, making it difcult to determine whether vitamin d levels are abnormal (<30 ng / ml) purely due to aed use or not. this research is a cross sectional study so that it cannot see a causal relationship. 4. conclusion there was no signicant association of antiepileptic drugs with vitamin d status in childhood epilepsy. x 101gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra references 1. cebeci an, ekici b. epilepsy treatment by sacricing vitamin d. expert rev neurother. 2014;14(5):481-91. 2. stafstrom ce, rho jm. pediatric epilepsy : an overview. dalam: swaiman kh, ashwal s, ferreiro dm, schor nf. pediatric neurology “principle and practice”.5th edition. england; 2012.p.703-10. 3. groves nj, mcgrath jj, burne thj. vitamin d as a neurosteroid affecting the developing and adult brain. annual review of nutrition, 2014; 34: 117-141. 4. sonmez, fm. the role 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gordon cm, hanley da, heaney rp, et al. evaluation, treatment, and prevention of vitamin d deciency: an endocrine society clinical practice guideline. the journal of clinical endocrinology & metabolism.2011 96.7: 1911-30. 21. gröber u, spitz j, reichrath j, kister k, holick mf. vitamin d: update 2013: from rickets prophylaxis to general preventive healthcare. dermato endocrinology,2013; 5.3: 331-347. 22. deluca hf. overview of general physiologic features and functions of vitamin d. the american journal of clinical nutrition, 2004;80.6 : 1689s-1696s 23. misra m, pacaud d, petryk a, solberg pfc, kappy m. vitamin d deciency in children and its management: review of current knowledge and recommendations. pediatrics, 2008; 122.2: 398-417. 24. munns c, zacharin mr, rodda cp, jennifer ab, morley r, cranswick ne, et al. prevention and treatment of infant and childhood vitamin d deciency in australia and new zealand: a consensus statement. medical journal of australia, 2006;185.5: 268-272. 25. li xh, hou xy, chen r. the roles of vitamin b12 and vitamin d in children with intractable epilepsy. int j clin exp med. 2015;8(1):764-9. 26. robert h, haslam h. the nervous system. dalam: klegman r, behrman r, jenson h, stanton b. nelson textbook of pediatrics.18 th edition. philadelphia: saunders; 2008.p.2457-530. 27. louis eks, rosenfeld we, barmley t. antiepileptic drug monotherapy: the initial approach in epilepsy management. current neuropharmacology, 2009;7: 77-82. 28. louis ek, gidal be, henry tr, kaydanova v, krumholz a, mccabe ph, et al. conversions between monotherapies in epilepsy: expert consensus. epilepsy & behavior, 2007;11.2: 222-34. 29. sreedharan m, devadathan k, kunju pm, sasidharan b, pillat jp, amma mav, et al. vitamin d deciency in ambulant children on carbamazepine or sodium valproate monotherapy. indian pediatrics, 2018; 55.4: 307-10. 30. nagarjunakond s, amalakanti s, uppala v, rajanala l, athina s. vitamin d in epilepsy: vitamin d levels in epilepsy patients, patients on antiepileptic drug polytherapy and drug-resistant epilepsy sufferers. european journal of clinical nutrition. 2016; 70.1: 140. 31. ramya s, anita c, ravi md. a study of vitamin-d status in epileptic children in age group 2-15 years. international journal of advances, 2016;3(2): 319-23. 32. valsamis ha, arora sk, labban b, mcfarlane s. antiepileptic drugs and bone metabolism. nutrition & metabolism, 2006; 3.36:1-11 33. zhou c, assem m, tay jc, watkons pb, blumberg b, schuetz eg, et al. steroid and xenobiotic receptor and vitamin d receptor crosstalk mediates cyp24 expression and drug-induced osteomalacia. the journal of clinical investigation, 2006;116.6: 1703-12. 34. pascussi jm, robert a, nguyen m, walrant-debray o, garabedian m, martin p, et al. possible involvement of pregnane x receptor–enhanced cyp24 expression in drug-induced osteomalacia. the journal of clinical investigation, 2005; 115.1: 177-86. 35. holick mf. stay tuned to pxr: an orphan actor that may not be d-structive only to bone. the journal of clinical investigation, 2005; 115.1: 32-34. 36. teagarden dl, meador jk, loring dw. low vitamin d levels are common in patients with epilepsy. epilepsy research. 2014; 108.8: 1352-1356. 37. robien k, oppeneer sj, kelly ja, hamilton-reeves jm. drug–vitamin d interactions: a systematic review of the literature. nutrition in clinical practice, 2013; 28.2: 194-208. 38. misra a, aggarwal a, singh o, sharma s. effect of carbamazepine therapy on vitamin d and parathormone in epileptic children. pediatric neurology, 2010;43.5: 320-24 39. menon b, harinarayan cv. the effect of anti epileptic drug therapy on serum 25-hydroxyvytamin d and parameters of calcium and bone metabolisma longitudinal study. seizure, 2010;19.3:153-58 40. feldkamp j, becker a, witte ow, scharff d, scherbaum wa. long-term anticonvulsant therapy leads to low bone mineral density-evidence for direct drug effects of phenytoin and carbamazepine on human osteoblast-like cells. experimental and clinical endocrinology & diabetes, 2000;108.01: 37-43. 41. lee rh, kenneth wl, cathleen ce. a review of the effect of anticonvulsant medications on bone mineral density and fracture risk. the american journal of geriatric pharmacotherapy, 2010;8.1: 34-46. 102 x gjra global journal for research analysis introduction with the advent of information technology and massive growth in multimedia concepts, the internet has the ability to support a variety of online advertising formats (rodgers & thorson, 2000). according to wolin, korgaonkar, & lund (2002), web advertising's broad format consists of commercial content paid for by sponsors, designed for audiences, delivered by video, print, audio, graphics or animation. all these online advertising formats can be a good source of information for making purchase decision. further, in every one's life internet becomes emerging media for information and entertainment. almost all demographic groups of people availing the internet facility and they come across with online advertisements while surng internet. this will ultimately raise a question whether the online advertisements creates any impacts. though there are many people using internet for information gathering, entertainment, chatting, exchanging information and ideas, buying and selling of products and services, teenagers are mostly attracted by internet sophistications. hence, this paper signies impacts of online advertisements among the teenagers. methodology adopted it was decided that case study method using primary data would be appropriate to investigate the objectives and the hypotheses. the instrument used to collect the data was a questionnaire. the geographical area of tamil nadu state was chosen as the universe. the main reason for choosing tamil nadu state is that the investigator is located here and is familiar with the state. more signicantly, tamil nadu state has the distinction of being an active commercial centre and a centre of learning of it and it related courses. the data was collected by the field investigator as well as the research assistant themselves which follows systematic sampling technique. also, snowball sampling technique was followed to collect data using questionnaires distributed to identied school and college students by the researcher himself. accordingly, a total of 2500 questionnaires were administered to sample respondents both by systematic and snowball s a m p l i n g t e c h n i q u e s . i g n o r i n g t h e i n c o m p l e t e questionnaires, 2001 usable questionnaires were used for the present study with a yielding rate of 80.04%. objectives of the study ÿ to analyze the general opinion about the online advertisements ÿ to study the respondents' opinion about online advertisements for commercial products analysis and discussion the general opinion of the teenagers about online advertisements was captured using six different statements and the responses were analyzed using appropriate statistical analysis. the results are discussed below. analysis on general opinion about online advertisements initially, the respondents were queried about possession of laptop, frequency of going online, time spent for browsing, general opinion about online advertisement, frequency of clicking online advertisements and the types of online advertisements. their responses were subjected to frequency analysis and test of signicance using chi-square test with the following null and alternative hypothesis. h : 0 there is no signicant difference in the respondents based on possessing a laptop h : 1 there is a signicant difference in the respondents based on possessing a laptop the result is tabulated in table 1 table 1 frequency analysis on possession of laptop by the respondents general opinion about online advertisements among the teenagers – an empirical study original research paper dr k pongiannan assistant professor in commerce, government arts & science college, sathyamangalam – 638 401, erode district, tamil nadu, india x 139gjra global journal for research analysis commerce in the electronic component of advertising media, internet advertising has completed about seven years till now and emerging as a new interactive media for advertising when compare to radio and tv as an electronic media for advertisement which are 40 years and 15 years old respectively. around 1.4 million users are added every month and internet is growing at an incredible fast in all the places of world. a recent survey reveals that in india during the year 2000 the number of internet users was 3.1 million and now in the year 2013 india is the second largest country in the world with more than 300 million internet users. this ultimately attracts the markets and advertisers to promote their products at global level. thus, this paper focussed on analysing the attitude of teenagers about online advertising because internet is surfed by the young people at large. abstract keywords : advertising, internet, online, teenagers jayakumar chinnasamy school of education and social sciences, university of the west of scotland, united kingdom *corresponding author dr muzammal khan lecturer, school of business and creative industries, university of the west of scotland, united kingdom. volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra dr sarfraz ahmed dakhan assistant professor, shukkar iba university, pakistan. s. no. owning a laptop frequency percentage cumulative percentage chi-square (signicance at 5% level) 1. yes 1916 95.8 95.8 1675.443 df=1 p=0.000 2. no 85 4.2 100.0 total 2001 100.0 140 x gjra global journal for research analysis it is obvious from table 1 that majority of the respondents (95.8%) own a laptop and only 4.2% of the respondents do not have a laptop with them. further, the signicant chi-square result (1675.443;p=0.000) reveal that there is a signicant difference in the respondents' based on possessing a laptop with them. hence, h is rejected and h is accepted at 5% level 0 1 of signicance. further, the responses for the frequency of going online was analyzed using frequency analysis and test of signicance using chi-square analysis with the following null and alternative hypotheses: h :0 there is no signicant difference in the respondents based on their frequency to go online h :1 there is a signicant difference in the respondents based on their frequency to go online the results are tabulated in table 2 table 2 analysis on frequency of going online it is clear from the table 2, that majority of the respondents (29.9%) have opined that they go online at least once a week, followed by 26.3% of them using online everyday, 24.3% of them go online at least once a month and only 19.4% of them go online more than once a month. also, there is a signicant difference in the respondents frequency of going online as d e p i c t e d b y t h e s i g n i  c a n t c h i s q u a r e v a l u e (45.623;p=0.000). hence, h is rejected and h is accepted at 0 1 5% level of signicance. further, the analysis on the time spent per session of internet usage is presented in table 5.3. the null and alternate hypotheses are : h :0 there is no signicant difference in the respondents based on their time spent per session of internet usage h :1 there is a signicant difference in the respondents based on their time spent per session of internet usage table 3 analysis on time spent per session from table 3, it can be extracted that majority of the respondents (33%) have opined that they spend about 1-2 hours online, followed by 31.3% of them stating that they are always online, 30.9% of them stating that they spend less than 1 hour online and only 4.7% of the respondents have stated that time spent online depends on their work. there is a signicant difference in the respondents' time spent per session of online access as depicted by the signicant chisquare value (439.610; p=0.000). hence, h is rejected and h 0 1 is accepted at 5% level of signicance. the null and alternative hypotheses for the test of signicance using chi-square for the respondents' opinion about online advertisements are as follows: h :0 there is no signicant difference in the respondents' opinion on online advertisements h :1 there is a signicant difference in the respondents' opinion on online advertisements volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra s. no. frequency of going online frequency percentage cumulative percentage chi-square (signican ce at 5% level) 1. everyday 527 26.3 26.3 45.623 df=3 p=0.000 2. at least once a week 598 29.9 56.2 3. at least once a month 487 24.3 80.6 5. more than once a month 389 19.4 100.0 total 2001 100.0 s. no. time spent per session frequency percentage cumulative percentage chi-square (signicanc e at 5% level) 1. less than 1 hr online 619 30.9 30.9 439.610 df=3 p=0.000 2. 1-2 hrs online 660 33.0 63.9 3. i'm always online 627 31.3 95.3 4. depends on the work 95 4.7 100.0 total 2001 100.0 table 4 respondents' opinion about online advertisements s. no. opinion about online advertisements frequency percentage cumulative percentage chi-square (signicance at 5% level) 1. irritating 244 12.2 12.2 553.725 df=3 p=0.000 2. informative 800 40.0 52.2 3. useful 724 36.2 88.4 4. depends on the type of dvertisement 233 11.6 100.0 total 2001 100.0 table 4 portrays the frequency analysis on the opinion of the respondents about online advertisements. it is obvious from the table that majority of the respondents (40%) state that online advertisements are informative. similarly, 36.2% of the respondents have stated that online advertisements are useful followed by 12.2% of them have opined that they are irritating and only 11.6% of the respondents have opined that it depends on the type of advertisements. the signicant chisquare value (553.725;p=0.000;df=3) depicts that h0 is rejected and h1 is accepted at 5% level of signicance. the analysis results of the respondents' opinion on the type of online advertisements are presented in table 5. the null and alternative hypotheses are as follows: h : 0 there is no signicant difference in the respondents' opinion on the types of online advertisements h :1 there is a signicant difference in the respondents' opinion on the types of online advertisements table 5 analysis on the types of online advertisements s. no. type of online advertisements frequency percentage cumulative percentage chi-square (signicance at 5% level) 1. banner advertisements 237 11.8 11.8 517.294 df=5 2. pop-up advertisements 509 25.4 37.3 x 141gjra global journal for research analysis volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 3. pop-down advertisements 486 24.3 61.6 p=0.000 4. interstitial advertisements 503 25.1 86.7 5. logo advertisements 136 6.8 93.5 6. e-mail advertisements 130 6.5 100.0 total 2001 100.0 it is clear from table 5 that majority of the respondents (25.4%) have come across popup advertisements followed by 25.1% of them stating about interstitial advertisements and 24.3% of them stating that they have come across pop-down advertisements. 11.8%,6.8% and 6.5% of the respondents respectively have come across banner advertisements, logo advertisements and email advertisements. also, there is a signicant difference in the respondents opinion on the different types of online advertisements as depicted by the signicant chi-square value (517.294;p=0.000). hence, h is 0 rejected and h is accepted at 5% level of signicance. 1 finally, the respondents' responses on the frequency of clicking online advertisements were analyzed using frequency analysis and chi-square test with the following null and alternative hypotheses: h :0 there is no signicant difference in the respondents' frequency of clicking online advertisements h :1 there is a signicant difference in the respondents' frequency of clicking online advertisements the results are tabulated in table 6 s. no. frequency of clicking online advertisements frequency percentage cumulative percentage chi-square (signicance at 5% level) 1. once in a week 202 10.1 10.1 50.096 df=2 p=0.000 2. only when i'm free 976 48.8 58.9 3. always 196 9.8 68.7 4. only for product which i need 627 31.3 100.0 total 2001 100.0 table 6 analysis on the frequency of clicking online advertisements it is clear from table 6 that majority of the respondents (48.8%) have stated that they click online advertisements only when they are free. but 31.3% of the respondents have stated that they will click on online advertisements only for those products which they need followed by 10.1% of them stating that they will click online advertisements once in a week and only 9.8% of the respondents have opined that they will click on online advertisements always. the signicant chi-square value (50.096;df=2;p=0.000) imply that h is rejected and h is 0 1 accepted at 5% level of signicance. the null and alternative hypotheses for the respondents' opinion on frequently available online advertisements are as follows: h :0 there is no signicant difference in the respondents' opinion on frequently available online advertisements h :1 there is a signicant difference in the respondents' opinion on frequently available online advertisements table 7 frequency analysis on the frequently available online advertisements s. no. frequently available online advertisements frequency percentage cumulative percentage chi-square (signicance at 5% level) 1. commercial products 757 37.8 37.8 811.464 df=3 p=0.000 2. social advertisements such as aids awareness, deforestation etc 194 9.7 47.5 3. harmful advertisements such as alcohol, drug use etc 175 8.7 56.3 4. misleading advertisements 875 43.7 100.0 total 2001 100.0 table 7 portrays the frequency analysis on the frequently available online advertisements. it is clear from the table that majority of the respondents (43.7%) have opined that misleading advertisements are frequently available online. 37.8% of the respondents have stated that advertisements about commercial products are frequently available on the internet, followed by 9.7% stating social advertisements and 8.7% of them stating harmful advertisements are frequently available on the internet. further, the opinion of the respondents are statistically different as depicted by the signicant chi-square value (811.464; p=0.000). hence, h is 0 rejected and h is accepted at 5% level of signicance. 1 analysis on the respondents' opinion about online advertisements for commercial products the respondents' opinion about the online advertisements on commercial products was analyzed using frequency analysis and test of signicance using chi-square test. the results are tabulated below. initially, the inuence of commercial product advertisements that are displayed online was analyzed and the result is tabulated in table 8. the appropriate null and alternative hypotheses are: h :0 there is no signicant difference in the respondents' opinion on the inuence of commercial product online advertisements on online h : 1 there is a signicant difference in the respondents' opinion on the inuence of commercial product online advertisements on online table 8 inuence of commercial product advertisements on the online table 8 depicts the frequency analysis on the opinion of the respondents about the inuence of commercial product advertisements on the online. it can be extracted from the table that majority of the respondents (67.3%) have stated that the online advertisements about commercial products inuences them to click for more details. on the other hand, 32.7% of the respondents have opined that the online advertisements about commercial products do not inuence them to click it for more information. further, there is a s. no. opinion frequency percentage cumulative percentage chi-square (signicance at 5% level) 1. yes 1347 67.3 67.3 240.004 df=1 p=0.000 2. no 654 32.7 100.0 total 2001 100.0 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra 142 x gjra global journal for research analysis signicant difference in the respondents' opinion as depicted by the signicant chi-square value (240.004; p=0.000). hence, h is rejected and h is accepted at 5% level of 0 1 signicance. the null and alternative hypotheses on the attractiveness of online advertisements about commercial products are: h :0 there is no signicant difference in the respondents' opinion on the attractiveness of online advertisements about commercial products h :1 there is a signicant difference in the respondents' opinion on the attractiveness of online advertisements about commercial products table 9 frequency analysis on the attractiveness of online advertisements about commercial products s. no. attractiveness of online advertisements about commercial products frequency percentage cumulative percentage chi-square (signicance at 5% level) 1. yes 1341 67.0 67.0 231.765 df=1 p=0.000 2. no 660 33.0 100.0 total 2001 100.0 it is clear from table 9 that majority of the respondents (67%) have stated that online advertisements about commercial products are attractive. but 33% of the respondents have stated that the online advertisements about commercial products are not attractive. also, there is a signicant difference in the respondents' opinion about attractiveness of online advertisements about commercial products as portrayed by the signicant chi-square value (231.765; p=0.000). hence, h is rejected and h is accepted at 5% level 0 1 of signicance. the null and alternative hypotheses on the inuence of commercial product online advertisements to buy are: h :0 there is no signicant difference in the respondents' opinion on the inuence of commercial product online advertisements to buy h :1 there is a signicant difference in the respondents' opinion on the inuence of commercial product online advertisements to buy s. no. inuence of commercial product online advertisements to buy the product frequency percentage cumulative percentage chi-square (signicance at 5% level) 1. yes 1255 62.7 62.7 129.476 df=1 p=0.000 2. no 746 37.3 100.0 total 2001 100.0 table 10 inuence of commercial product online advertisement to buy the product table 10 presents the frequency analysis on the inuence of commercial product online advertisements to buy the product. table 10 depicts that majority of the respondents (62.7%) have agreed that the online advertisements about commercial product inuence them to buy the product. but, 37.3% of the respondents have stated that they are not inuenced by the online advertisements on commercial product. further, there is a signicant difference in the respondents' opinion as depicted by the signicant chi-square value (129.476; p=0.000). hence, h is rejected and h is accepted at 5% level 0 1 of signicance. the null and alternative hypotheses on the respondents' opinion about their ability to differentiate harmful and useful advertisements are: h :0 there is no signicant difference in the respondents' opinion on their ability to differentiate harmful and useful advertisements h : 1 there is a signicant difference in the respondents' opinion on their ability to differentiate harmful and useful advertisements table 11 frequency analysis on the ability to differentiate between harmful and useful advertisements s. no. ability to differentiate between harmful and useful advertisements frequency percentage cumulative percentage chi-square (signicance at 5% level) 1. yes 633 31.6 31.6 269.978 df=1 p=0.000 2. no 1368 68.4 100.0 total 2001 100.0 table 11 presents the frequency analysis on the respondents' ability to differentiate between harmful and useful advertisements. it is clear from the table that majority of the respondents (68.4%) have stated that they can differentiate between harmful and useful advertisements in the online advertisements about commercial products. the signicant chi-square value depict that h is rejected and h is accepted 0 1 at 5% level of signicance. the null and alternative hypotheses on the respondents' responses on various items displayed on online commercial advertisements are: h :0 there is no signicant difference in the respondents' responses on various items displayed on online commercial advertisements h : 1 there is a signicant difference in the respondents' responses on various items displayed on online commercial advertisements table 12 respondents' responses on various items displayed on online commercial advertisements s no. queries response frequency percentage chi-square (signicance at 5% level) 1. if you see an advertisement on internet about drug/alcohol what will you do? click on it immediately 695 34.7 412.258 df=2 p=0.000 click on it when elders are not near 283 14.1 close it immediately 1023 51.1 2. if you see an ad on internet about your favorite actor/ actress what will u do? click on it immediately 977 48.8 831.436 df=2 p=0.000 click on it when elders are not near 965 48.2 close it immediately 59 2.9 volume-8, issue-12, december-2019 • print issn no. 2277 8160 • doi : 10.36106/gjra x 143gjra global journal for research analysis table 12 represents the respondents' responses on the different queries related to online advertisements about commercial products. it can be extracted from the table that majority of the respondents (51.1%) have opined that they will close the online commercial advertisement about drug/alcohol. further 48.8% (majority) of the respondents have stated that they will click immediately the online advertisements that contain picture of their actor/actress. also, 95.4% of the respondents have agreed that they will click immediately on the online commercial advertisements about cosmetic products. similarly, 96.6% of the respondents have stated they wi l l c l ick immediately on the onl ine advertisements containing costumes. 98.8% of the respondents have stated that they will click immediately on the online commercial advertisements containing accessories. but 93.9% of the respondents have stated that they will close immediately the commercial online advertisements about health products. but 88.2% have opined that they will click immediately on the commercial online advertisements about educational products. 59.2% of the respondents have opined they will click immediately the online commercial advertisements about movie/song/games. finally, 41.4% of the respondents have stated that they will close immediately the online advertisements containing dirty pictures. further, the chi-square value is signicant for all the queries portraying signicant difference in the opinion of the respondents for all the queries. hence, h is rejected and h is 0 1 accepted at 5% level of signicance. conclusion thus, this paper gives a vivid picture of general opinion about online advertisements among the teenagers. although, the sample size is more than that required to imply the results as a whole, a few questions has given maximum responses to be neutral. further, the opinion and attitude changes from time to time may result in a different nding in future. but, the nding from the study has paved way for implications and policies that will enhance the quality of online advertisements and thereby stop ruin of the youngsters. further, it is also recommended to implement a regulatory body to monitor the advertisements that are available on the internet so as to make it more effective and less harmful. hence, it is concluded that the online advertisements can be used for right purposes and it is in the hands of the government/parents and the society as a whole to either educate the youngsters to demarcate right from wrong or to completely avoid such felonious advertisements. references 1. rodgers, s. & thorson, e. (2000), the interactive advertising model: how users perceive and process online ads. journal of interactive advertising 1(1), pp. 26-49. retrieved december 26, 2006 from http://www. jiad. org/vol1/no1/rodgers/rodgers.pdf. 2. wolin, l.d., korgaonkar, p., and lund, d. (2002), beliefs, attitudes, and behaviour towards web advertising. international journal of advertising, 21, 87-113. retrieved december 9, 2006 from the communication & mass media complete database. 3. if you see an ad on internet about cosmetics what will u do? click on it immediately 1908 95.4 3463.469 df=2 p=0.000 click on it when elders are not near 49 2.4 close it immediately 44 2.2 4. if you see an ad on internet about costumes what will u do? click on it immediately 1932 96.6 3601.682 df=2 p=0.000 click on it when elders are not near 66 3.3 close it immediately 3 0.1 5. if you see an ad on internet about accessories such as shoe/belt/chains/clips/bands what will u do? click on it immediately 1971 98.5 3824.072 df=2 p=0.000 click on it when elders are not near 11 0.5 close it immediately 19 0.9 6. if you see an ad on internet about health products such as health drinks/food what will u do? click on it immediately 119 5.9 3313.559 df=2 p=0.000 click on it when elders are not near 3 0.1 close it immediately 1879 93.9 7. if you see an ad on internet about educative products such as cd/books what will u do? click on it immediately 1764 88.2 1165.282 df=2 p=0.000 click on it when elders are not near 0 0 close it immediately 237 11.8 8. if you see an ad on internet about entertainment such as movie/song/games what will u do? click on it immediately 1185 59.2 68.046 df=2 p=0.000 click on it when elders are not near 0 0 close it immediately 816 40.8 9. if you see an ad on internet showing dirty pictures what will u do? click on it immediately click on it when elders are not near close it immediately 351 17.5 224.612 df=2 p=0.000 821 41.0 829 41.4